An Evaluation of the Army Medical Home and the Management of Temporary Profile Days
Soldiers are the U.S. Army's greatest strength and vital to overall operational readiness. A soldier's medical readiness facilitates their ability to perform combat tasks and deploy to harsh environments (U.S. Army Medical Department, 2014). The most well thought out operational plans, training, and multimillion dollar equipment are futile without healthy, agile soldiers. Thus, there is an intense emphasis on maximizing health outcomes for soldiers. Soldiers have unique needs including acute illness and injury prevention and management, and the preservation of physical performance.
The unique nature of soldier health prompted our research team to evaluate the concept of soldier-centered care.
“Understanding the impact of the medical home on temporary profile days is vital to medical readiness.”
9 Defining Attributes
We concluded soldier-centered care is realized through the presence of nine defining attributes preceded by empowered soldiers, a therapeutic alliance, and a mutual exchange of dignity and respect among medical providers, soldiers, and leaders. We proposed the following theoretical definition: "Soldier-centered care is individualized, comprehensive healthcare tailored to the soldier's unique medical needs delivered by a team of competent providers and support staff who prioritize trust and expectation management, operational alignment of care, leadership support, care coordination, and the management of limited and lost workdays through the use of Evidence-Based Practice approaches that employ innovative information technology to balance access to care and continuity" (Taylor-Clark & Patrician, 2020).
This initial work led to the examination of a unique health outcome for soldiers: limited duty or temporary profile days caused by acute musculoskeletal injuries (MSKIs). Researchers posit that the greatest threat to soldier medical readiness is acute MSKIs, caused by required physical activities that significantly strain the musculoskeletal system (Canham-Chervak et al., 2018; Sapp et al., 2018; Smith et al., 2016). MSKIs among soldiers result in more than two million outpatient visits (Jones & Hauschild, 2015) and $400 million in direct care costs each year (Defense Health Agency, 2019).
To facilitate treatment and recovery of an acute MSKI, Army medical providers place injured soldiers on duty limitations or "temporary profile" (Department of the Army, 2019a). These duty limitations are documented in "e-Profile," an automated web-based system (Department of the Army, 2019b), to facilitate three-way communication between soldiers, medical providers, and leaders regarding soldiers' capabilities and duty limitations (Department of the Army, 2019b). Poorly managed temporary profiles negatively impact a soldier's work attendance, resulting in more than 25 million lost workdays annually (Canham-Chervak et al., 2018; Caravalho, 2015).
Studies suggest that temporary profile management has improved over the last decade with upgrades to the e-Profile system (Malish et al., 2014), revisions to the policies that govern medical readiness monitoring (Department of the Army, 2019a, 2019b), and changes within the Army primary care setting (Hudak et al., 2013; Lewis & Holcomb, 2012), specifically the implementation of the Army Medical Home. The Army Medical Home includes various care delivery platforms, including the Patient-Centered Medical Home (PCMH) and Soldier-Centered Medical Home (SCMH). The PCMHs provide primary care for soldiers, family members, and retirees. The SCMHs, the "soldier version" of the PCMH, provide services to active-duty soldiers.
The Army PCMHs and SCMHs play an essential role in supporting timely MSKI recovery through efficient temporary profile management. The medical homes consist of structural attributes and care processes such as access to care, primary care manager continuity, and patient-centered communication, which have been described as essential factors in reducing lost workdays and functional limitations in workers after an acute injury (Cancelliere et al., 2016; Hu et al., 2014). Temporary profile days is a crucial soldier health outcome that had not been studied in relation to the PCMH and SCMH structures or care processes. Understanding the impact of the medical home on temporary profile days is vital to medical readiness.
Our research team examined the relationships between medical home structural characteristics, care processes, and temporary profile days among active-duty U.S. Army soldiers to explore this important soldier health outcome. A retrospective, cross-sectional, correlational study design, guided by Donabedian's (1966) framework, resulted in three published, peer-reviewed articles.
3 Peer-reviewed Articles
In the first article, we reported the results of our integrative literature review using Whittemore et al.'s (2005) five-step process to explore the relationships between medical home implementation, care processes, and outcomes. We also discussed the empirical connection between the medical home and outcomes related to returning to work after an acute injury (Taylor-Clark, Swiger, et al., 2022). The evidence was mixed regarding improved access to care, continuity, and communication after PCMH implementation but certainly supports return-to-work outcomes after an acute condition (Taylor-Clark, Swiger, et al., 2022). This review highlighted gaps in the literature, which our study begins to address.
The second article reported the results of our comparison of access to care, primary care manager continuity, and patient-centered communication between Army PCMHs and SCMHs (Taylor-Clark et al., 2021). Using a subset of data from the Military Data Repository collected in 2018, our sample included 266 medical home teams providing care for active-duty soldiers. General linear mixed regressions were used to evaluate the associations between medical home type and outcome measures. Our findings suggest that structural differences between Army PCMHs and SCMHs may impact continuity but not access to care or communication. Additionally, our analysis showed that while the PCMH and SCMH models were designed to improve access to care, primary care manager continuity, and communication, medical home teams within the Army are not consistently meeting the Military Health System standard of care benchmarks for these care processes (Taylor-Clark et al., 2021).
The last article reported the results of our comparison of temporary profile days between Army PCMHs and SCMHs and the influence of medical home structures and care processes on temporary profile days (Taylor-Clark, Loan, et al., 2022). Using secondary data from the Military Data Repository collected in 2018, we sampled 27,214 temporary profile records of active-duty Army soldiers receiving care for MSKIs and 266 Army PCMH and SCMH teams. We evaluated associations between outcomes and predictors using general and generalized linear mixed regression models. We found that total temporary profile days ranged from 1 to 357, with a mean of 37 days. There was a significant difference in mean temporary profile days between PCMHs (43) and SCMHs (35), and soldiers in PCMHs were more likely to have temporary profiles over 90 days. We also found that age, sex, rank level, physical demand category, profile severity, medical home type, the "explain things" communication subscale, and primary care manager continuity were significant predictors of temporary profile days (Taylor-Clark, Loan, et al., 2022).
This work supports continued efforts to improve MSKI-related outcomes among soldiers and aligns with the Army's fundamental premise that the soldier is the center of warfighting capability. The PCMH was initially created to improve the management of chronic illnesses. However, the structure and care processes of Army PCMHs and SCMHs should also be responsive to the care needs of soldiers with acute conditions that may affect their ability to be medically ready to deploy. Knowledge gained from this study can guide future research to help the Army better meet soldier needs and ultimately help soldiers achieve their overall health goals.