Veterans Affairs' Whole Health System of Care for Transitioning Service Members and Veterans.

The Department of Veterans Affairs (VA) has launched an organization-wide transformation to a Whole Health System of Care that will ideally begin at the time of transition from active duty through the end of a Veteran's life. A brief history and overview of the Whole Health approach are provided along with selected evaluation results and planned initial actions as a result of the Total Force Fitness-Whole Health Summit held in March 2022. More work is required to strengthen the natural linkages between the Department of Defense's Total Force Fitness and Veterans Affairs' Whole Health approach to care. The Total Force Fitness-Whole Health collaboration is a model of whole-person care for the nation.

The Untapped Power of Health and Wellness Coaching.

The Department of Veterans Affairs (VA) has launched an organization-wide transformation to a Whole Health System of Care, which relies heavily on Health and Wellness Coaching. A brief history and overview of Health and Wellness Coaching, in general, is provided, along with specific developments within VA, selected evaluation results, and coordination to date with the Department of Defense. As VA's Whole Health transformation reaches maturity, there is an opportunity to adopt VA's Health and Wellness Coaching approach into the Department of Defense's Total Force Fitness efforts with integration at the unit level.

The Whole Health Transformation at the Veterans Health Administration: Moving From "What's the Matter With You?" to "What Matters to You?"

The Veterans Health Administration is undergoing a system-wide transformation to a Whole Person/Whole Health approach to care. The Whole Health model of care is described including early outcome data on utilization and effectiveness. The paper describes the first 10 years of this transformation and provides lessons learned during that process regarding large-scale system change.

Health care use and costs for participants in a diabetes disease management program, United States, 2007-2008.

INTRODUCTION: The Disease Management Association of America identifies diabetes as one of the chronic conditions with the greatest potential for management. TRICARE Management Activity, which administers health care benefits for US military service personnel, retirees, and their dependents, created a disease management program for beneficiaries with diabetes. The objective of this study was to determine whether participation intensity and prior indication of uncontrolled diabetes were associated with health care use and costs for participants enrolled in TRICARE's diabetes management program. METHODS: This ongoing, opt-out study used a quasi-experimental approach to assess program impact for beneficiaries (n = 37,370) aged 18 to 64 living in the United States. Inclusion criteria were any diabetes-related emergency department visits or hospitalizations, more than 10 diabetes-related ambulatory visits, or more than twenty 30-day prescriptions for diabetes drugs in the previous year. Beginning in June 2007, all participants received educational mailings. Participants who agreed to receive a baseline telephone assessment and telephone counseling once per month in addition to educational mailings were considered active, and those who did not complete at least the baseline telephone assessment were considered passive. We categorized the diabetes status of each participant as "uncontrolled" or "controlled" on the basis of medical claims containing diagnosis codes for uncontrolled diabetes in the year preceding program eligibility. We compared observed outcomes to outcomes predicted in the absence of diabetes management. Prediction equations were based on regression analysis of medical claims for a historical control group (n = 23,818) that in October 2004 met the eligibility criteria for TRICARE's program implemented June 2007. We conducted regression analysis comparing historical control group patient outcomes after October 2004 with these baseline characteristics. RESULTS: Per-person total annual medical savings for program participants, calculated as the difference between observed and predicted outcomes, averaged $783. Active participants had larger reductions in inpatient days and emergency department visits, larger increases in ambulatory visits, and larger increases in receiving retinal examinations, hemoglobin A1c tests, and urine microalbumin tests compared with passive participants. Participants with prior indication of uncontrolled diabetes had higher per-person total annual medical savings, larger reduction in inpatient days, and larger increases in ambulatory visits than did participants with controlled diabetes. CONCLUSION: Greater intensity of participation in TRICARE's diabetes management program was associated with lower medical costs and improved receipt of recommended testing. That patients who were categorized as having uncontrolled diabetes realized greater program benefits suggests diabetes management programs should consider indication of uncontrolled diabetes in their program candidate identification criteria.

Disease management 360 degrees: a scorecard approach to evaluating TRICARE's programs for asthma, congestive heart failure, and diabetes.

OBJECTIVE: To assess the effect of TRICARE's asthma, congestive heart failure, and diabetes disease management programs using a scorecard approach. EVALUATION MEASURES: Patient healthcare utilization, financial, clinical, and humanistic outcomes. Absolute measures were translated into effect size and incorporated into a scorecard. RESEARCH DESIGN: Actual outcomes for program participants were compared with outcomes predicted in the absence of disease management. The predictive equations were established from regression models based on historical control groups (n = 39,217). Z scores were calculated for the humanistic measures obtained through a mailed survey. DATA COLLECTION METHODS: Administrative records containing medical claims, patient demographics and characteristics, and program participation status were linked using an encrypted patient identifier (n = 57,489). The study time frame is 1 year prior to program inception through 2 years afterward (October 2005-September 2008). A historical control group was identified with the baseline year starting October 2003 and a 1-year follow-up period starting October 2004. A survey was administered to a subset of participants 6 months after baseline assessment (39% response rate). RESULTS: Within the observation window--24 months for asthma and congestive heart failure, and 15 months for the diabetes program--we observed modest reductions in hospital days and healthcare cost for all 3 programs and reductions in emergency visits for 2 programs. Most clinical outcomes moved in the direction anticipated. CONCLUSIONS: The scorecard provided a useful tool to track performance of 3 regional contractors for each of 3 diseases and over time.

Outcomes and lessons learned from evaluating TRICARE's disease management programs.

OBJECTIVE: To share outcomes and lessons learned from an evaluation of disease management (DM) programs for asthma, congestive heart failure (CHF), and diabetes for TRICARE patients. STUDY DESIGN: Multiyear evaluation of participants in voluntary, opt-out DM programs. Patient-centered programs, administered by 3 regional contractors, provide phone-based consultations with a care manager, educational materials, and newsletters. The study sample consisted of 23,793 asthma, 4092 CHF, and 29,604 diabetes patients with at least 6 months' tenure in the program. METHODS: Medical claims were analyzed to quantify program effect on healthcare utilization, medical costs, and clinical outcomes. Multivariate regression analysis with an historical control group was used to predict patient outcomes in the absence of DM. The difference between actual and predicted DM patient outcomes was attributed to the program. A patient survey collected data on program satisfaction and perceived usefulness of program information and services. RESULTS: Modest improvements in patient outcomes included reduced inpatient days and medical costs, and (with few exceptions) increased percentages of patients receiving appropriate medications and tests. Annual per patient reductions in medical costs were $453, $371, and $783 for asthma, CHF, and diabetes program participants, respectively. The estimated return on investment was $1.26 per $1.00 spent on DM services. CONCLUSION: Findings suggest that the DM programs more than pay for themselves, in addition to improving patient health and quality of life. Lessons learned in program design, implementation, effectiveness, and evaluation may benefit employers contemplating DM, DM providers, and evaluators of DM programs.

Use of six clinical preventive services in TRICARE Prime compared to insured, managed care, and all U.S. populations and Healthy People 2010.

OBJECTIVES: Timely preventive healthcare services are important to troop readiness and the health of Military Health System (MHS) beneficiaries. Prior studies have reported on use of preventive care among select MHS subgroups, but broader performance is undocumented. This study addresses that gap by comparing TRICARE Prime beneficiaries to select U.S. populations. METHODS: Rates of prenatal care in the first trimester, flu shots, and screening for breast cancer, cervical cancer, cholesterol, and blood pressure were estimated from the 2004 Health Care Survey of Department of Defense (DoD) Beneficiaries. Rates for U.S. populations were estimated from several national health surveys. Healthy People 2010 goals provided a comparison benchmark. RESULTS: Utilization rates of TRICARE Prime enrollees significantly exceeded the U.S. population for all services examined and exceeded the insured U.S. population for flu shots, prenatal care, and screening for breast cancer and cervical cancer. Two Healthy People 2010 goals were met but three were not. CONCLUSIONS: TRICARE Prime enrollees had similar rates of six clinical preventive care services as insured U.S. populations in 2004, but failed to meet several Healthy People 2010 guidelines. Increased emphasis on these services will be required in order to meet such objectives and reduce long-term health and financial pressures on the MHS.

Analysis of weight and associated health consequences of the active duty staff at a major Naval medical center.

OBJECTIVE: The purpose of this study was to analyze the prevalence of overweight and obesity among active duty staff members at one the Navy's largest medical centers, in an effort to clarify the relationship between weight, physical fitness, health care utilization patterns, and health care costs. METHODS: Data obtained from the Physical Readiness Information Management System were linked with health care utilization data obtained from the Military Health System Management Analysis and Reporting Tool. This information was applied to the National Heart, Lung, and Blood Institute risk-stratification criteria to clarify the roles overweight and obesity play as factors contributing to increased health risk, comorbid conditions, and health care costs in this military health care setting. RESULTS: At least 53% of the active duty staff members (1,755 of 3,306) at this medical center were either overweight or obese, based on body mass index (BMI). Three hundred fifty-one personnel did not have body composition analyses recorded. Using the Navy's current system, only 149 personnel were identified as being "out of standards" and 2,806 personnel were considered to be "within standards." Remarkably, the within-standards group included 241 personnel with obese BMIs and 1,365 personnel with overweight BMIs. The National Heart, Lung, and Blood Institute risk-stratification criteria identified 445 personnel as having increased risk of premature death, based on their BMIs and other risk factors. The Navy's current program resulted in 296 (445 minus 149) missed opportunities to provide weight loss intervention when it is most effective, in the early stages of weight gain. CONCLUSION: The system currently used by the U.S. Navy to characterize personnel by weight ignores opportunities to identify and to treat high-risk personnel and provides neither a consistent nor an evidence-based model for early intervention and treatment of high-weight personnel at risk for increased morbidity, loss of productivity, and associated increased medical costs.