The document describes the experiences of an 18-year-old college student diagnosed with possible Crohn's disease or ulcerative colitis. Their care was fragmented across multiple providers and hospitals, resulting in a lack of education, unnecessary tests and hospitalizations, missed school, and feelings of helplessness. Communication improved after the patient obtained direct contact information for their provider, reducing subsequent hospitalizations. The case demonstrates how poorly coordinated care can negatively impact the patient experience.

1. The Case for Change –
People are suffering
18 yo college freshman with first episode rectal bleeding,
anemia
Diagnosis:
• Evaluated by PA at Bethesda, referred immediately for colonoscopy at
Walter Reed.
• Team of Gastroenterologists reviews biopsy –
• Dx: Possible Crohn’s vs. Ulcerative Colitis – Medications initiated
• No education provided --- Patient is terrified.
Initiation of Care:
• Enrolled at NNMC but, since in college, “you should change your
enrollment site”
• 20 phone calls by patient and patient’s mother, unable to transfer
enrollment site
• Patient’s mother flies to Chicago to change enrollment and find PCM
• Initial visit with PCM to get GI referral – PCM states - “Why don’t you
just quit college, you need a GI guy”
• Initial Specialty Visit– “Excellent” but rushed;
• Treatment focused on medications and diet 6-1
• No educational provided

2. The Case for Change – Care is
Fragmented
Chronic Illness Care
• Hospitalization one - flu symptoms – GI specialist defers to PCM;
PCM not available;
• ER Visit – Hospitalized for “Crohn’s Flare”
• Put on prednisone – “I got really crazy, I didn't know who to call”
• Hospitalization two –bleeding, (Hct 28), abdominal pain for 3 days,
• PCM not available, ER visit - repeated all labs and two more CTs
• After 3 days, released to dorm, falling behind in school
• Hospitalization three –abdominal pain, vomiting and HA, (PCM /GI
not available)
• ER Visit – Lumbar Puncture and Admitted – after two days, HA
worse, “when I stand up” but discharged anyway --“I lost the
chance to take my finals”
• Readmitted for 3 days, received blood patch after caffeine
unsuccessful
• Patient initiates talk with PCM – about availability and self care,
obtains e mail, direct phone number – no more hospitalizations
for 18 months. 6-2
• Communication is a GAME CHANGER !!

3. The Case for Change:
Processes are Not Patient Centered
July 2009 – Happy Birthday – “You are no longer eligible
for TRICARE and have been dropped from PRIME”
Several hours to reestablish PRIME but, needed new
referral for gastroenterologist. Had to be there in person.
• Waited 2 hours in PCM office, seen for 3
minutes, to get referral, no exam.
• Referral lost by TRICARE or PCM?
Pain returns, PCM not available, referral not done so could
not see gastroenterologist.
• ER, Hospitalized, returned home but, no F/U,
ER again one week later. (10.23 then 10/31)
6-3

4. Let’s Evaluate the Outcomes
Experience of Care:
Patient Centered – no helplessness
• “Most of the time, I just need someone to answer my questions
or tell me I don’t need to worry, I hate going to doctors and I
don’t want to be in the hospital.”
• ” If they had explained what this illness is all about, I would have
learned sooner. I could have figured out how to live my life with
Crohn’s”
• “And why can’t they keep my records? I feel like they don’t
believe anything that comes out of my mouth. But, its my body.
Now, I have my own personal health record – its self defense. I
am not going to get screwed again.”
Timely – no unwanted waits
Effective - evidence based interventions
• Who is following outcomes for all Crohn’s patients?
• Were the hospitalizations consistent with evidence based care?
How would we know?
Equitable – care for everyone
Safe – no needless death or injury
• Was the LP a harm event?
Efficient – No Waste
• Four hospitalizations and five ER visits – 2007
• One hospitalization and two ER visits - 2009
• Could any of these have been avoided?
6-4

5. Cost of Care –
Actual Billed Charges
Hospitalization 10/22-10/24 ER Visit 11/01
Med-Surg $1,109 • Med Sur $112
Pharm $556 • Lab/Chem $587
IV $11 • Lab/Hem $91
Supplies $109 • Lab/Bact $295
Lab $58 • Lab/Uro $60
Lab/Immun $378 • Ultrasound $893
Lab/Hem $301 • ER $1,134
Lab/Micro $75 • Pul Fxn $112
Lab/Uro $143 • Drugs $305
CT Scan Body $4,263 • Per Vasc $1,531
ER $1,668 • Other Rx $1,104
Pulmonary Fxn $224 • Total $6,224
Drugs $360
Other Rx $1,249
Total $11,677
6-5

6. MHS Performance Report Card
2011 *
Target Current Improving
Readiness
1 Medically Ready to Deploy 81% 78%
2 PTSD Screening, Referral (R) and Treatment (T) 50%/75% 46%/76%
3 Depression Screening, Referral (R) and Treatment (T) 50%/75% 65%/79% /
Population Health
4 MHS Cigarette Use Rate (Active Duty 18-24) ($) 19% 20%
5 Percent of Overweight/Obese Adults with Documented Weight Issue 30%/75% 17%/54% /
6 Percent of Overweight/Obese Adolescents/Children with Documented Weight Issue 30%/50% 11%/33% NC /
7 Exclusive Breastfeeding During Newborn Hospitalization 65% 62%
8 HEDIS Index: Preventive Cancer Screens & Well Child Visits (DC/PC) 10/10 8/6 NC
Experience of Care
9 HEDIS Index: Cardiovascular, Diabetic & Mental Health Care (DC/PC) 29/18 23/5 / NC
10 Hospital Readmission Rate (Medical/Surgical) -- -- --
11 Patient Safety - Wrong Site Surgery (Under Development) 0 2 NC
12 Antibiotic Received Within 1 Hour Prior to Surgical Incision 98% 95% NC
13 Percentage of Medical Boards Completed Within 35 Days (IDES) 60% 43%
14 Percent of Service Members Rating Medical Evaluation Board Experience as Favorable 65% 50%
15 Primary Care 3rd Available Appointment (Routine/Acute) 92%/70% 69%/48% /
16 Satisfaction with Getting Timely Care 78% 75%
17 Potentially Recapturable Primary Care Workload for MTF Enrollment Sites ($) 26% 34%
18 Percent of Visits Where MTF Enrollees See Their PCM 65% 53%
19 Satisfaction with Health Care 61% 59% NC
Per Capita Cost
20 Annual Percent Increase in Per Capita Costs ($) 3.1% 5.5%
21 Emergency Room Visits Per 100 Enrollees Per Year ($) 35 47
22 Primary Care Staff Satisfaction -- -- --
6-6
($) Denotes lower is better Yes No 6* 2011 data lag 3-6months

7. Turning Strategy to Action: Our 2012
MHS Strategic Initiatives
Readiness
• Operating our MTFs at full capacity
• Implement policies, procedures & partnerships to meet individual medical readiness
goals
• Integrate & optimize psychological health programs to improve outcomes and enhance
value
• Implement DoD/VA Joint strategic plan for mental health to improve coordination
Population Health
• Improve measurement and management of population health to accelerate the shift from
healthcare to health
Experience of Care
• Implement evidence based practices across the MHS to improve quality and safety
• Implement patient centered medical home of care to increase satisfaction, improve
performance in achieving the Quadruple Aim
• Optimize pharmacy practices to improve quality and reduce costs
• Create alternative strategy for purchasing care to improve Quadruple Aim performance
Per Capita Cost
• Implement alternative payment mechanisms to pay for value (performance planning)
Learning & Growth
• Implement modernized EHR to improve outcomes and enhance interoperability
• Improve governance to achieve better Quadruple Aim performance
6-7

8. Bringing Care Back into our MTFs
Military Treatment Facility Workload
Outpatient Weighted Workload Inpatient Weighted Workload
450
50
400
45
40 350
Thousands of RWPs
35 300
Millions of RVUs
30 250
25 200
20 150
15
100
10
50
5
0
0
2004 2005 2006 2007 2008 2009
2004 2005 2006 2007 2008 2009
In-House Care Private Sector Care In-House Care Private Sector Care
Note: Private sector care has increased
about 20% while in-house care has
decreased about 10%.
6-8

9. The Partnerships for Patients –
Background and Focus
• Originally sponsored by the White House under the title: “National
Patient Safety Initiative”
• Renamed “The Partnership for Patients” with two aims:
− Keeping patients from getting injured or sicker. Accidents happen, and too often
patients in hospitals experience preventable harm. The initiative seeks to
increase efforts to prevent patient harm in hospitals. By the end of 2013, hospital
acquired harm would decrease by 40% compared to 2010
− Helping patients heal without complication. Patients are often at their most
vulnerable state when leaving the hospital to continue healing at home, in an
assisted living facility, or in other care settings. The initiative seeks to improve
continuity and effectiveness of care during transitions from one care setting to
another and thereby to decrease preventable hospital readmissions within 30
days of discharge. By the end of 2013, preventable complications during a
transition from one care setting to another would be decreased such that
unplanned hospital readmissions would be reduced by 20% compared to 2010
6-9

10. What is our Aim? To work collaboratively across the entire
MHS to reduce hospital acquired conditions, improve
quality and reduce costs
-Reduce hospital acquired conditions by 40% by the
end of CY 2013
• Need to identify types of hospital acquired conditions (i.e.
infections, falls, pressure ulcers, etc.) and 2010 baseline
-Reduce unplanned readmissions by 20% by the end
of CY 2013
• Need to agree on what readmissions will be excluded
• Need to focus on best opportunities for improvement (Mental
health, cardiovascular disease, diabetes, etc.)
-Demonstrate MHS success in knowledge transfer and
best practice dissemination
• This is about execution of established protocols to reduce
patient harm and avoid non-value added health services
(unplanned readmissions)
6-10

11. Direct Care Acquired Conditions
LAW 10 USC 1102, the confidential and privileged information contained herein may not be disclosed
outside of DoD without appropriate authorization. Violations are punishable by fines or other actions. 6-11

12. Why are we doing this now?
• It is a strategic imperative for the MHS
• Need to prove our assertion that we can improve quality while reducing costs
• MHS readmission rates are comparable to national benchmarks
• Need to demonstrate excellence in management of mental illness
• We do not measure hospital acquired harm in a standard and transparent
manner so it is difficult to systematically improve
• We have committed to the National Partnership for Patients
• ASD(HA) formally joined partnership with HHS in May
• Over 3000 hospitals and health systems have joined to reach the goals of the
partnership for patients
6-12