Active Duty Only vs All Beneficiary Clinics: Facilitating Injury Recovery

Background and Significance: Alarmingly, more than 471,000 (22%) military Service Members (SMs) are unable to deploy every year, which undermines the U.S. Armed Forces’ ability to respond to adversary threats and protect our Nation. Acute musculoskeletal injuries (MSIs) are the number one medical issue preventing SMs from performing their essential job duties and deploying in support of war and peacetime missions. Moderate to severe MSIs place SMs in a temporary limited duty status, commonly referred to as a “profile,” from the onset of injury to return to full functioning. Temporary duty limiting MSIs result in the loss or limitation of over 25 million duty/workdays, annually. The goal of MSI management is for SMs to regain optimal strength, range of motion, and functionality in a timely manner, which results in improved overall health and well-being, and reduced profile days. This goal is achieved by maximizing Military Health System (MHS) primary care capabilities and implementing evidence-based health care strategies to support SM needs. Little is known about how differences in operational characteristics, such as structures, functions, and activities of care within the MHS primary care delivery model, the Patient-Centered Medical Home (PCMH), affect the management of MSIs and profile days. In addition to the basic national standards of the PCMH model, the MHS implemented care provisions focused on SM health and readiness outcomes by establishing “active duty (AD) only” medical homes (i.e., all patients, primary care providers, and nursing support staff assigned to the clinic are AD SMs aligned with the same operational unit). However, not all AD SMs receive care in this clinic type. Active duty SMs also receive care in “all-beneficiary” medical homes (i.e., active duty and retired SMs and their families are assigned to and receive care from a mixture of civilian and military primary care providers and nursing support staff). Both MHS medical home structures encompass key care processes, such as access to care, primary care manager (PCM) continuity, and patient-centered communication, which have been associated with improved patient outcomes. Empirical evidence suggests that variation in how healthcare organizations operationalize medical home concepts may result in different patient outcomes. Using Donabedian’s framework, the purpose of the study is to determine how variations in medical home structures and processes affect the management of MSIs in AD SMs. The specific aims of this study are to: 1) Describe the clinic and patient demographic characteristics of the two MHS medical home structures (i.e., AD only and all-beneficiary); 2) Compare the care processes (i.e., access to care, PCM continuity, and patient-centered communication) and the outcome (i.e., temporary duty limiting profile days for AD SMs with acute lower extremity MSIs) between the two MHS medical home structures; and 3) Determine whether and to what extent patient characteristics, access to care, PCM continuity, and patient-centered communication explain the variance in the outcome.
Methods: This is a retrospective, cross-sectional, descriptive and correlational study of the differences in and associations between military medical home structures, care process, and SM outcomes using a de-identified data set from the Military Data Repository. In this study, the population of interest is all active duty SMs. The sample includes secondary data representing AD U.S. Army SMs (n=800-1200) cared for in 130 U.S. Army primary care clinics. Quantitative characteristics for structures, processes, and outcomes will be summarized with mean and standard deviation (SD) or frequency and proportions, as appropriate. The comparison of structural characteristics will be conducted with Chi-square test or two samples t-test, as appropriate. The evaluation of the effect of patient characteristics and care processes on patient outcomes between two medical home types will be conducted using general or generalized linear mixed models. The reliance on secondary data and the use of an U.S. Army only sample are study limitations.