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ARMY MEDICINEOne Team, One Purpose Conserving the Fighting Strength Since 1775!Readiness # 1COL Myron McDaniels, LTC Christopher Cowan, LTC Chester JeanCOL Matt Garber, Ms. Theresa (Tracie) Lattimore, LTC Sharon RosserHealth Care Delivery29 November 2018UNCLASSIFIED

ARMY MEDICINEDisclosureOne Team, One Purpose Conserving the Fighting Strength Since 1775!Presenter has no interests to disclose.AMSUS and ACE/PESG staff have no interests todisclose.This continuing education activity is managed andaccredited by Affinity CE/Professional EducationServices Group (ACE/PESG) in cooperation withAMSUS. ACE/PESG, AMSUS, planning committeemembers and all accrediting organizations do notsupport or endorse any product or servicementioned in this activity.Lawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 2 of 3229 November 2018

ARMY MEDICINEOne Team, One Purpose Purpose and OutlineConserving the Fighting Strength Since 1775!Purpose:To provide an overview on how Army Medicine improves Readiness throughPrimary Care, Behavioral Health, Musculoskeletal initiatives, Traumatic BrainInjury, and Comprehensive Pain Integration.Agenda:1. Introduction & Learning Objectives2. Priorities and Imperatives3. Army Medical Home4. Behavioral Health Service Line (BHSL)5. Physical Performance Service Line (PPSL)6. Traumatic Brain Injury (TBI)7. Army Comprehensive Pain Management ProgramLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 3 of 3229 November 2018

ARMY MEDICINEOne Team, One Purpose Learning ObjectivesConserving the Fighting Strength Since 1775!At the conclusion of this activity, the participant will be able to: Show how Army Medical Homes assist in maintaining the Ready Medical Force. Describe how at least one core BHSL program supports Readiness. Describe the role of the Behavioral Health Data Portal in linking patient care tothe Behavioral Health Service Line's role in promoting Readiness. Show PPSL holistic approaches that have allowed for fewer limited duty daysmaking Soldiers Mission Ready. Describe advances in the understanding of TBI and how they will be integratedinto clinical practice on the battlefield, in training and in the clinics. Show how Army Medicine has established an enduring comprehensive painmanagement strategy; integrating holistic, complementary and integrativetherapies; vital in shaping the future of the Military Health Systems; whiledirectly impacting readiness – not only of the Warfighter but also of the ArmyFamily.Lawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 4 of 3229 November 2018

ARMY MEDICINEOne Team, One Purpose Conserving the Fighting Strength Since 1775!Priorities and ImperativesCSA Priorities: Readiness (#1), Future Army, Take Care of the Troops“Readiness to fight and win in groundcombat is, and will remain, the UnitedStates Army’s No. 1 priority, and there willbe no other No. 1. We will always be ready tofight today. We will always prepare to fighttomorrow.”"Our challenge today is to sustain the counterterrorist andcounterinsurgency capabilities that we've developed with a highdegree of proficiency over the last 15 years, whilesimultaneously rebuilding the capability to win in ground combatagainst higher-end threats such as Russia, China, North Koreaand Iran We can wish away these threats, but we'd be veryfoolish as a nation to do so."General Mark A. Milley, Army Chief of StaffGeneral Mark A. Milley, Army Chief of Staff“Our readiness to deploy healthy individualsand organizations in support of the world’spremier combat force must be withoutquestion. Readiness is #1.”“The future of Army Medicine at the individual, organizationaland enterprise levels is being determined today. We mustrapidly develop scalable and rapidly deployable medicalcapabilities that are responsive to Operational needs and areable to effectively operate in a Joint/Combined environmentcharacterized by highly distributed operations and minimal, ifany, pre-established health service infrastructure.”LTG Nadja Y. West, Army Surgeon GeneralLTG Nadja Y. West, Army Surgeon GeneralReadinessReadiness Begins with Leaders!Lawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 5 of 3229 November 2018

ARMY MEDICINEOne Team, One Purpose Army Medical HomeMedic DevelopmentConserving the Fighting Strength Since 1775! Ready Medical ForceOperational CorrelationBroadening ScopeDelegated e (Reps/Sets)TrainingProviderExpeditionaryCombat MedicCombat MedicCombat LifesaverClinical Decision MakingLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 6 of 3229 November 2018

ARMY MEDICINEOne Team, One Purpose Conserving the Fighting Strength Since 1775!Algorithm DirectedTroop Medical CareExpanded Medic Capability Expanded Medic Treatment Utilization of ECM/NCO IAW ICTs and MEDCOM 40-50Increased Quality & Safety Documented in EHR Provider Co-signature Medic Peer Reviews NCO Chart ReviewsLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 7 of 3229 November 2018

ARMY MEDICINEA Piece of the WholeOne Team, One Purpose Conserving the Fighting Strength Since 1775!Utilization ofAlgorithm Directed Troop Medical Care1 Week AMH Orientation24-36 Hours Didactic Instruction 300 Hours Clinical PreceptorshipPrimary Care ICTs TrainedMEDCOM 40-50 Skills Trained 10 Week Rotation vs 3 Day CourseTraining StandardizationDocumented in DTMSTraining Evaluation ProvidedMSTC UC/ER SCMH Inpatient Experience Prolonged Field CareLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 8 of 3229 November 2018

ARMY MEDICINEBHSL OverviewOne Team, One Purpose Conserving the Fighting Strength Since 1775!Lawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 9 of 3229 November 2018

ARMY MEDICINEOne Team, One Purpose Conserving the Fighting Strength Since 1775!EBH Concept of Operations Embedded Behavioral Health (EBH):– Reorganization of traditional model of outpatient BH care to one that isproactive, forward-positioned and aligned with active componentoperational units (direct support relationship)– Addresses gaps in access and continuity of care throughmultidisciplinary teams– Care occurs in an easily accessible (forward) locationBattalionBrigade CombatTeam/Combat AviationBrigade/SustainmentBrigade/etc.- Frequent consultation- Coordinated management of high riskSoldiers- Trend identification and responseBH ProviderMultidisciplinary EBH teamLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 10 of 3229 November 2018

ARMY MEDICINEOne Team, One Purpose Conserving the Fighting Strength Since 1775!Behavioral Health Data PortalPrecision Healthcare Enables Recovery Recognized as the DoD frontrunner in BH outcomesmonitoring, the Army’s Behavioral Health Data Portal(BHDP) enables precision medicine, enhances quality andcontinuity of care, and embeds systems for providingindividualized feedback and action at the point of care. Recognized in the December 2016 Harvard BusinessReview, BHDP enables a real-time, standardized approachto enhance and demonstrate individual and populationhealth improvement. As of September 2018, the Army used BHDP in over95,000 BH encounters every month with a total of over 4.5million surveys collected to date.Lawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 11 of 3229 November 2018

ARMY MEDICINEArmy Behavioral Health Utilization(2005 to 2017)One Team, One Purpose Conserving the Fighting Strength Since 1775!Army Behavioral Health CareCorrelated with 2016 ASAPtransformation, 2016 stand up ofRTFs at BAMC and MAMC, andIOP expansion at multiple sites.3,0001800016000eRVUs Direct and Purchased Care 6000400050020000020052006Outpt BH eRVUs200720082009ER Encounters201020112012Admissions Direct CareLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIED201320142015Admissions Purchased CareSlide 12 of 3220162017AD, ARNG, USAR Suicides29 November 2018

ARMY MEDICINEOne Team, One Purpose Conserving the Fighting Strength Since 1775!Total Number of MSK Days on ProfileSoldier Musculoskeletal (MSK)Profile Days are DecreasingAVG Number of MSK Days on Profileper .8290 ys201620173 million day decrease in MSK profile days from CY15 to CY1723% decrease in MSK profile days exceeds 4% decrease in size of Army fromCY15 to CY17Lawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 13 of 3229 November 2018

ARMY MEDICINEOne Team, One Purpose Conserving the Fighting Strength Since 1775!Achieving ContinuousImprovementSurveillance& AnalysisConsultationPolicy,process,procedureto preventchronicityShareLeadingPracticesLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) esUNCLASSIFIEDSlide 14 of 3229 November 2018

ARMY MEDICINEOne Team, One Purpose Conserving the Fighting Strength Since 1775!Do Units with Physical Therapists / MedicalSupport Do Better Than Units Without?% Soldiers on Temporary MSK profile 90 days inthe previous 180 h2016April 2016 May 2016 June 2016 July 2016BCT w/ PTBCT w/PT: Infantry, Armor, and StrykerAugust2016September October20162016November December20162016Combat w/o PTSustain/Support w/o PTCombat w/o PT: FA and CABSUST/Support w/o PT: SUST, TRANS, (BfSB), (MEB)Combat units with organic medical personnel, including PTs, have considerablyfewer Soldiers on chronic MSK profiles than combat support and combat servicesupport units with fewer medical personnel and no PTs.In June 2016 MEDCOM released the new eProfile system. The methodology for identifying MSK profiles changed from U& L in PULHES to key term search based on review of 4000 MSK profiles.Lawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 15 of 3229 November 2018

ARMY MEDICINEIs There VarianceBetween Units?One Team, One Purpose Conserving the Fighting Strength Since 1775!% Soldiers on MSK profile 90 days inthe Last 6 Months76543210I CORPSIII CORPSXVIII ABN CORPS Yes there is significant variance in MSK burden even at the Army Corps levelLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 16 of 3229 November 2018

ARMY MEDICINEHow Many Chronic MSKSoldiers Progress to DES?One Team, One Purpose Conserving the Fighting Strength Since 1775!3.8% of Soldiers with chronic MSK 48% all limited duty daysPercent of chronic ( 90 days in previous 180) MSK SoldiersReceiving an MSK P3 Profile Over 24 Months40%33.8%35%30%25%20%15% 12.4%10%Lawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 17 of 5November-150%October-155%29 November 2018

ARMY MEDICINEOne Team, One Purpose Conserving the Fighting Strength Since 1775!Readiness Focused MSKHealthcare Delivery Improved profile management Early access to physical therapist Embedded vs. co-located Forward multi-disciplinary MSK care in the unit Reconditioning physical readiness training Screening (Medical Readiness Assessment Tool - MRAT) Non-deployment risk Non-responder risk Disability Evaluation System efficiencyLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 18 of 3229 November 2018

ARMY MEDICINETBI ProgramOne Team, One Purpose Conserving the Fighting Strength Since 1775!Mission: Produce an educated force trained and prepared to provide earlyrecognition, treatment and tracking of traumatic brain injuries in order to protectSoldier healthLawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 19 of 3229 November 2018

ARMY MEDICINETBI ProgramOne Team, One Purpose Conserving the Fighting Strength Since 1775!Lawanda D. Warthen / lawanda.d.warthen.mil@mail.mil / (703) 681-1876UNCLASSIFIEDSlide 20 of 3229 November 2018