Medical Management Guide, 2009, Version 3.0 - Tricare

Instructions:When accessing this Guide from the CD-ROM:1. Links to outside websites and CD-ROM Resources will open inthe same browser window as this Guide. When accessing theselinks, use your browser’s “Back” button to return to this Guide.2. The CD-ROM Resources are saved as browser-viewable AdobeAcrobat PDF files and other native file formats from programs suchas Microsoft Word, Excel, PowerPoint, etc. These programs must beinstalled on your computer for access.A note about hyperlinks to outside websites: Links to outside websites found printedhere are provided only as a convenience to assist you in locating information that may behelpful. You should note that changes may occur since the printing of this Guide which mayaffect the accuracy or availability of the referenced link.All contents © 2009 DoD/Office of the Chief Medical Officer (OCMO)/TRICARE ManagementActivity (TMA) and the various other organizations whose work is reproduced here.

Medical Management Guide Version 3.0 Executive SummaryPage iiiExecutive SummaryINTRODUCTIONThe Department of Defense (DoD) TRICAREManagement Activity (TMA) values all staffinvolved in the delivery of high-quality healthcare to DoD beneficiaries — Service members andtheir families. TMA is constantly working to providethe most current information to its partners in thiseffort.The Medical Management Guide is issued by theOffice of the Assistant Secretary of Defense forHealth Affairs (ASD [HA]) and TMA, Office of theChief Medical Officer (OCMO), Population Healthand Medical Management Division (PHMMD).The Guide covers the components of a MedicalManagement (MM) program, including applicableprinciples, implementation concepts, processes, andtools/databases for Utilization Management (UM),Case Management (CM), and Disease Management(DM). It complements the 2001 DoD PopulationHealth Improvement Plan and Guide published byTMA and the Government Printing Office (http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf, and CD-ROM Resource ES-1).The ASD (HA) annually signs a five-year performanceplan for the Defense Health Program (DHP) with theSecretary of Defense, along with Army, Navy, andAir Force Assistant Secretaries for Manpower andReserve Affairs. MM-related measures (i.e., metrics)highlighted in the FY 2009 DHP Plan ( CD-ROMResource ES-2) include:• Beneficiary satisfaction with the health plan.• Inpatient production target (relative weightedproducts [RWP]).• Outpatient production target (relative valueunits [RVUs]).• Primary care productivity (RVUs per primary careprovider per day).• Medical cost per member per year.LEGISLATIVE GUIDANCEUnder legislative mandates, the ASD (HA)submits an annual report to Congressregarding healthcare delivery for 9.4 millionMilitary Health System (MHS) beneficiaries. The2009 report documents the MHS goal of providinghigh-quality care, improving performance throughclinical and process outcomes, and increasingpatients’ confidence in the care they receive.Version 3.0 of the Guide draws more specificallyfrom the Report to Congress on the ComprehensivePolicy Improvements to the Care, Management and

Page viExecutive SummaryVersion 3.0Medical Management GuideCONTACT INFORMATIONAssistant Secretary of Defense, Health Affairs/TRICARE Management ActivityOffice of the Chief Medical OfficerPopulation Health and Medical ManagementDivision5111 Leesburg PikeSuite 810Falls Church, VA 22041COMM: (703) 681-0064DSN 761-0064FAX: (703) 681-1242CD-ROM RESOURCESES-1 DoD TMA Population Health ImprovementPlan and Guide (2001)ES-2 DoD Defense Health Plan (DHP) 2009HighlightsES-3 Report to Congress on the ComprehensivePolicy Improvements to the Care,Management and Transition of RecoveringService Members (Sept. 16, 2008)ES-4 National Defense Authorization Act (NDAA)of 2008, Title XVI, Sections 1611 and 1615ES-5 An Achievable Vision: Report of theDepartment of Defense Task Force onMental Health (2007)ES-6 Rebuilding the Trust: The IndependentReview Group (IRG) on Rehabilitative Careand Administrative Processes at Walter ReedArmy Medical Center and National NavalMedical Center (2007)ES-7 The Secretary of Veterans Affairs Task Forceon Returning Global War on Terror Heroes(2007)ES-8ES-9ES-10ES-11ES-12Serve, Support, Simplify: The President’sCommission on Care for America’sReturning Wounded Warriors (2007)Veteran’s Disability Benefits Commission,Honoring the Call to Duty: Veterans’Disability Benefits in the 21st Century (2007)The President’s Task Force to Improve HealthCare Delivery for Our Nation's Veterans(2003)The Report of the CongressionalCommission on Service Members andVeterans Transition Assistance (1999)The President’s Commission on Veterans’Pensions (1956)‘

Page viiiAcknowledgementsVersion 3.0Medical Management GuideAir ForceCarol Andrews, Lt Col, NCDeona J. Eickhoff, Lt Col, NCSabrina M. Preston-Leacock, Lt Col, NCMelanie A. Prince, Lt Col, NCBrij B. Sandill, Lt Col, NCTammy R. Tenace, Lt Col, NCIwona E. Blackledge, Maj, NCShawn Dunne, Maj, NCKaryn L. Revelle, Maj, NCPaula M. Winters, Maj, NCSherry A. Herrera, MSN, NE-BC, CPUM, CMACBeverly K. Luce, MHSA, BSN, RN, CCMU. S. Department of Veterans AffairsKaren M. Ott, RN, MSNMilitary Patient Centered MedicalHome ModelThis model was used with permission from andwas created by the National Naval Medical CenterPatient Centered Medical Home and by CDR KevinDorrance, USN, MC.Cover PhotoSource: http://www.defenseimagery.mil/Photographer: MSgt Steve Cline‘IndustryTerry Kelley, BSN, RN, CCM — Case ManagementSociety of AmericaContractor SupportTechnology, Automation and Management(TeAM), Inc.• Charles G. Davis, CEO, Program Manager• Anne F. Cook, Technical Writer/Editor• Keira R. Thrasher, Senior Curriculum Developer• Syreeta M. Collier, Logistics Coordinator• Valerie Thompson, Graphic Designer

Medical Management Guide Version 3.0Page ixTable Of ContentsClick text listing to viewExecutive Summary..................................................................................................................................... iiiIntroduction............................................................................................................................................................ iiiLegislative Guidance................................................................................................................................................ iiiDescription of Guide Contents................................................................................................................................ ivContact Information................................................................................................................................................ viCD-ROM Resources................................................................................................................................................. viAcknowledgements ........................................................................................................................................... viiSection I – Medical Management Essentials.......................................................................................... 1Introduction............................................................................................................................................................ 1Definition of Medical Management.................................................................................................................. 1Primary Care Management Team Approach...................................................................................................... 2Policy Requirements for Medical Management within the Direct Care System................................................... 4Medical Management Goals and Approach...................................................................................................... 5The Link between Medical Management and Population Health.............................................................................. 7Population Health Elements in Action............................................................................................................... 8TRICARE and Other Benefit Programs..................................................................................................................... 10Working with Managed Care Support Contractors........................................................................................... 10The Link between Clinical and Business Operations................................................................................................. 11Integrating Utilization, Case, and Disease Management Functions........................................................................... 12Staffing for Combined Functions...................................................................................................................... 16Essential Considerations for Medical Management Staff.......................................................................................... 18Benefitting from Information Technology.......................................................................................................... 18Privacy and Confidentiality of Patient Information............................................................................................. 19Program Sustainment.............................................................................................................................................. 20Summary................................................................................................................................................................ 21CD-ROM Resources................................................................................................................................................. 21

Page Version 3.0Medical Management GuideSection II – Utilization Management...................................................................................................... 25Introduction............................................................................................................................................................ 25Definition, Goals, and Purpose.......................................................................................................................... 26Utilization Management Components .................................................................................................................. 26The Seven-Step Quality Improvement Process................................................................................................... 27Identify the Purpose................................................................................................................................... 28Determine What to Measure...................................................................................................................... 28Determine the Gaps................................................................................................................................... 29Attempt to Fix the Problem(s)..................................................................................................................... 29Determine the Effectiveness of the Corrective Action................................................................................. 30Make Additional Attempts to Fix the Problem(s)......................................................................................... 30Learn from the Quality Improvement Process.............................................................................................. 30Utilization Review............................................................................................................................................. 31Types of Review......................................................................................................................................... 32Outcome Measurement and Management........................................................................................................ 33McKesson ® InterQual ® ............................................................................................................................... 33Milliman Care Guidelines ® .......................................................................................................................... 36Provider Profiling.............................................................................................................................................. 36Referral Management....................................................................................................................................... 37Referral Management Center..................................................................................................................... 38Active Duty Service Member Referrals........................................................................................................ 39Authorization............................................................................................................................................. 40Episode of Care.......................................................................................................................................... 40The Electronic Referral Process................................................................................................................... 41Utilizing Military Treatment Facility Capability and Right of First Refusal Reports......................................... 43Additional Information............................................................................................................................... 43The Grievance and Appeal Process.................................................................................................................... 44Overview................................................................................................................................................... 44Grievances................................................................................................................................................. 45Appeals..................................................................................................................................................... 46Risk Management............................................................................................................................................. 51Utilization Management Program Accreditation....................................................................................................... 52The Utilization Management Professional................................................................................................................ 52Qualifications................................................................................................................................................... 52Staffing to Support Utilization Management..................................................................................................... 53Summary................................................................................................................................................................ 53CD-ROM Resources........................................................................................................................................... 54

Medical Management Guide Version 3.0Page xiSection III – Case Management............................................................................................................ 57Introduction......................................................................................................................................................... 57Definition, Goals, and Purpose.......................................................................................................................... 58Philosophy ....................................................................................................................................................... 60The Military Case Manager............................................................................................................................... 60Case Management Components ........................................................................................................................... 62Beneficiary Identification/Case Finding.............................................................................................................. 62Triggers for Potential Referral..................................................................................................................... 63Case Screening................................................................................................................................................. 64Case Selection.................................................................................................................................................. 64The Six-Step Case Management Process............................................................................................................ 65Assessment................................................................................................................................................ 66Planning..................................................................................................................................................... 66Implementation.......................................................................................................................................... 68Coordination.............................................................................................................................................. 69Monitoring................................................................................................................................................. 69Evaluation.................................................................................................................................................. 70Case Closure.................................................................................................................................................... 70Documentation................................................................................................................................................ 71Outcome Measurement and Management........................................................................................................ 71Patient Outcome Evaluation....................................................................................................................... 73Program Outcome Evaluation..................................................................................................................... 73Establishing a Case Management Program........................................................................................................... 78Organizational Framework................................................................................................................................ 78Goals................................................................................................................................................................ 78Implementation................................................................................................................................................ 79Quality....................................................................................................................................................... 79Caseload.................................................................................................................................................... 80Discharge Planning..................................................................................................................................... 81Care Coordination...................................................................................................................................... 83Accreditation.................................................................................................................................................... 83Promoting Your Program.................................................................................................................................. 83Legislative Guidance Specific to Integrating Physical and Psychological Rehabilitation........................................... 83Disability Evaluation System.............................................................................................................................. 85Medical Evaluation Board........................................................................................................................... 85Physical Evaluation Board........................................................................................................................... 85Other Types of Evaluation ....................................................................................................................................... 86

Page xiiVersion 3.0Medical Management GuideRecovery Coordination Initiatives............................................................................................................................. 87Federal Recovery Coordination Program............................................................................................................ 87Recovery Care Coordinators....................................................................................................................... 87Transition/Coordination of Care............................................................................................................................... 88Transition of Care............................................................................................................................................. 88Service-Specific Care Transition Programs................................................................................................... 89Inter/Intra-Regional Transfer....................................................................................................................... 89Aeromedical Evacuation............................................................................................................................. 90Coordination of Care........................................................................................................................................ 92Coordination from the Military Health System to the Department of Veterans Affairs................................. 92Coordination for Active Duty Service Members in the TRICARE Prime Remote Program.............................. 92Coordination for Exceptional Family Member Program and Special Needs Families...................................... 93Transition/Coordination Challenges................................................................................................................... 95Other Types of Transition/Coordination............................................................................................................. 95Outside the Continental United States and TRICARE Global Remote Overseas Program.............................. 96The Case Management Professional........................................................................................................................ 97Qualifications................................................................................................................................................... 97Education and Experience Requirements.................................................................................................... 97Certification............................................................................................................................................... 98Ethical Practice Standards........................................................................................................................... 98Resources for Orienting and Training the New Case Manager........................................................................... 99Summary................................................................................................................................................................ 100CD-ROM Resources................................................................................................................................................. 100Section IV – Disease Management.......................................................................................................... 105Introduction............................................................................................................................................................ 105Definition, Goals, and Purpose.......................................................................................................................... 106The Current State of Disease Management....................................................................................................... 107Managing Chronic Disease in the Military Health System............................................................................ 107Employer-Funded Health Plans................................................................................................................... 108Cost Savings for Disease Management....................................................................................................... 108Disease Management Components........................................................................................................................ 109Population Identification Processes................................................................................................................... 109Evidence-Based Clinical Practice Guidelines....................................................................................................... 110Fundamentals............................................................................................................................................ 110Department of Defense/Department of Veterans Affairs Clinical Practice Guidelines................................... 112National Guideline Clearinghouse........................................................................................................... 114

Medical Management Guide Version 3.0Page xiiiU.S. Preventive Services Task Force............................................................................................................. 114Collaborative Practice Models........................................................................................................................... 115Patient Self-Management Education................................................................................................................. 116Process and Outcome Measurement, Evaluation, and Management.................................................................. 118Clinical Quality Measures........................................................................................................................... 119Feedback and Reporting................................................................................................................................... 123Stakeholder Reporting................................................................................................................................ 123Establishing a Disease Management Program....................................................................................................... 124Implementing a Disease Management Plan....................................................................................................... 124Assess the Target Population...................................................................................................................... 125Assemble a Team....................................................................................................................................... 125Adopt Guidelines and Protocols................................................................................................................. 126Establish Goals and Target Outcomes......................................................................................................... 126Create a Prioritized Plan and Implement the Plan........................................................................................ 127Collect and Analyze Outcomes Data........................................................................................................... 127Evaluate and Refine the Program................................................................................................................ 127Accreditation............................................................................................................................................. 127The Disease Management Professional................................................................................................................. 128Qualifications................................................................................................................................................... 128Certification..................................................................................................................................................... 129Summary............................................................................................................................................................. 129CD-ROM Resources.............................................................................................................................................. 130Section V – Medical Management Tools............................................................................................ 133Introduction......................................................................................................................................................... 133Using Information Systems and Data Marts ......................................................................................................... 133Accessing the Data........................................................................................................................................... 133Understanding the Methodology and Limitations............................................................................................. 134Data Quality Concerns...................................................................................................................................... 134Information Systems And Data Marts ................................................................................................................ 134Military Health System-Level Decision Support Tools and Executive Information Systems................................ 134Armed Forces Health Longitudinal Technology Application............................................................................... 134Executive Information and Decision Support..................................................................................................... 134Tools for Utilization, Case, and Disease Management Collaboration...................................................................... 135TRICARE Management Activity Reporting Tools .............................................................................................. 136Health Assessment Review Tool........................................................................................................................ 139MHS Insight...................................................................................................................................................... 140

Page xivVersion 3.0Medical Management GuideProspective Payment System............................................................................................................................. 140Protected Health Information Management Tool............................................................................................... 140Service-Level Information Systems........................................................................................................................... 140Army................................................................................................................................................................ 140Navy................................................................................................................................................................. 141Air Force........................................................................................................................................................... 141Business Planning Tools........................................................................................................................................... 141Tri-Service Business Plans.................................................................................................................................. 141CD-ROM Resources................................................................................................................................................. 144Appendix A – References.......................................................................................................................... 147Appendix B – Acronyms............................................................................................................................. 156Appendix C – Definitions........................................................................................................................... 161Appendix D – Resources............................................................................................................................ 185

Medical Management Guide Version 3.0Page xvTable Of FiguresClick text listing to viewSection I – Medical Management EssentialsFig. 1 – Military Medical Home Model................................................................................................................. 3Fig. 2 – MHS Medical Management Model.......................................................................................................... 3Fig. 3 – MHS Population Health Model (2006)..................................................................................................... 7Fig. 4 – Integrated Medical Management Model (IM3)......................................................................................... 14Fig. 5 – Distinctions between UM, CM, and DM.................................................................................................. 15Fig. 6 – Questions to Consider when Creating an Integrated MM Program........................................................... 17Section II – Utilization ManagementFig. 7 – Utilization Management within the MHS Integrated MM Model (IM3)..................................................... 25Fig. 8 – Seven-Step Quality Improvement Process................................................................................................. 27Fig. 9 – Sample UM Data Elements or Measures.................................................................................................. 34Fig. 9 (cont.) – Sample UM Data Elements or Measures ....................................................................................... 35Fig. 10 – TRICARE Referrals/Preauthorizations/Authorizations............................................................................... 42Fig. 11 – MTF Review and Appeal Process: Internal Review................................................................................... 47Fig. 11 (cont.) – MTF Review and Appeal Process: Internal Review/Appeal............................................................ 48Fig. 11 (cont.) – MTF Review and Appeal Process: External Appeal....................................................................... 49Section III – Case ManagementFig. 12 – Case Management within the Integrated MM Model (IM3).................................................................... 57Fig. 13 – Chronic Care Management Model......................................................................................................... 59Fig. 14 – Military-Specific Designations, Programs, and Offices............................................................................. 61Fig. 15 – Potential Sources for Case Finding......................................................................................................... 62Fig. 16 – The Six-Step CM Process........................................................................................................................ 65Fig. 17 – Categories of Assessment...................................................................................................................... 67

Medical Management GuideVersion 3.0Medical Management EssentialsPage Medical Management EssentialsSECTIONIINTRODUCTIONDefinition of Medical ManagementIn the healthcare industry, organizations haveestablished programs or systems to improveclinical outcomes and manage rising healthcarecosts. This is broadly referred to as the field of“Medical Management” (MM).The 2006 Department of Defense Instruction (DoDI)6025.20, Medical Management (MM) Programs inthe Direct Care System (DCS) and Remote Areas( CD-ROM Resource MME-1, and http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf)defines MM as an “integrated managed care modelthat promotes Utilization Management (UM), CaseManagement (CM), and Disease Management (DM)programs as a hybrid approach to managing patientcare.” MM includes a shift to evidence-based,outcome-oriented programs that place “a greateremphasis on integrating clinical practice guidelinesinto the MM process, thereby holding the systemaccountable for patient outcomes” (DoDI 6025.20).This guide provides specific, how-to guidance onestablishing MM programs within Military TreatmentFacilities (MTFs) in accordance with the DoDinstruction.The three components of MM are commonlydefined as follows:• Utilization Management: An organization-wide,interdisciplinary approach to balancing cost,quality, and risk concerns in the provision ofpatient care. UM is an expansion of traditionalUtilization Review (UR) activities to encompassthe management of all available healthcareresources, including Referral Management (RM).• Case Management: A collaborative processunder the Population Health continuum thatassesses, plans, implements, coordinates,monitors, and evaluates options and servicesto meet an individual’s health needs throughcommunication and available resources topromote quality, cost-effective outcomes.• Disease Management: An organized effort toachieve desired health outcomes in populationswith prevalent, often chronic diseases forwhich care practices may be subject toconsiderable variation. DM programs useevidence-based interventions to direct patientcare. DM programs also equip the patient withinformation and a self-care plan to managehis/her own health and prevent complicationsthat may result from poor control of the diseaseprocess. The term “condition management”includes non-disease states (e.g., pregnancy).See also Appendix C, Definitions.

Page Medical Management EssentialsVersion 3.0Medical Management GuideBoth patients and MTF leadership have been drivingforces for more efficient, effective, and integratedMM programs in the following ways:• In today’s healthcare arena, patients are moreinformed and empowered consumers. Asa result, they demand more choice in theirhealthcare benefits than ever before.• MTF leadership strives to control risinghealthcare costs, demonstrate return oninvestment (ROI), and ensure that patients areprovided with safe, quality care. MTF leadershipis key to providing the organizational structure,appropriate resources, and necessary expertiseto ensure the success of any MM program.Primary Care Management Team Approachand continuity of care as well as serving as the pointof first contact when problems or questions arise.MM is an integral part of the PCM model and PCMHteam approach to patient care. Case managers assistthe PCM team in coordinating, communicating,and integrating care. Disease managers assist theteam in consistently implementing evidenced-based,clinical-based guidelines. Utilization managers assistthe team in the optimal allocation of scarce medicalresources within the medical home.The successful application of MM activities withinMTFs is geared toward achieving the primary targetgoals of improving access and quality, managingcost, and optimizing readiness.Primary care in the MHS revolves around the role ofthe Primary Care Manager (PCM) — this PCM modelis built on the documented value of patients, withconsistent access to comprehensive primary care,achieving better health outcomes, improved patientexperience, and more efficient use of resources. Inthis model, each patient has an ongoing relationshipwith a personal primary care provider trained toprovide continuous and comprehensive care.While the MHS primary care system is ultimatelysupervised and led by a PCM, the concept of a teamof healthcare professionals, under the leadershipof the credentialed provider team leader, is widelyaccepted and highly valued as a key component ofthe MHS culture. The PCM model in the MHS hasbeen expanded to include the concept of a Patient-Centered Medical Home (PCMH), as illustrated inFig. 1. In the PCMH, patients have a continuousrelationship with a medical home that offers stabilityIn addition to applying to the civilian-basedPurchased Care System (PCS), MM traverses theDirect Care System (DCS), which encompasses Army,Air Force, and Navy facilities in the North, South,and West regions of the United States; and overseasin the designated region Outside of the ContinentalUnited States (OCONUS). MTF staff work closelywith their Contracting Officer’s Representative/Contracting Officer’s Technical Representative (COR/COTR) to help ensure that MTF activities are closelycoordinated to meet patient needs. Fig. 2 depicts theMHS MM model.

Medical Management GuideVersion 3.0Medical Management EssentialsPage CONTINUOUS RELATIONSHIPPATIENT-CENTERED CAREAccess to Care• Improve phone and electronic apptscheduling• Open access for acute care• Emphasis on coordination of care• Proactive appointing for chronic andpreventive careAdvanced IT Systems• Secure mode of e-communication• Creation of educational portal• Reminders for preventive care• Easy, efficient tracking of populationdataDecision Support Tools• Evidence-Based Training• Integrated Clinical Guidelines• Decision Support Tools at the point ofcareTeam-BasedHealthcare Delivery• Creation of Clinical Micropractices• Appropriate utilization of medicalpersonnel• Improve communication among teammembersMilitaryMedicalHomePatient & PhysicianFeedback• Real-time data• Performance reporting• Patient feedback• Partnership between patients and careteams to improve care deliveryPopulationHealth• Emphasis on preventive care• Form basis of productivity measures• Evidence-based medicine at the pointof carePatient-Centered Care• Empower active patient participation• Seamless communications• Encourage patient participation inprocess improvementRefocused MedicalTraining• Emphasize health team leadership• Incorporate patient-centered care• Focus on quality indicators• Evidence-based practiceWHOLE PERSON ORIENTATIONPERSONAL PHYSICIANSFig. 1 – Military Patient Centered Medical Home ModelMilitary Health ServicesMedical Management ModelFig. 2 – MHS Medical Management Model

Page Medical Management EssentialsVersion 3.0Medical Management GuidePolicy Requirements for Medical Managementwithin the Direct Care SystemDoDI 6025.20 defines terms for MM, implementspolicies, assigns responsibilities, and specifiescontent for component activities within the MTF.It also codifies support for an interdependent MMsystem between the DCS and Purchased CareSystem (PCS). The instruction outlines the followingminimal requirements:Medical Management (General)• Designate one individual to be responsible forthe facility’s MM program.• Establish an integrated MM plan and programusing the quality improvement approach.Utilization Management• Use systematic, data-driven processes to a)proactively define referral patterns for focusedinterventions and b) identify and improve clinicaland business outcomes.• Incorporate UR activities using the same generallyaccepted standards and criteria for medicalnecessity, appropriateness, and reasonablenesswhen reviewing the quality, completeness, andadequacy of health care provided within theMTF.• Adhere to the established MTF review andappeal process.• Establish a referral and authorization managementprocess for internal and external referralsin accordance with MHS policies.• Establish a solid relationship with the ManagedCare Support Contractor (MCSC) — seeTRICARE and Other Benefit Programs,Working with Managed Care SupportContractors, later in this section.• Establish processes to monitor, manage, andoptimize access to care within the MTF (e.g.,to meet demand and access standards bymaximizing use of template management tools).• Encourage collaboration and communicationamong all MM staff, including clinical and businesspersonnel, to promote efficient, effective,and high-quality care and services.Case Management• Use CM to manage the health care of patientswith multiple, complex, chronic, and/orcatastrophic illnesses or known conditions thatmeet CM criteria.• Provide the appropriate level of care (e.g., carecoordination, discharge planning) for individualsrequiring special assistance (e.g., woundedwarriors).• Coordinate the transfer of information withMCSC CMs when patients require CM outsidethe DCS.• Encourage case managers to communicate withall members of the healthcare team, especiallywith other MM personnel.• Use CM to promote a seamless transition fromone duty station to the next for families enrolledin the Exceptional Family Member Program(EFMP) and Special Needs Identification andAssignment Coordination (SNIAC) programs,and who are also enrolled in a CM program.Disease Management• Assess the population to determine theneed for specific DM programs by evaluatingMTF Population Health data through variousinformation systems.

Page Medical Management EssentialsVersion 3.0Medical Management GuideThe MM approach in the health industry hasevolved rapidly in recent years. This evolution can beattributed to several factors, including:• The desire to increase the effectiveness ofpatient-provider relationships and improveclinical outcomes.• Greater demand to contain costs and improvereturn on investment (ROI) (i.e., to demonstratevalue).• The need to improve technology andcommunication to facilitate data collection,analysis, and information sharing (UtilizationReview Accreditation Commission [URAC],2005).• The need to fulfill regulatory and legislativemandates per the Code of Federal Regulations(CFR).MM policy and programs built from high-qualitydata collection, proper analysis, interpretation,dissemination, and outcome measurement ensurebetter clinical outcomes and improved quality ofcare for MHS beneficiaries. Cohen and Cesta (2001)cite three major types of outcome that are measuredin healthcare systems:• High-quality care – Measured by complications,readmission rates, morbidity and mortality, andpatient satisfaction. These quality measures(i.e., metrics) reflect greater accountability onthe part of healthcare providers to patients andother stakeholders.• Decreased or appropriate costs – Includemeasures such as length of hospital admission,avoidable admission days, decrease in EDvisits, and decrease in excessive utilizationof outpatient appointments. In military CM,appropriate costs are also measured by retainingcare in the DCS (i.e., MTFs) if the capability andcapacity exist. This outcome relates directly to aMTF’s business plan.• Improved health status — Often measuredthrough surveys that examine how a patientperceives the impact of health on quality of life.Other measures may include functional healthstatus, reduction or elimination of symptoms,resumption of employment, or improved copingmechanisms.It should be noted that many of the same resourcesused to calculate corporate outcome measures areavailable to MM teams at the MTF level. Further,healthcare teams should be apprised of and alignedwith other quality and outcome measure sets thatfall under the rubric of Quality Management (QM).One particular example is quality measures forperinatal care. MTF performance for obstetricalsurgery, complications, post-partum readmissions,and neonatal mortality rates is tracked using theNational Perinatal Information Center (NPIC) datasetfor comparison across both the MHS and civilianfacilities. Other sources for quality measures includethe National Surgical Quality Improvement Program(NSQIP) and the Anesthesia Report and MonitoringPanel (ARMP). Local QM representatives should beable to provide greater detail on which measuresand data sources are tracked at a specific MTF.(Section II, Utilization Management; SectionIII, Case Management; and Section IV, DiseaseManagement each offer detailed discussions ofoutcome measurement.)

Medical Management GuideVersion 3.0Medical Management EssentialsPage THE LINK BETWEEN MEDICALMANAGEMENT AND POPULATION HEALTHThe link between MM and Population Healthis an important one, with the trend in recentyears for organizations to incorporate totalPopulation Health techniques as part of their MMprograms. Four Population Health concepts specificto military medical care are:• Maintain a fit and healthy Active Dutypopulation (which affects readiness).• Improve the health status of the enrolledpopulation.• Improve the efficiency and effectiveness of theMTF healthcare delivery system.• Improve the military community populationhealth status.In order to incorporate Population Healthtechniques, MM and Population Health staff needto evaluate the current health practices of MTFenrollees and identify opportunities to improvethe health of that beneficiary population. The keyPopulation Health process elements listed belowrelate directly to MM:1. Population Identification and Assessment2. Demand Forecasting3. Demand Management4. Capacity Management5. Evidence-based Care and Prevention6. Program Evaluation and FeedbackFig. 3 illustrates the relationship between PopulationHealth elements and environmental influenceswithin the military community.Fig. 3 – MHS Population Health Model (2001)

Page Medical Management EssentialsVersion 3.0Medical Management GuideBecause many of the process steps are similar,Population Health and MM staff often collaborateon developing, reviewing, and meeting programgoals.For example:• UM activities focus on the four PopulationHealth principles of defining the population,applying epidemiological methods to describethe population and its risks, identifying andemploying evidence-based interventions, andmanaging information — all in the interest ofsupporting ongoing assessment, planning, andperformance monitoring/improvement.• Population-based CM coordinates care andservices for groups with similar characteristics.Case managers are responsible for “managinghealth, illness, prevention, and coordinationof care and services, including during acuteepisodes or hospitalization.” The casemanager’s role is to “develop and manage acomprehensive plan of care throughout thecontinuum in a way that takes advantage of allthe resources an integrated system has to offer”(Qudah, Brannon, 1998).• Population Health looks at the broaderpopulation in a larger context, while DM focuseson a particular segment of the population witha specific set of co-morbidities. DM activitiesare directly linked to population identification,evidence-based care and prevention, andprogram evaluation and feedback.Population Health Elements in ActionPopulation identification and assessment involvesstudying and understanding the population, whichmay consist entirely of beneficiaries within the MTFor represent a subset of that group. Regardless ofthe actual size of the population, you should be ableto identify sub-populations that may benefit fromspecific programs. Knowing your population allowsyou to extract information on age, gender, anddisease burden in the interest of planning healthcareservices that best meet beneficiary needs.Demand forecasting involves making an estimateof the volume of care required by a population orpopulation subset. This requires not only accuratedemographic and disease information, but alsopopulation-specific knowledge of healthcare needs,established clinical practice standards (chronicand preventive), and system- or Service-specificdemands (e.g., pre-deployment exams). Populationidentification and assessment activities allow MMstaff to anticipate, or “forecast,” the healthcareneeds of the relevant population or sub-population.Demand is typically measured by aspects suchas workload units by provider type, number ofspecific treatments, and pharmacy demand. Byunderstanding the demand forecast for an MTF,the healthcare team can determine staffing andbudgetary requirements and prioritize programs tosupport health promotion, prevention, and chroniccare services.Demand management involves proactiveintervention to reduce the rate of unnecessaryhealthcare resource utilization while encouraging

Medical Management GuideVersion 3.0Medical Management EssentialsPage patients to use healthcare resources appropriately.Related activities include:• Evaluating primary care manager (PCM)assignments to address the right patient mix forthe provider role and to generate even patientdistribution among providers.• Optimizing the activities of all healthcare teammembers during patient visits.• Utilizing functions such as nurse triage, groupappointments, etc.• Promoting the enrollment of beneficiaries toproviders at the MTF when sufficient MTFresources are available.• Educating beneficiaries about primary caretriage systems and self-care programs (e.g.,advice lines, Web-based materials).Capacity management involves matching the needsof the population served (as identified duringdemand forecasting) with the quantity and qualityof services available at the MTF. Related activitiesinclude:• Implementing proactive strategies to meetforecasted demand.• Managing clinical processes.• Clarifying staff roles and responsibilities.• Controlling leakage to the network.To accomplish these endeavors, it is important tooptimize the supply of healthcare resources to alignwith beneficiary needs or demand. This may include:• Identifying actions that will reduce excesshealthcare demand.• Improving processes to increase system“throughput” (amount of work completedwithin a given period of time).• Using evidence-based practices to perform theright actions at the right time.In terms of patient demand, the CapacityManagement element is affected by bothactual healthcare needs and military readinessrequirements. From the healthcare team perspective,it is affected by factors such as provider, supportstaff, and ancillary staff availability; physical space;equipment needs; and appointment processes.Evidence-based care and prevention involves using asystematically developed, research-based approachto health care. This approach increases the qualityof care delivered, reduces variation, and decreasescost. When evidence-based care is practiced,patients will typically experience an enhancedquality of life as a result of higher functional status,greater ability to self-manage, and less frequenthospitalizations. Evidence-based care is informedby research rather than provider consensus. It relieson an interdisciplinary team to manage care andprovide referral to health promotion and educationresources.Program evaluation and feedback rests on theassumption that Population Health programsand their respective outcomes (as with any otheraspect of health care) should be evaluated todetermine performance and progress. This elementincorporates a range of tools and programs to a)identify and address barriers to achieving desiredoutcomes, and b) make changes, as needed, toimprove healthcare delivery processes.

Page 10 Medical Management EssentialsVersion 3.0Medical Management GuideTRICARE AND OTHER BENEFIT PROGRAMSMTF Commanders are responsible for all healthcare provided or purchased within their catchment/market area. As such, they have direct control overappointment and referral services as well as overMM programs for their TRICARE Prime enrollees.The TRICARE healthcare program (http://tricare.mil) serves Active Duty Service members (ADSMs),National Guard and Reserve members, retirees,their families, survivors, and certain former spousesworldwide. TRICARE contracts augment MTFservices. Each MTF, Multi-Service Market Office(MSMO), and TRICARE Regional Office (TRO) mustwork with its regional contractor (see Workingwith Managed Care Support Contractors, laterin this section) to develop individual memoranda ofunderstanding (MOUs) that establish programs andactivities specific to that particular facility. Contractimplementation may vary based on how each facilityinterprets an MOU. For additional information onTRICARE, contact your local TRICARE Service Center(TSC) and/or Benefits Counseling and AssistanceCoordinator (BCAC).TRICARE offers special programs, including theExtended Care Health Option (ECHO), ContinuedHealth Care Benefits Program (CHCBP), andComputer/Electronic Accommodation Program(CAP). For more information, go to http://tricare.mil/mybenefit/home/overview/SpecialPrograms.Most beneficiaries will have TRICARE as theirprimary provider or payor. But MM staff, specificallyUM and CM personnel, also need to have a basicunderstanding of other programs beneficiaries maybe enrolled in, such as:• Medicare, Medicaid: http://www.cms.hhs.gov/• Supplemental Security Income (SSI):http://www.ssa.gov/ssi/• Social Security Disability Insurance (SSDI):http://www.ssa.gov/disability/• U.S. Family Health Plan: http://www.usfhp.com/• U.S. Department of Veterans Affairs (VA):http://www.va.gov/See Appendix C, Definitions; and Appendix D,Resources for more information.Working with Managed Care SupportContractorsThe United States are divided into three TRICAREregions. Each of the regions has a regionalcontractor that helps administer the TRICAREbenefit plan. This role is defined as the ManagedCare Support Contractor (MCSC). MCSCs provide avariety of functions, including:• Establishing TRICARE provider networks.• Operating TRICARE service centers.• Operating customer service call centers.• Providing administrative support, such asenrollment, care authorization, and claimsprocessing.• Communicating and distributing educationalinformation to beneficiaries and providers.MCSCs work with their TRO to manage the benefitat the local level, and receive overall guidance fromTMA headquarters (TRICARE Fact Sheets, TRICARERegional Contractors for the United States, 2006).(See also Appendix C, Definitions.)

Medical Management Guide Version 3.0Medical Management EssentialsPage 11The MHS necessitates close collaboration betweenMM staff located in the DCS, embodied by the MTF— an Active Duty setting; and the PCS, embodiedby the MCSC — in a civilian setting. Patientsbenefit when their healthcare services are smoothlycoordinated between the DCS and PCS. This “handoff,”or patient transition, is the act of transferringMM functions from one responsible entity toanother. Patients may frequently transition betweenthe MTF and the network, or between individualMTFs.By contract, the MCSC runs programs that managethe health care of individuals with high-costconditions or with specific diseases addressedby proven clinical management programs; thisresponsibility extends to providing MM servicesfor beneficiaries enrolled in ECHO. The MCSC alsoassumes responsibility for enrolled beneficiaries withcatastrophic, high-risk, high-cost situations whosecare occurs (or is projected to occur), in whole orin part, in the civilian sector. Program specificationsvary by region and are governed by specific MTFMOUs with the MCSC.THE LINK BETWEEN CLINICAL ANDBUSINESS OPERATIONSThe fundamental concepts in determiningappropriate MM measures within the MTFare a) integration with the Command’smeasures and b) alignment with the local MTF’sstrategic vision and business plan.Business planning “encompasses all strategic goalsand activities needed to ensure an organization’ssurvival and growth,” with the outcome of thebusiness planning cycle being “a consolidated MHSbusiness plan that serves as a primary input to theProspective Payment System (PPS).” In this regard,Tri-Service business plans provide “a commonframework across the MHS for improving andmeasuring performance” in the DCS (FY 2010-2012Navy Bureau of Medicine and Surgery [BUMED]Business Planning Supplemental Guidance,CD-ROM Resource MME-2).According to the DoD’s Defense Health Program(DHP) FY 2009 budget estimates, the DoD’s totalhealth costs more than doubled between 2001 and2006, from $19 billion to $38 billion — an increaserepresenting 8 percent of the DoD budget. Thisincrease was attributed to a combination of benefitenhancements, increased beneficiary use, stablecost shares, and high healthcare inflation. Thosecosts were projected through trend analysis to reach$64 billion, or 11.3 percent of the DoD budget, byFY 2015 (refer to CD-ROM Resource ES-2, DoDDefense Health Plan (DHP) 2009 Highlights).The business plan is the MTF’s roadmap for financialsuccess, but clinical operations, in collaborationwith Resource Management staff, are crucial indetermining that road map. It is therefore essentialfor clinical staff to actively engage in the businessplanning process. Their knowledge gives them theability to validate baseline historical data such asenrollment, outpatient/inpatient workload, and outpatient/inpatientutilization.The staff primarily involved in producing workload,documentation, and coding should be consultedwhen the MTF is determining a particulardepartment’s productivity targets or goals (e.g.,

Page 12 Medical Management EssentialsVersion 3.0Medical Management Guidenumber of relative value units [RVUs]). Clinicalprofessionals will also be involved in implementingsome of the critical initiatives identified within thebusiness plan, such as RM and evidence-basedhealth care (i.e., DM). (See also IntegratingUtilization, Case, and Disease ManagementFunctions; Staffing for Combined Functions,later in this section.)Eight critical initiatives frame business planning inthe MTF:1. Improve Access to Care2. Improve Provider Productivity3. Manage Referrals4. Labor Reporting (performed through theMedical Expense & Performance ReportingSystem, or MEPRS: http://www.meprs.info/— see also Section V, Medical ManagementTools)5. Improve Documented Value of Care (Coding)6. Evidence-based Health Care7. Manage Pharmacy Expenses8. Expeditionary Planning (Readiness)To help MTF Commanders execute their localbusiness plans, the MHS has established MM as partof both its clinical and business operations. Businessplanning offers the opportunity for annual strategicmanagement by creating a defined relationshipbetween current performance and the criticalrequirements needed to reach market goals. Asa new resource allocation methodology, businessplanning forecasts healthcare needs within the DCSand PCS with budgets focused on outputs ratherthan inputs. MM measures are calculated at variouslevels within the MHS, with a number of sourcesthat centrally calculate and display measures fromService-level aggregate to provider-level detail.(See Section V, Medical Management Tools,for information and resources related to Tri-Servicebusiness planning.)INTEGRATING UTILIZATION, CASE, ANDDISEASE MANAGEMENT FUNCTIONSIntegrating MM components not only improvesclinical outcomes; it improves organizationalefficiency and effectiveness. For example, whilemore CM and DM personnel are used to implementcomprehensive and integrated MM programs,staffing needs shift as fewer direct UM-relatedauthorizations are needed.Integrating UM, CM, and DM functions in the MTFfacilitates transitions of care and stewardship ofresources. The National Transitions of Care Coalition(http://www.ntocc.org/) advocates for and hasdeveloped tools to support transitioning patients.Historically, MTFs placed UM within their BusinessOperations or Resource Management department,while CM and DM were placed within the Nursingdepartment. This produced significant fragmentationof services, higher staffing requirements, andincreased costs. It also generated the view,particularly among providers, that the priority of UMstaff was to save money for the institution ratherthan to provide safe and quality health care topatients.Current trends focus on co-locating UM and CMresources to maximize and balance both clinicaland business outcomes. Fully integrating UM andCM staff has helped improve the overall quality of

Medical Management Guide Version 3.0Medical Management EssentialsPage 13care through a highly synergistic effect, with thefollowing results:• Significant decrease in the duplication of effortand redundancy.• Decrease in negative outcomes from improperor poor handoffs.• Improvement of overall workload management.• Improvement in the appropriate patient use ofbenefits.UM, CM, and DM have many similarities in termsof goals, concepts, and tasks. The key to successis establishing links of communication betweenprograms or departments. In this regard, it is helpfulto consider these three MM components within thecontext of a healthcare continuum as described inthe 2001 DoD Population Health Improvement Planand Guide (next iteration due to be published in2011). The Guide is available at http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf (see alsoExecutive Summary, CD-ROM ResourceES-1).Continuum is defined as an uninterrupted period,referring to the various stages of health andapplications of the CM process. It may be seenas running parallel to a "preventive model" thatmeasures cause and effect in MM interventions.This model comprises three phases, as describedin part by Wilson, Carneal, and Newman (2008)(see CD-ROM Resource MME-12 for fullarticle):• Primary prevention is about preventing theonset, or incidence, of disease (e.g., throughvaccinations).• Secondary prevention is about detection ofdisease.• Tertiary prevention is about the prevention offurther suffering among end-stage prevalentcases (e.g., through ameliorating pain andproviding psychosocial comfort).Based on this model, success (achievement ofoutcomes) can be understood in one of two ways:• Slowing, halting, or reversing advancementwithin the same phase.• Slowing, halting, or reversing transition to thenext phase.Fig. 4 illustrates how UM, CM, and DM functionsinteract within the MHS in the context of thePopulation Health continuum and in keeping withthe three levels of prevention.While the end goal is to integrate the componentsof MM, MTFs may first need to developtheir individual UM, CM, and DM programs. Fig. 5compares and contrasts each component.Some challenges may prevent successfulintegration. For example, each Service — from theheadquarters to the local MTF level — organizesits medical services and departments differently,using a variety of titles, terms, and personnelresources. Additionally, there continues to be alack of process standardization within the Servicesthemselves. Identification of poor clinical outcomesor other red flags (e.g., an inability to meet accessstandards, longer lengths of stay, or outliers ofany performance measure) may indicate system ororganizational issues rather than a clinical problem.

Page 14 Medical Management EssentialsVersion 3.0Medical Management GuideIntegrated Medical Management Model (IM3)The Integrated Medical Management (MM) Model (IM3) is a pictorial representation of the clinical approach topatient management (i.e., MM) along the healthcare continuum. The components of the model are as follows:• The curved arc depicts how MM falls within the spectrum of Population Health. The clinical activities ofUtilization Management (UM), Case Management (CM), and Disease Management (DM) are geared towardachieving healthy populations.• The vertical arrows indicate the integration of Population Health and MM functions.• The large horizontal arrow depicts the healthcare continuum, illustrating the correlation between health, risk,disease, and impairment states and their alignment with primary, secondary, and tertiary prevention efforts. Apatient may move anywhere along the healthcare continuum.• The red bar represents UM activities and functions along the entire healthcare continuum. UM functionsinclude collecting and analyzing data that assist CM and DM in identifying populations or individuals who maybenefit from services.• The green triangle highlights DM activities and functions. DM typically intervenes on the left side of thehealthcare continuum with populations who benefit from DM, using primary and secondary preventionactivities.• The blue triangle highlights CM activities and functions. CM typically intervenes on the right side of thehealthcare continuum with individuals who benefit from CM, using secondary and tertiary prevention activities.• The middle triangle is the area where clinical interventions may fall in both DM and CM. These are patientswho need assistance with care coordination but do not require either extensive DM or long-term CM services.• The purple bar indicates the MM requirement to link UM, CM, and DM activities to outcomes of readiness,quality, cost, and access. Outcomes are the foundation of MM activities in the Military Healthcare System(MHS).Source: 2001 DoD Population Health Improvement Plan and Guide (see Executive Summary, CD-ROM Resource ES-1)Fig. 4 – Integrated Medical Management Model (IM3)

Medical Management Guide Version 3.0Medical Management EssentialsPage 15Distinctions between UM, CM, and DMUtilization Management Case Management Disease ManagementCharacteristics of Target Population• Cost-based approach• Most expensive patients, providers, andprocedures• Patients who may not be at the appropriatelevel of care• Patients not medically authorized for hospitaladmission and specific procedures• Patients who underutilize or overutilizeservices• Tracks over/underutilization of services andcosts• Reviews provider prescription patterns forhigh-cost brand versus low-cost genericmedications• Evaluates compliance with CPG requirementsor Drug Utilization Evaluations (DUEs) withinthe MTF• Individual approach• At high-risk for costly, adverse medicalevents and poor health outcomes• Medically, socially, and/or financiallyvulnerableMethods for Identifying PatientsAnalysis of Encounter or Claims Data• Searches for patients with patterns ofrepeated hospitalizations or ED visitsAnalysis of Pharmacy Data• Reviews medication profiles for variousindividuals or populations (medicationmisuse, elder non-adherence)Referrals• Population-based approach• Diagnosed with specific disease orcondition• Searches for patients with selectedICD-9 diagnosis codes• Searches for prescriptionscommonly used for specificdiseases (i.e., Albuterol forasthmatics)• Aggregate data in terms of practice patternsfor referrals• Prospective review of referrals• Referrals meet Severity of Illness and Intensityof Service criteria (InterQual ® )• Identifies patients in need of more intensiveinterventions whose length of stay might belong and resource utilization high• Provides opportunity to coordinate with casemanagement• Tracks appropriateness of care• Providers who identify patients as “highrisk” or “vulnerable”• Self/family referrals• Specific beneficiary screening criteriaPreadmission/Concurrent Review• Identifies expensive, complex cases (redflags) prior to/during admission• Identifies organizational processes thatneed to be streamlined to better addresspatient needs and increase efficiencyPatient Education• Providers who identify patientswith a particular diagnosis orcondition• Identifies patients with specificdiseases/conditions who couldbenefit from an outpatientdisease management program formonitoring and reinforcement ofpatient/family education• Generally no formal education; however,patients should be informed of the differentlevels of care and the appeal process• Providers are educated on recurring initiativesand roles in process improvement• Not applicable (uses InterQual ® and MillimanAmbulatory Care Guidelines TM criteria, whichare based on best practices during utilizationreviews)• Moving toward better use of information inclinical practices, identification of needs andreferrals to targeted support services; andgreater use and more consistent delivery ofevidence-based practices• Generally no classes developed by theprogram itself, although may refer toexternal classes• Generally no standardized curriculum• Generally no standardized educationalmaterials; individual-specificRelative Reliance on National, Evidence-based, Disease-specific Guidelines• ModerateRelative Reliance on Protocols and Standardization• Moving toward better use of informationin clinical practices (i.e., critical pathways),identification of needs and referrals totargeted support services; and greater useand more consistent delivery of evidencebasedpractices• Program may have developed itsown classes• Standard curriculum• Standardized educational materials• Tailored to individual situation• Extremely high• HighSource: Chen, A., et al., (2001, March). Best Practices in Coordinated Care. Mathematica Policy Research Institute, Inc.Fig. 5 – Distinctions between UM, CM, and DM

Page 16 Medical Management EssentialsVersion 3.0Medical Management GuideMTF-specific circumstances will dictate whetherdistinct, standalone programs or integrated MMprocesses are required. Large MTFs may choose tohave individualized UM, CM, and DM programs.In such cases, effective communication can beaccomplished through regular face-to-face meetings(e.g., patient care conferences, individual meetings,e-mail, MM team meetings, Population HealthWorking Group, teleconferencing). In smaller MTFs,there may be staffing limitations that mean one ortwo staff members are responsible for several MMcomponents.When developing an integrated MM program,network with your peers at other similar-sizedfacilities to partner and share information. Thisconsultation process should be expanded to includesister Services and civilian organizations (e.g., URAC,CMSA, hospitals).Staffing for Combined Functions• Performance indicators must be set inconsideration of the complexity of patient careneeds.• Performance monitoring should be an ongoingprocess between clinical and administrativepersonnel.• The staffing plan should be updated periodicallybased on changing patient care needs.An organization’s position descriptions, missionand vision, and business plan can help in thedevelopment of objectives for utilization managers,case managers, and disease managers. Thoseobjectives provide a basis for constructing corecompetency and performance assessments for eachposition. Objectives and competencies should evolveas roles evolve. New employees should completea competency self-assessment at the beginning oftheir orientation programs. The director can thenindividualize orientation and training to their specificneeds.Although the composition, organization, mission,etc. of each MTF varies greatly, general staffingguidelines should be followed. According toa 2003 Air Force study, Access to Care (FirstConsulting Group), healthcare organizations shouldestablish the right staffing mix based on specificcriteria to address the quantity and complexity ofbeneficiaries’ needs. The study made the followingrecommendations:• A written staffing plan should be developedwith clearly defined roles and responsibilities.• Leadership should analyze actual staffing patterns,program requirements, and findingsfrom quality improvement and benchmarkingactivities and apply that analysis to staffingdecisions.When integrating a UM, CM, or DM role into anMM program, MTF leadership should review theoverall program and assess the effectiveness ofeach aspect of the program. Occasionally, troubleareas may arise that hinder the ability of staff tofocus on their primary responsibilities. Such areasinclude job overload, roles with a limited sphere ofinfluence, responsibility for multiple roles or extraduties, and unclear priorities. Ensure that staff haverole clarification in addition to the skills, equipment,mentoring, and support to be successful in theirpositions.MTFs located OCONUS face additional challengesin staffing MM. Typically, overseas regions offer farfewer candidates with the requisite expertise to be

Medical Management Guide Version 3.0Medical Management EssentialsPage 17successful in MM activities than are available in theUnited States. This may force MTFs to make thecritical decision of leaving positions empty; or ofhiring inexperienced staff and training them, withthe knowledge that these staff are likely to remainin the position for two to three years at most.(See Section III, Case Management, for moreinformation on OCONUS considerations.)MTFs need to promote close collaboration amongall MM staff and encourage them to communicatewith other MTF departments or personnel, such as:• The local TRICARE Service Center Coding andcoding auditing departments.• Information Management (IM)/InformationTechnology (IT).• Patient Administration.• Population Health Resource Management.• Quality/Risk Management — MM programmeasures may align with those obtainedas part of an MTF’s quality program — forexample, benchmarking against HealthcareEffectiveness Data and Information Set (HEDIS ® )measures. HEDIS ® is a tool used by more thanQuestions to Consider When Creating an Integrated MM Program• What are our objectives?• What are our short- and long-term goals?• What are the health needs of our population?• What are our current UM, CM, and DM resources? Who are our experts in those areas?• How should we integrate MM roles?• How do we facilitate inter-organizational integration? What are the advantages to our MTF? Which stakeholdersshould be involved in this effort?• Which roles are responsible for making which specific decisions to move a patient efficiently and cost-effectivelythrough the system?• How do we promote standardization of UM, CM, and DM processes among team members?• How do we maintain or restructure individual titles and scopes of work?• How do we currently handle referrals?• How do our nurse reviewers alert CM staff that a patient needs evaluation for CM?• What are the DRG procedures for our patient population?• Which ICD-9, DRG, and current procedural terminology (CPT) codes do we use most frequently for inpatient andoutpatient visits?• Which processes can we automate to expedite tasks and reduce administrative costs?• Which continuum of care, patient safety, discharge planning, or other regulations apply? Which roles are responsiblefor ensuring that specific regulations are followed?• Which types of information from external systems would be useful for our MM functions? Who has access to thatinformation?• Which mode of information sharing will increase our effectiveness? How can we facilitate it?• Which tools do we currently have in place to standardize processes, measure outcomes, maintain reports, anddocument variances?• Where do we report MM data?• Which staff members have the authority to make changes regarding reported MM data?Fig. 6 – Questions to Consider when Creating an Integrated MM Program

Page 18 Medical Management EssentialsVersion 3.0Medical Management Guide90 percent of America's health plans to measureperformance on important dimensions ofcare and service. To view the current HEDIS ®measures, go to http://www.ncqa.org/. (See alsoSection IV, Disease Management.)• Relevant MSMO.• Relevant TRO.• MCSCs — Contractually, MCSCs are responsiblefor different aspects of MM within their region.Depending on the local memorandum ofunderstanding (MOU) between an MCSC andMTF, the MCSC may have additional processesor activities in place to support patient careactivities.• Medical staff (e.g., Medical Director).• Nursing staff (inpatient and ambulatory).• Decision support (e.g., data analysis) staff.Successfully integrating UM, CM, and DM functionsrequires careful strategic planning and effectiveresource allocation. Even if integration plansare included during development of the overallMM plan, MM staff need to consider some keyquestions, as shown in Fig. 6.ESSENTIAL CONSIDERATIONS FORMEDICAL MANAGEMENT STAFFBenefitting from Information TechnologyInformation technology (IT) is the approach ofprocessing and disseminating data through theuse of computers or other electronic devices and“virtual” communication tools (e.g., the Internet).Some healthcare facilities still rely largely on apaper-based system to collect, store, retrieve, anddisseminate data. However, IT is the preferredmethod in today’s healthcare arena, where quickaccess to usable, reliable information is critical foreffective decision-making.The MHS Population Health Portal (MHS Portal,or MHSPHP) is an excellent resource for tools andtemplates related to MM activities within the MTF.The Portal demonstrates the benefit of applyingadvanced technology across the enterprise,allowing for information-sharing by multiple userswithin Army, Air Force, and Navy MTFs. For moreinformation, see Section V, Medical ManagementTools.“With healthcare costs once again rising significantlyfaster than inflation, though for different reasonsthan existed two decades ago, pressure is beingplaced once again on the entire healthcare industry,including health plans, to identify ways to be moreproactive in managing the health of individuals.Medical management and predictive modeling arekey components of this effort” (Kongstvedt, 2007).Predictive modeling is “a set of tools used to stratifya population according to its risk of nearly anyoutcome … ideally, patients are risk-stratified toidentify opportunities for intervention before theoccurrence of adverse outcomes that results inincreased medical costs” (Cousins, et. al., 2002). Fora broader perspective on predictive modeling, referto CD-ROM Resources MME-2 and MME-3.Effective utilization of IT resources and systemsenhances the ability of MM staff to meet the goalsof the patient, the MM department, and the MTF.“The information system is a purposefully designedsystem that brings people, data, information, and

Medical Management Guide Version 3.0Medical Management EssentialsPage 19procedures together for the purpose of managinginformation to support operations, management,and decision functions important to an individual,team, or organization” (Powell and Tahan, 2008).IT can be used in innumerable ways within the MMarena, as demonstrated in the examples below.UM staff can use IT systems to:• Identify variations in provider practice patterns.• Identify clinics within the DCS with access-tocareissues.• Review and track referrals for network care.• Analyze patient patterns of use within the MTF.CM and DM staff can use IT systems to:• Identify patients who may benefit from theirservices.• Manage voluminous information about theirpatients.• Document care and services.• Analyze, track, and provide outcome reports.As Powell and Tahan discuss in their book, the CaseManagement Society of America’s Core Curriculumfor Case Management, a well-designed IT systemshould:a. Enable data to be viewed in several places byseveral people at the same time in a format thatis understandable.b. Ensure appropriate information security ismaintained at all times.c. Communicate with other systems in real time ornear-real time.d. Provide users with the ability to filter outunnecessary information.e. Act as a central repository for patient andpopulation levels of data.f. Generate user-specific reports enabling users toevaluate outcomes.g. Standardize terminology, documentationpractices, and reporting functions.Despite significant benefits associated with ITimplementation, MM staff should be aware of itslimitations, including:• Lack of interconnectivity across several differentsystems, which can result in fragmentation ofcare and services.• Information security practices that can hindertimely and consistent access to information.• Non-standard IT terminology, which canfrustrate communications between healthcareteam members managing patient information.• The absence of an intuitive ability to makepatient care decisions when something “justdoesn’t feel right.”Privacy and Confidentiality of PatientInformationRecords, documents, and data generated in thecourse of MM may contain information subjectto the Privacy Act, Medical Quality Assuranceprotection, and/or regulations under the HealthInsurance Portability and Accountability Act (HIPAA),Title 45, CFR Parts 160 and 164 (see Appendix C,Definitions). HIPAA addresses the use, disclosure,and security of protected health information (PHI).MM staff should complete HIPAA training, becomefamiliar with HIPAA rules, and contact their localPrivacy Officer for further guidance. (See alsoSection V, Medical Management Tools; Toolsfor Utilization, Case, and Disease ManagementCollaboration; Protected Health InformationManagement Tool.)

Page 20 Medical Management EssentialsVersion 3.0Medical Management GuidePROGRAM SUSTAINMENTProgram sustainment is a frequentlyoverlooked step that should begin uponinitiation of new programs. It is important forthe MM plan to match the needs of the organizationand its primary stakeholders. In the MTF, providerstransfer and deploy. This means new providersare always entering the system, along with newbeneficiaries. It is therefore crucial to continuouslypromote your services to healthcare team members,patients, and families; and to educate them on howto refer.Leadership and organizational culture are key factorsin effective program sustainment. With this in mind,the MM plan should:• Develop a leadership strategy to gain and maintainsupport at all levels of the organization.• Clearly describe the benefits of the program andregularly report on its progress to stakeholders.• Include feedback from patients, providers, andother healthcare team members.• Build a seamless organizational culture byintegrating MM with other MTF programs.• Make sure MM program data are communicatedas feedback to clinical and executive staff.o Providers must be actively engaged as keymembers of the MM team.o Practice patterns must change to meetthe goal of clinical and financial outcomesimprovement.An important sustainment strategy is to promote theMM program through marketing. Marketing involvesplanning and executing the conception, promotion,and distribution of services that satisfy individualand organizational objectives.To develop a successful marketing strategy, you mustfirst define the services your department has to offer.Ask questions such as the following: Do we currentlyhave MM services? If working in an inpatient facility,does that facility require discharge planning?The next step is to determine the target audience.Do you market only to your healthcare providers ordo you allow patients and their families to self-refer?Understanding your organization’s mission will helpyou develop your plan. Where does the organizationneed you to focus your services? On patients withhigh utilization? On wounded, ill, and injured Servicemembers? On patients with complex needs? OnADSMs, family members, or retirees? Who is usingmost of the organization’s resources?After developing the plan, it is time to promoteyour services. Suggestion: Develop brochures forproviders and for patients, for the different servicesyou offer, or for all services ( CD-ROM ResourceMME-4 provides a sample MM marketingbrochure; see also Section III, Case Management,CD-ROM Resource CM-23). It may be useful todevelop a simple reference pocket card for providersfeaturing trigger diagnoses for referral, screeningcriteria, how to refer, and a phone number to callwith questions.Other methods for promoting your services include:• Speaking at professional staff meetings.• Communicating with your organization’sleadership.• Advertising in the clinic or hospital newsletter.

Medical Management Guide Version 3.0Medical Management EssentialsPage 21Explain the benefits of using your services to theprovider, patient, and family. The initial challenge isto gain exposure.SUMMARYTo successfully implement MM in the MTF,MM staff should incorporate PopulationHealth principles and integrate evidencebased,business, and Resource Managementpractices. More specifically, MM program designshould reflect the integration of UM, CM, and DMfunctions to optimize patient outcomes. Leadershipsupport, active provider engagement, appropriateresource allocation, and inter/intradepartmentalcommunication all play a role in sustaining aneffective MM program.CD-ROM RESOURCESMME-1MME-2MME-3MME-4Department of Defense Instruction(DoDI) 6025.20, Medical ManagementPrograms in the Direct Care System (DCS)and Remote Areas (2006)Article: Meek, Julie A., DNS.:Predictive Modeling and Proactive CareManagement, Part I – Lippincott’s CaseManagement (July/August 2003)Article: Meek, Julie A., DNS.: IncreasingReturn on Investment Potential in CareManagement, Predictive Modeling andProactive Care Management, Part II –Lippincott’s Case Management(September/October 2003)Sample Medical Management MarketingBrochure – Air ForceMME-5* HA Policy Memo on Implementation forProspective Payment Systems (2004)MME-6* HA Policy on Right of First Refusal (2005)MME-7* HA Policy for Active Duty ServiceMember Enrollment to TRICARE Prime(2005)MME-8* HA Policy on Short-term Solutionsfor the Enterprise-wide Referral andAuthorization System (2005)MME-9* HA Interim Policy for MedicalManagementMME-10* Article: Despite Barriers, MCOs IntegrateCase, Disease, Utilization ManagementFunctions – Managed Care Week (March14, 2005)MME-11* Article: Mullahy, C. M. The EffectiveIntegration of Utilization and CaseManagement –The Case Manager (TCM)(March/April 2000)MME-12 Article: Wilson, Carneal, and Newman,Documenting Case ManagementOutcomes: Advancing The Science WhilePreserving The Art –Case In Point (CIP)(February/March, 2008)*Not referenced in text‘

Medical Management GuideVersion 3.0Utilization ManagementPage 25Utilization ManagementSECTIONIIINTRODUCTIONEffective Utilization Management (UM) is akey process within Medical Management(MM) for improving the quality of health careand ensuring the cost effectiveness of healthcareservices. UM relates to all components of ahealthcare delivery system, including care within theprimary, specialty, and inpatient settings.This section discusses the concept of UM and howto develop an effective UM program within theDirect Care System (DCS). It describes a seven-stepprocess for quality improvement and includesinformation on Utilization Review (UR), decisionsupport tools, Referral Management (RM), and thegrievance and appeal process. This section also coversthe role and necessary qualifications of today’s UMprofessional.Fig. 7 illustrates the focus of UM activities throughoutthe various stages of the healthcare continuum.Specifically, as the focus of healthcare delivery movesalong the Population Health continuum from primarythrough tertiary prevention, UM helps guide thequality and cost effectiveness of healthcare services.Fig. 7 – Utilization Management within the MHS Integrated MM Model (IM3)*See also Section I, Medical Management Essentials: Fig. 4, Integrated Medical Management Model (IM3) with Key info, page 14.

Page 26Utilization Management Version 3.0Medical Management GuideAs discussed in Section I, Medical ManagementEssentials, the recent trend in MM has been toreplace traditional approaches with more carecoordination activities based on an integrated MMmodel.Definition, Goals, and PurposeUM is a methodology that addresses the issueof managing the use of resources in the deliveryof health care, while also measuring the qualityassociated with the delivery of that care (McKesson,2009).UM is an organization-wide, interdisciplinaryapproach to balancing quality, risk, and costconcerns in the provision of patient care. It isthe process of evaluating the medical necessity,appropriateness, and efficiency of healthcareservices. “Utilization review takes a retrospectiveview of cases, while UM describes proactiveprocedures and processes” (Freedman, 2006). UR isthe process of determining whether all aspects of apatient’s care, at every level, are medically necessaryand appropriately delivered (McKesson, 2009).In addition, UR in the private sector includesmany of the following activities: pre-certificationreview, admission review, continued stay review,retrospective review, discharge planning, bill review,and individual medical Case Management (CM).The ultimate goal of UM is to maintain the qualityand efficiency of healthcare delivery by:• Providing patients with the appropriate level ofcare.• Coordinating healthcare benefits.• Promoting the least costly, most effectivetreatment benefit.• Determining the presence of medical necessity(see Appendix C, Definitions).The purpose of UM within the Military TreatmentFacility (MTF) is to identify, monitor, evaluate, andresolve issues that may result in inefficient healthcaredelivery or that may have an impact on resourcesand services.UTILIZATION MANAGEMENT COMPONENTSAs with CM and Disease Management(DM), the role of UM in the MTF is partof a progressively integrated approachthat emphasizes the importance of facilitatingenvironments, treatments, and procedures thatgenerate opportunities for improved clinicaloutcomes and/or cost avoidance.In the practice of UM, such facilitation isaccomplished through the regular application ofUM monitoring — a form of data analysis. The UMmonitoring process provides MTFs with a “warningsystem” that can help identify at-risk patients at theearliest opportunity for intervention, such as duringthe preadmission and concurrent review processes.For example, patients with specific diseases/conditions scheduled for admission to the hospitalcan be identified and referred as potential candidatesfor CM or DM services. These patients may requireproactive discharge planning to help address theirpost-hospitalization needs.Appropriate data analysis and reporting providesUM personnel with a foundation for improving

Medical Management GuideVersion 3.0Utilization ManagementPage 27performance and developing a sound programthrough an action plan. Effective data analysiscan reveal obstacles to implementing the actionplan. This helps decision-makers refine that planand establish new priorities for the next cycle ofperformance improvement.The Seven-Step Quality Improvement ProcessA key element of any UM program is to follow aquality improvement (QI) process. A seven-stepprocess is used here (see Fig. 8), based on QIactivities recommended by the 2008 AccreditationAssociation for Ambulatory Health Care Handbook(for more information, go to http://www.aaahc.org/).As shown in Fig. 8, in the “ideal” process (numbers1 through 7) the seven steps progress in a linearmanner. However, in practice the process allows forflexibility and may not always begin at Step 1. Forexample — as shown in letters a, b, and c in thefigure — after attempting to fix a problem, you mayneed to adjust what you are measuring then redeterminethe gaps before continuing forward.This seven-step QI process is just one of manydifferent models that can be used to develop aUM program. MTFs can choose any model (suchas FOCUS PDCA or Lean Six Sigma), as long asthe approach offers a systematic, step-by-steptechnique. Using a template based on a sevenstepQI process, a UM plan would consist of threecolumns or sections for UM, CM, and DM. ( CD-ROM Resource UM-1 provides a UM plan templatebased on a seven-step QI process, which can becustomized for MTF use. CD-ROM ResourceUM-2 provides a completed example.)The seven steps for establishing a UM action planare listed below in sequential order based onstandard expectations as data becomes available.7Learn from the QualityImprovement Process6Make Additional Attemptsto Fix the Problem(s)5Determine the Effectivenessof the Corrective Action4Attempt to Fix the Problem(s)3Determine theGapsb2Determine Whatto Measureca1Identify the PurposeFig. 8 – Seven-Step Quality Improvement Process

Page 28Utilization Management Version 3.0Medical Management Guide1. Identify the PurposeStep 1 is to identify priorities for focus andexamination. Priorities evolve from utilization data,suspected problem areas, MTF strategic goals,Command initiatives, and directives from an MTF’sService Branch and/or other higher authority. Whendefining priorities, UM staff should solicit input fromall departments/services within their MTF.2. Determine What to Measurewhen the patient has been prescribed sevenor eight concurrent medications), unexpectedadmissions, or death following ambulatorysurgery.Utilization measures facilitate the MTF’s ability to:• Identify Service Branch-specific areas for focusedUR.• Develop reports that display the applicable dataelements for study.• “Drill down” for patterns of care.Step 2 is to select measures (i.e., metrics) and collectdata relevant to the MTF — this despite the fact thatthere is no higher-level mandate to obtain a specificset of measures.Utilization managers should select measures andcollect data based on priorities. Typically, thesemeasures relate to:• High-cost, high-volume, or “problem-prone”diagnoses, procedures, and services.• Patients who have demonstrated high utilizationrates.The definition of what constitutes a problem-pronesituation varies by setting. For example:• Inpatient services — Refers to diagnosesincluding those related to high mortality, highmorbidity, prolonged length of stay (LOS), highreadmission rates, and preventable admissions.• Ambulatory services — Includes multiplevisits for the same condition across varioussettings (e.g., primary care clinic, EmergencyDepartment [ED], specialty care) or with multipleproviders. Also includes polypharmacy (e.g.,A data query can either focus on a particular,identified problem or issue (e.g., number of ED visitsin the MTF and network during the past year forall Active Duty Service members [ADSMs]); or beexpanded to include a broad range of data elements(e.g., all inpatient and outpatient visits for the pastyear for all patient categories) that might helpidentify potential trends or patterns of care that givecause for concern. (See also Section V, MedicalManagement Tools.)If the data include a general range of elements, it isbest to sort those data into categories to distinguishwhere problems may lie. For example, one table orreport may list high-cost, high-volume, or problempronediagnoses and procedures for patients withdemonstrated high-cost, high-volume, or highlycomplex utilization patterns (i.e., “high utilizers”).Your data must make sense to the people who arereceiving the information and be considered valid(Hospital Peer Review, 2008).Categories are used to present data clearly. Theydo not imply that ambulatory care facilities shouldstudy only outpatient data; an ambulatory care

Medical Management GuideVersion 3.0Utilization ManagementPage 29facility might evaluate inpatient admissions to thePurchased Care System (PCS) to identify opportunitiesfor cost savings or coordination of care.UM staff should remember that they are not alwaysexpected to perform the role of data miner. Rather,they need to identify who has access to data (e.g.,M2 users, data analysts, decision support staff) andpartner with them by asking what is really going toaffect patient care, who needs to be involved, andhow to make the process a priority for decisionmakers(Hospital Peer Review, 2008).3. Determine the Gapsand tertiary preventive interventions (seeSection I, Medical Management Essentialsand Appendix C, Definitions). This can helpUM staff identify and refer patients who mightbenefit from specific management strategies,such as CM or DM. When evaluating data relatedto a particular occurrence, priorities will varyfrom facility to facility. Staff in a smaller MTFmay elect to focus on their five most frequentlyperformed procedures, while staff in a larger MTFmight study their 10 or even 15 most frequentlyperformed procedures. Alternatively, MTF staffmight focus on the most problematic or prevalentdiagnoses rather than the most frequent.Step 3 is to determine the gaps, if any, betweenactual and desired conditions. Identify:• Any red flags or undesirable trends andvariations from internal/external benchmarksand comparative data.• Other potential areas for process improvement.When comparing MTF performance to nationalbenchmarks, you must take into account differencesbetween the MHS and the civilian health system(notably the unique MHS benefit, funding structure,military mission, diverse healthcare environments,and population distribution). You must also considerrisk adjustment and severity of illness (i.e., througha case mix index) when comparing an MTF to acivilian facility or comparing one MTF to another.4. Attempt to Fix the Problem(s)Step 4 is to attempt to fix the problem(s) byprioritizing opportunities for improvement based onthe MTF’s strategic goals, population needs, qualityinitiatives, and patient safety considerations. Hereit is important to focus on areas with the greatestcost-to-benefit ratio and the highest probabilityfor success. When evaluating which processes toimprove, be sure to consider whether or not theapplicable measures are reliable and valid. Whenreviewing those measures, consider where you canrealize improvements within the data systems ordata collection and reporting processes to ensuredata accuracy and reliability, which, in turn, affectsdecision-making.By drilling down further, MTF staff can identifyhigh-volume diagnoses, procedures, and services;and individual patients with high utilization rates.They can then define significant trends anddetermine where to focus primary, secondary,Formulate an action plan and attempt to fix theproblem, which involves selecting appropriatestrategies to address each priority stated in the UMprogram. This plan should include milestones anddelineate individuals or departments responsible formeeting those milestones.

Page 30Utilization Management Version 3.0Medical Management GuideUM strategies may include a wide range ofinterventions to:• Target gaps in healthcare delivery.• Enhance performance and quality of care.• Assist in managing resources and improving thehealth of patients.• Refer patients who might benefit from otherprograms, such as CM and DM.How you determine the most appropriate typeof intervention will depend on the needs of thepopulation; the MTF’s capabilities, resources, andgoals; and available metric data. Consider incorporatingvarious UM strategies as well as otherMTF programs (e.g., Population Health, InformationManagement, or Resource Management) into theaction plan.Implement the action plan by performing theinterventions identified. Staff members responsiblefor implementing parts of the plan must:• Document their actions and any issues,obstacles, lessons learned, etc. Thisdocumentation will serve as formal feedback forfuture reference and help establish continuity inprocess improvement.• Report that information to the appropriatesupervisor.5. Determine the Effectiveness of theCorrective ActionStep 5 is the crucial step of determining howeffective you have been in implementing a correctiveaction. This step includes refreshing data elementsat consistent and regular intervals. It is essential toevaluate the impact of the actions taken so you candetermine whether the UM program was successful.Compare the action(s) taken to the outcome goalsand measures. Were there other unknown or newfactors that allowed for successful implementation?If the desired result or outcome was not achieved,then refine, adjust, or re-implement the strategiesand re-measure after an appropriate interval. Repeatthis step until the desired outcome is achievedwithout undesirable or unintended consequences.6. Make Additional Attempts to Fix theProblem(s)Step 6 is to continue to address any outstandingissues by periodically monitoring the measures.This will help you sustain any change or processimprovement through successive generations ofstaff and/or organizational structure, once you haveachieved desired outcomes.7. Learn from the Quality Improvement ProcessStep 7 is to ensure you have learned from the QIactivity by evaluating outcomes. This step helps youdetermine whether you have achieved your goalsand makes it easier to update the UM program, ifneeded. If goals have not been achieved, identifyimpediments (e.g., limited resources, poor training,ineffective communication). Discuss and validatefindings, formulate with the process owners aplan to address those findings, and communicatethe results of that evaluation to the involveddepartments and MTF leadership through theappropriate channels.When updating the UM plan, make sure it continuesto reflect current goals and mission needs. If

Medical Management GuideVersion 3.0Utilization ManagementPage 31applicable, redefine UM priorities and begin anew performance improvement cycle. Considerincorporating the strategy that resulted in successfuloutcomes into a written MTF policy that formallyincorporates prolonged sustainment of thoseimprovements as “routine business.”Review criteria may be employed as a screening toolduring the first level of UR when:a) The purpose is to manage resource utilization.b) There is a potential to deny payment for servicesthat are not medically necessary or that do notrepresent the most appropriate level of care.This QI process format is not mandatory. MTF staffmay use whichever format best meets their needs,but they should include all of the steps described inthe QI process when conducting UM. The range ofgoals and priorities will vary by MTF.As noted in Step 2, while MM staff are not alwaysrequired to act as data miners themselves, they areresponsible for assisting data analysts by identifyingissues, asking appropriate questions, and selectingthe relevant data elements when querying variousdata marts.Utilization ReviewUtilization Review (UR) as a component of UM isintegral to the success of both the MTF’s MM andbusiness plans. UR is the process of determiningwhether all aspects of a patient’s care, at everylevel, are medically necessary and appropriatelydelivered (McKesson, 2009). It is systematic becausethere is a prescribed sequence in applying thecriteria and in further reviewing the case if criteriaare not met. It is criteria-based because factorsbased on sound clinical principles and processes areapplied objectively in the first step of the evaluationprocess.Care is never denied for failure to meet criteria.Failure to meet criteria is only an alert that the caserequires further examination by a physician or otherqualified second-level reviewer.UM staff perform UR to ensure patients receive theright care, at the right time, in the right place, withthe right provider, and at the right cost. Withoutproper UR, the cost of health care, particularlyspecialty care referred inappropriately to the PCS,will spiral out of control. There is an absolutecorrelation between specialty care referrals (e.g.,RM) and business planning processes. (See alsoSection I, Medical Management Essentials,and Section V, Medical Management Tools,for more information on business planning andbusiness plans.)All healthcare services for which payment is soughtshould undergo review for appropriateness ofutilization. UM staff should work with business orpatient administrative personnel to set up a processin which third-party (insurance) payors are givenpriority consideration. For example, third-partypayors may require completed prospective reviewsfrom the MTF for surgery (e.g., hysterectomy, gastricbypass) before they will provide authorization andreimbursement for a surgical procedure performedwithin the MTF.

Page 32Utilization Management Version 3.0Medical Management GuideUM staff can also apply review criteria to assist theMTF in identifying areas for improvement within thesystem. For example:• If a group of admissions are reviewedretrospectively using McKesson ® InterQual ®evidence-based decision support criteria and alarge number do not meet admission criteria,further investigation is warranted to determineand resolve the underlying cause.• If a group of cases referred for specialty caredoes not meet Milliman Care Guidelines ® , atraining issue may exist indicating the need foradditional clinical education.In both instances cited above, the criteria orguidelines have been used to reveal potential areasfor improvement, but the admissions and referralswere not denied. (For more information, seeOutcome Measurement and Management, laterin this section.)Types of ReviewThe procedures for UR may be:• Prospective (before care is provided—preadmission)• Concurrent (while care is in process— hospitalization)• Retrospective (after care has been provided— discharge)Prospective review is designed to evaluate proposedtreatment, determine medical necessity, and assessthe appropriate level of care prior to the deliveryof services. When performing reviews, referralsto CM or DM target early intervention to improveoutcomes. Formal prospective review determinationsrequire timely attention. Prospective reviews are onlyvalid for 30 days. If treatment was authorized butnot initiated within the window, the review shouldbe repeated.The MTF’s plan for UR may include more focusedreviews in which it identifies a list of healthcareservices for which preauthorization and concurrentreview may be required. It is neither necessary norcost effective to perform a 100 percent review of allreferrals for medical necessity. Criteria for UR mayinclude, but are not limited to, services defined byany of the following characteristics:• Costly• Known to pose potential medical risks formembers• Known to produce variable outcomes• New or investigational• Often performed for cosmetic reasons• Overutilized• Utilized differently by various providersConcurrent review is designed to evaluate carewhile it is occurring to validate medical necessity,appropriateness, and quality of care. The revieweralso looks for delays in service or complications,assesses if tests are appropriate, or evaluates thestatus of discharge planning.Inpatient concurrent review consists of twocomponents:• Admission review is conducted within 24 hoursof admission or on the next business day toverify the appropriateness and medical necessityof the hospitalization. Documentation in themedical record should justify the admission andplan of care. Discharge planning must begin atthe time of admission to resolve potential issuesthat may delay timely discharge or prevent thebest patient outcome.

Medical Management GuideVersion 3.0Utilization ManagementPage 33• Continued stay review is conducted at regularintervals throughout hospitalization to assessthe need for continued inpatient treatment.Review is usually conducted at prescribed timeframes throughout hospitalization or with achange in the level of care or the addition ofprocedures. If the patient is staying longer thanoriginally anticipated, CM should be notified.Patient-specific discharge plans should identifythe need for follow-up (see also Section III,Case Management, Discharge Planning).(Refer to Section V, Medical Management Tools,for data information systems and analysis that arevital to successful MM measurement and integrationfor both clinical and business practices.)UM outcome measures are commonly divided intodaily, monthly, and quarterly summaries and trackedover specific time frames according to the processimprovement or business planning needs of thefacility. Fig. 9 provides examples of UM measures foroutpatient, ancillary, and inpatient services.Retrospective review is conducted after treatmentand/or services are completed. It may identifytargets for future prospective or concurrent review.Third-party payors may require retrospective reviewto verify that the care being billed was actuallyprovided.• This process utilizes specific data elements tomeasure outcomes, identify areas of concernthat may require implementation of a qualityimprovement project, and evaluate theeffectiveness of health care.Focused retrospective review concentrates on oneaspect of care, such as appropriateness of service.General retrospective review examines the entirespectrum of care including quality, utilization,coding, appropriateness, necessity, and so forth.Outcome Measurement and ManagementMeasuring UM outcomes involves data collectionand analysis, and appropriate reporting. This processis essential for a successful program, but it can bechallenging to understand and apply the availableinformation systems and resources used by the DoD.The TRICARE Management Activity (TMA)Population Health and Medical ManagementDivision (PHMMD) maintains a centralized, externalcontract to license and distribute specific criteria andguidelines to MTFs and TRICARE Regional Offices(TROs). The selected products are believed to bethe best choices for the MHS, although they are notthe only products available in the industry. Theseproducts include McKesson InterQual evidencebasedclinical decision support criteria, which covera broad spectrum of medical/surgical and behavioralhealth care; and Milliman Care Guidelines, whichaddress the ambulatory care arena.McKesson ® InterQual ® — http://www.mckesson.comMcKesson InterQual evidence-based clinicaldecision support criteria are sets of measurable,objective, clinical indicators reflecting the need forhospitalization and for diagnostic and therapeuticservices in both the medical/surgical and behavioralhealth arenas.

Page 34Utilization Management Version 3.0Medical Management GuideSample UM Data Elements or MeasuresOutpatient Measures Ancillary Measures Inpatient MeasuresAmbulatory procedures (CPT) per 1000MTF enrolled per month/per year• Identify procedures with the highestfrequency.• Is the highest frequency of a givenprocedure within the MTF or thePurchased Care System (PCS)?• If higher in the PCS, is that procedureavailable within the MTF? If yes,identify causes for referral andconsider strategies for recapturingcare.• Conduct a focused retrospective reviewto determine if the highest frequenciesmeet medical necessity criteria. If highnumbers do not meet the criteria,consider a short-term prospective reviewfor high frequency/high cost.ED encounters per 1000 MTF enrolledper month/per year• Identify high ED utilizers.• Consider CM, education, DM, andmarketing of an advice line.• Is there inappropriate use or overutilizationof the ED? Is there anaccess issue?• Are there implications for communityoutreach (e.g., is there a high volumeof fractures)?• Is there a pattern to the cause?• Which safety factors might be missingto prevent fractures?High volume ICD-9-CM principaldiagnoses for ED visits for MTFenrolled per month/per year• Identify the highest occurring principaldiagnoses within the ED.• Identify patterns by enrollee and by typeof visit. Consider CM, DM, etc.• Are there implications for communityoutreach (e.g., is there a high volumeof fractures)? Is there a pattern forthe cause?• Which safety factors might bemissing?Radiology procedures perMTF enrolled per month/peryear• Identify the highest volumeprocedures.• Are criteria availablethat must be met priorto ordering a high-costradiological procedure? Arethey being used?• Identify the referral rate tothe PCS if the procedure isavailable in house.• If unacceptable andinappropriate procedures arebeing ordered, determinewhether criteria exist toaddress the problem.• If there are existing criteria,ensure all providers areeducated in their use.• If not, consider forming ateam to develop criteria.MTF average length of stay (ALOS) per diagnosisrelatedgroup (DRG) per month/per year• Identify the overall MTF ALOS.• Identify the highest frequency DRGs and comparethem to the overall MTF ALOS.• Are one or more DRGs skewing the overall ALOS?• Compare MTF ALOS to external averages.• Is the MTF ALOS higher or lower?• Stratify by department/service (medical, surgical,maternity, newborn, behavioral health) and identifyproblem areas for further study.• Conduct a DRG-specific retrospective focused reviewto determine if discharge planning, CM, clinicalpathways, or other strategies are indicated foraberrant DRGs.Is concurrent review indicated for a brief periodto pinpoint barriers to timely discharge?Admission rate per 1000 MTF enrolled per month/per year• Stratify by MTF and PCS and compare admissionrates.• Identify the reasons for PCS admissions if your MTFhas the same inpatient resources.• Why are MTF beds unavailable?• Can steps be taken to decrease MTF LOS andincrease capacity?• What are the preventable admission rates?• Are there indications for CM, DM, etc.?• Stratify data by department/service. Select priorityand use the UM process to form an action plan.• Stratify by DRG and/or diagnoses to identify thetarget population for intervention.Top diagnoses for same-day surgeries withunplanned admissions for MTF enrolled permonth/per year• Consider reasons for the admissions.• Were any of these preventable?• Are there clusters or patterns to the preventableadmissions?• Is a quality review indicated?Fig. 9 – Sample UM Data Elements or Measures

Medical Management GuideVersion 3.0Utilization ManagementPage 35Sample UM Data Elements or Measures (cont.)Outpatient Measures Ancillary Measures Inpatient MeasuresICD-9-CM principal diagnoses seen withinthe outpatient setting for MTF enrolled permonth/per year• Identify the highest occurring diagnoses.• Stratify by medical, surgical, and behavioralhealth; and by adult/pediatrics.• Would group visits for select diagnoses beappropriate?• Are CPGs in use? Are they being usedcorrectly? Is provider education indicated?Procedures (CPT): Top high volume for MTFenrolled per month/per year• Identify the highest occurring procedureswithin the outpatient setting.• Stratify by adult and pediatric categories.• Conduct a focused review to confirm themedical necessity and appropriateness ofhigh-volume procedures.Specialty referrals per MTF enrolled permonth/per year• Stratify by referrals within the MTF andreferrals to the PCS.• If there is a high volume of referrals sent tothe PCS, determine contributing factors.• Reference Milliman Ambulatory CareGuidelines TM or InterQual® criteria.• Are these guidelines being used to assistPCMs?• Could the care be managed by the PCMs? IsPCM education indicated?Total discharges within 24 hours of an admission forMTF enrolled per month/per year• Distinguish inappropriate admissions (i.e., those that didnot meet medical necessity or level-of-care criteria).• Conduct a focused review to identify underlying causes.• Select appropriate strategies.• Was the observation level of care more appropriate?• Is that level of care available within the MTF?• Can you potentially designate certain beds asobservation-level?Top DRGs by RWP for all MTF enrolled per month/per year (Note: DRG Weight Table lists RWP for eachDRG)• Identify the highest frequency DRGs for the date range.• Identify the ALOS for individual DRGs.• Utilize the DRG weight table to identify relative weightsand LOS.• Stratify by department/service.• Are there patterns that warrant further investigation?• Are preventable admissions included in the topDRGs?• Are CM, DM, discharge planning, or other strategiesindicated?Total MTF admissions for enrolled population byprincipal diagnosis per month/per year• Stratify by department/service and key demographics.• Identify patterns and potential problem areas.• Compare admission diagnosis to principal diagnosis toidentify potential patterns (e.g., admission diagnosisis rule-out myocardial infarction while the principaldischarge diagnosis is gastroenteritis).• Conduct a focused review to confirm theappropriateness of targeted admissions.MTF readmission rate for same or related diagnosiswithin 30 days of discharge for MTF enrollees permonth/per year• Identify potential quality-of-care concerns.• Compare the first and second or subsequent dischargesfor a specific enrollee.• Were the first discharge or subsequent dischargespotential premature discharges?• Was the readmission related to insufficient dischargeplanning, patient education, or follow-up care?Fig. 9 (cont.) – Sample UM Data Elements or Measures

Page 36Utilization Management Version 3.0Medical Management GuideThese criteria are not based on diagnosis butrather on the severity of the patient’s illness andthe intensity of the services required. Thus, theyserve as criteria for all hospital care, regardless oflocation or facility size. McKesson InterQual productsare packaged in criteria sets that are continuouslyevolving. The DoD licensing agreement providesWeb-based access, with online modules availablefor distance learning through the TMA PHMMDSupport Center at http://www.tricare.mil/ocmo.Milliman Care Guidelines ® — http://www.careguidelines.comThe Milliman Care Guidelines target conditionsordinarily seen by primary care managers (PCMs) inthe ambulatory care arena.The guidelines are published by Milliman in aWeb-based format and are accessed through itsCareWeb portal (http://www.careguidelines.com/login-careweb.htm). Access via CareWeb requiresa DoD account, which provides a username andpassword. Access is granted only to users employeddirectly by the MTF. For more information and logoninstructions, contact your local MTF or designatedTMA point of contact (POC).A Milliman Care Guidelines distance learning trainingmodule is available through the Population Healthand Medical Management Division (PHMMD)Support Center at http://www.tricare.mil/ocmo.( CD-ROM Resource UM-3 shows screenshotsand provides descriptions of various Millimanresources.)These guidelines:• Provide clinical detail about diagnostic andtherapeutic approaches, and about referralsand procedures.• Introduce and integrate pharmaceutical andmanagement considerations.• Define the assessment and treatment modalitiesthat should occur at the primary care level priorto referral for specialty care.• Help PCMs provide the fullest spectrum of careat the most appropriate level, while helping theMTF conserve specialist resources.The guidelines are not intended to be used withoutthe judgment of a qualified healthcare providerwith the ability to consider each patient’s individualcircumstances. They are updated every one to twoyears, or as necessary, to reflect industry changes.Provider ProfilingProvider profiling can be defined as theidentification, collection, collation, and analysis ofdata to develop a provider-specific characterizationof performance. The process represents animportant application of analytics to improve qualityand reduce costs. The data analysis that results fromprovider profiling gives providers a more completepicture of the quality of care they provide.Provider profiling can be tailored to meet specificneeds based on the healthcare delivery model.According to Kongstvedt (2007), profiles shouldshare the following characteristics:• Accurately identify the provider in the profile.• Accurately identify the specialty of the provider.• Help improve the process and outcome of carein both dollar and quality outcomes.

Medical Management GuideVersion 3.0Utilization ManagementPage 37• Have a firm basis in scientific literature andprofessional consensus.• Meet certain statistical thresholds of validityand reliability.• Compare the provider to the norm.• Cost the minimum amount possible to produce.• Respect patient confidentiality.When profiling a provider, consider the level ofanalysis involved. Profiling at the individual providerlevel is often not possible because the numberof episodes for each physician is too small. Theresulting statistical instability introduces too mucherror to generate robust comparative conclusions.Instead, profiling should be performed at theclinic/group level. This also has the advantage oftaking into account the fact that care is deliveredby teams of providers, particularly for complex andchronic diseases.Referral ManagementReferral Management (RM), considered a subcomponentof a UM program, is the process ofmanaging and tracking internal/external patientreferrals within the MTF, to another MTF (i.e., withinthe DCS), or to network specialists (i.e., to thePCS). RM provides a mechanism for determiningpatient access to specialty clinics, durable medicalequipment (DME), and network inpatient admissionsthat use evidence-based criteria and predeterminedclinical/business outcomes.RM is an important business and clinical processwithin the MHS. It provides a clear capability tominimize costs for care referred to the network.RM goals are to promote continuity of care,timely intervention, access to care, recapture careappropriately, and make informed decisions aboutthe most effective utilization of resources.MTFs hold primary responsibility for coordinatingthe tracking and closure of specialty referrals fortheir enrolled population. A referral is the processof directing an MHS patient from one healthcareprovider to another within the DCS, or to a network(preferably) or non-network (as necessary) civilianprovider. A referral request is expected in mostcases; in some circumstances, a preauthorizationmay be required. A consult report, known as aClearly Legible Report (CLR), is the primary methodused to close out a referral.The RM process involves two types of component:clinical and administrative.The clinical component includes performing URfor medical necessity of specialty referrals anddetermining appropriateness of care. RM staffshould apply the use of approved clinical practiceguidelines (CPGs) and proactively identify and referpatients for CM or DM.The use of clinical practice guidelines (CPGs) canfacilitate the RM process, since recommendedreferrals for specialty care are included withinthe practice guidelines (see Section IV, DiseaseManagement, and Appendix C, Definitions,for more information on CPGs). The ability to verifythe appropriateness of a referral for a particulardisease or procedure is available as a function inMilliman Ambulatory Care Guidelines (http://www.careguidelines.com/brochures/ac/ACebrochure.pdf)and McKesson InterQual evidence-based decision

Page 38Utilization Management Version 3.0Medical Management Guidesupport criteria. Clearly identifying recommendedreferral points can decrease inappropriate referralsand improve the timeliness of appropriate referrals.The administrative component of RM relatesprimarily to managing the electronic transmissionof specialty referral requests from the MTF to theMCSC, to include ensuring referrals meet accessand continuity of care standards.Administrative staff need to closely monitor andtrack the return of referral results. Tracking ofreferrals encompasses monitoring, timeliness ofresult return, and legibility. The utilization managerinitiates services by sending a referral to theManaged Care Support Contractor (MCSC) (seealso Section I, Medical Management Essentials,TRICARE and Other Benefit Programs, Workingwith Managed Care Support Contractors).Contact the MCSC in your region on how toappropriately send a referral.With contract modifications, the MCSC performsbenefit and medical necessity reviews for all patientsexcept ADSMs. RMC staff must perform benefitand medical necessity reviews for ADSMs sincethe MCSC will not deny their care. However, theMTF may establish its own internal review processto select referrals for appropriateness and medicalnecessity.Additionally, red flag situations such as the followingmay require further review:• Travel• Out-of-area care• Non-network provider requests• Continuity of care• Care following PCS enrollmentThe MTF should have an established process toappropriately respond and coordinate high-expenserequests. However, these items are available to thebeneficiary but should be closely reviewed for costcontainment and appropriately addressed by MTFstaff prior to “defer to network.”The following are some tips for implementing asuccessful RM program:• Perform retrospective reviews to validatereferral patterns.• Evaluate the appropriateness of referrals forADSMs and the strategy for further review.• Evaluate multiple referrals for quality andcontinuity of care (e.g., referrals for newversus established patients).• Maintain current capabilities list to facilitateRight of First Refusal (ROFR) opportunities.• Monitor access for specialty appointmentswithin the MTFs through sound templatemanagement.• Identify opportunities to refer patients forCM or DM.• Collaborate and coordinate processes andproblem resolution with the MCSC.• Educate patients and staff about the referralprocess.• Establish a tracking process to account for 100percent referrals.Referral Management Center (RMC)The ASD (HA)/TMA have mandated theestablishment of a Referral Management Center(RMC) within each MTF or multi-service market.The RMC functions as the primary source forprocessing specialty referrals. With the exceptionof multi-service markets, the RMC should be

Medical Management GuideVersion 3.0Utilization ManagementPage 39the “one-stop shop” for both MTF and MCSCpersonnel and, most importantly, for the patient.The RMC is the place where the MTF can maximizeits MM plan through the recapture of specialty careand containment of its TRICARE Prime enrollees(access and demand management). The RMCoperates in accordance with the standardizedbusiness rules for referrals and authorizations.Duties include referral administration, appointments,and tracking. Each Service Branch has developedits own particular RM processes. RMC staffshould have a working knowledge of the TRICAREbenefit program as it applies to referrals (TRICAREOperations Manual 6010.51-M). CD-ROMResources UM-4 and UM-5 contain RM policymemoranda for the Army and Navy. CD-ROMResource UM-6 is a comprehensive document thatprovides guidelines for establishing an RMC. TheArmy and Navy medical departments defer to theAir Force RMC Guide.Active Duty Service Member Referralsneed to meet mission requirements. For example,in one scenario an ADSM is suffering from a severecase of pseudofolliculitis that requires dermatologyvisits every six weeks. In this case, due to theseverity of the disease process, the dermatologistrefers the patient for laser hair removal. However,laser hair removal is not currently a covered benefit.Yet in this case, laser hair removal is a long-termsolution that should ultimately decrease the needfor multiple visits to the dermatologist, which in turnwill decrease time away from the ADSM’s dutysection/mission. As a result, UM staff wouldrecommend that the procedure be approved.Elective care without prior approval is prohibited.Written approval must be obtained from theADSM’s Squadron or Unit Commander and MTFCommander. The ADSM must notify his/her PCMprior to the elective care and, finally, the MTF withinthree days of treatment. Elective care requires themember to provide the report of care describingtreatment, medications ordered, etc., to be filed inhis/her medical record.Referrals for ADSMs require special attention.The MCSC does not perform medical necessity orbenefit review on ADSM referrals. Once the ADSMreferral is reviewed and approved by the MTF, theMCSC will not deny care to the patient.The MTF Commander or designee is the approvalauthority for network specialty care for ADSMs. UMstaff members need to complete a medical necessityand benefit review on the referral and make arecommendation to the MTF approval authority forapproval/disapproval of the specialty care requested.Within the recommendation, consideration forapproval hinges on medical necessity and on theFor elective care in the private sector, the ADSM isresponsible for all expenses related to his/her owncare, travel, and standard leave for all time awayfrom duty. Convalescent leave is not authorized.ADSMs are also ineligible under such circumstancesfor any compensation related to elective care. Ina DCS that offers elective services, members areeligible for permissive Temporary Duty (TDY) andconvalescent leave, with the ADSM responsible forall expenses.It is important to note that approval for a noncoveredbenefit only applies to ADSMs. There alsomay be Service Branch-specific directives or policies

Page 40Utilization Management Version 3.0Medical Management Guidethat preclude receipt of certain care/procedures. UMstaff must be aware of Line of Duty (LOD) policiesof their respective Service Branch in orderto appropriately process LOD-related referrals.services. After analyzing data for the MTF’sexisting practice patterns, MTF staff shoulddecide which service line, if any, would requirepreauthorization review.MTFs should have a protocol in place for the MTFCommander designee during initial review ofreferrals, to identify those that could go forwardto the MCSC and those that need furtherreview/approval.AuthorizationRM staff should be aware of authorizationpolicies (TRICARE Operations Manual 6010.51-M,Chapter 8, Section 5, Referrals/Preauthorizations/Authorizations) as they review referrals forappropriateness. An authorization (orpreauthorization) is defined as a “prior authorizationfor payment of medical/surgical or psychologicalservices based on certain criteria that are generallyaccepted by qualified professionals to be reasonablefor diagnosis and treatment of an illness, injury, ormental disorder” (Code of Federal Regulations [CFR],Title 32, National Defense — Chapter 1, Section199.2, Definitions). It is essentially a determinationthat a referral for civilian health care represents arequest for services that are:• Covered as a TRICARE benefit.• Medically necessary and delivered in anappropriate setting.A consult report is not required because it will beprovided during the referral process.Not all referrals require prior authorization.Referrals that require close scrutiny are usuallyhigh-cost or problem-prone procedures orMCSCs maintain a preauthorization list based onbest business practices for their region on theTRICARE website (http://www.tricare.osd.mil) orat the local TRICARE Service Center (TSC).Episode of CareA business principle utilized by MCSCs as part ofthe referral process is the concept of “episodeof care” (EOC). An EOC is a range of predefinedprocedure codes that can be performed by a singleprovider to render reasonable medical servicesrelated to a specific condition. It may include aninitial assessment, follow-up interventions, andreassessments in accordance with best businesspractices.Applying an EOC as a business rule in RM can beadvantageous because an EOC:• Is based on claims data.• Conforms to norms of civilian clinicalpractice/community standards of care vs.overutilization.• Enhances accurate and timely claims processing.• Incorporates MCSC best practices.• Minimizes the frequency of communicationsbetween the MTF and the MCSC, networkprovider, and patient.• Provides clarity on package or bundle of servicesbeing ordered or requested.• Provides positive return on investment (ROI).

Medical Management GuideVersion 3.0Utilization ManagementPage 41When the MCSC approves the MTF’s referral fortreatment, a referral letter is sent to the civilianprovider. The referral letter authorizes the servicesor EOC, using current procedural terminology (CPT)codes that can be rendered to either “evaluateonly” (provide second opinion) or “evaluate andtreat” the patient’s condition.MTFs should be reassured that the application ofEOCs is a best business practice that should notincrease healthcare costs, due to safeguards builtinto the process. That is, the approval of an EOConly applies to care for the original diagnosis orspecialty referral ordered by the MTF PCM.The network provider should not refer the patientback to his/her PCM for more specialized care.When a patient requires admission to the hospitalor referral to a similar or more specialized provider,the original network provider must submit a requestfor another referral to the MCSC (e.g., non-invasivecardiologist to a cardiac surgeon, orthopedist toa physical therapist or an orthospine surgeon).Cardiology cannot refer a patient to an unrelatedspecialty such as urology or endocrinology; suchrequests must come from the PCM.At this point, the MTF has the opportunityto recapture the patient based on the MTF’scapabilities and capacity to render the new care(e.g., Right of First Refusal [ROFR]). The patientmust return to the PCM for a new referral if anyof the following occur:• There is a break in medical care.• The period of time between treatments isgreater than one year.• The authorization has expired.The Electronic Referral ProcessThe RMC will access an electronic copy of thereferral via CHCS/AHLTA (see Section V, MedicalManagement Tools) or, in very limited cases, apaper copy and review it for appropriateness andcompleteness. If the MTF/DCS does not have thecapability or capacity to process the document, thereferral will be forwarded manually or via an autofaxsolution to the MCSC for specialty care approval/authorization. Referrals to the MCSC will includethe minimum data elements found in the TRICAREOperations Manual (see Fig. 10).Once the MCSC receives the referral via fax, he/sheenters it into the referral tracking system, assignslevel-of-service CPT codes, and verifies that allneeded information is present. If information ismissing, the referral will be returned to the PCMvia the RMC. The MCSC will perform a medicalnecessity review (MNR), as needed, and a coveredbenefit review (CBR).If the referral passes the MNR and CBR, the MCSCwill notify the patient, the MTF, and the selectednetwork provider that network specialty care hasbeen authorized.If the referral does not pass the MNR and CBR, thepatient and MTF will be notified of the denial. Thedenial notice will be faxed to the MTF’s RMC andmailed to the patient. The patient has the right toinitiate an appeal with the MCSC.

Page 42Utilization Management Version 3.0Medical Management GuideTRICARE OPERATIONS MANUALReferrals/Preauthorizations/AuthorizationsRequired Data ElementRequest Date/TimeRequest PriorityDescription/Purpose/UseDDMMYY/hhmmSTAT/24-hour/ASAP/Today/72-hour/RoutineRequester• Referring Provider NAME• Referring Provider NPI• Referring TF• Referring MT NPIName of PCM/MTF individual provider making requestHIPAA National Provider Identifier (NPI) — Type 1 (individual)Name of Military Treatment Facility (MTF)HIPAA National Provider Identifier (NPI) — Type 2 (organizational)Patient InformationSponsor SSNPatient IDPatient NamePatient DOBPatient GenderPatient AddressPatient Telephone NumberPatient Primary Provisional DiagnosisReason for RequestEDI_PN (from DEERS), if availableFull name of patient (if no EDI_PN available)Date of birth (required if patient not on DEERS)Full address of beneficiary (including zip code)Telephone number (including area code), if availableClinical InformationDescriptionSufficient clinical info to perform MNRServiceService1 — ProviderSpecialty of service providerService 1 — Provider Sub-specialtyService 1 — By Name ProviderRequest if Applicable — First and Last NameService 1 — Service TypeAdditional sub-specialist Info, if needed (free text clarifying info entered,with reason for request — e.g., Pediatric Nephrologist)Optional info regarding preferred specialist provider (free text)Inpatient, specialty referral, DM purchase/rental, other health service, etc.DME provider to do CMNService 1 — Service Quantity (optional)Number of visits, units, etc.CHCS Generated Order Number(DMIS-YYMMDD-XXXXX)Unique Identifier Number (UIN) — The DMIS of the referring facilityidentified in the “Referring MTF” field on this request(Date in format indicated — consult order number from CHCS)Source: TRICARE Operations Manual 6010.51-M, Chapter 8, Section 5, (Aug. 1, 2002)Fig. 10 – TRICARE Referrals/Preauthorizations/Authorizations

Medical Management GuideVersion 3.0Utilization ManagementPage 43Communication between MTFs and MCSCs• There will be a single RM POC at the MTF withone phone and fax number.• MTF staff will fax referrals to the MCSC (someMTFs may be using e-fax to perform thisfunction).• MTF staff will not be responsible for coding thediagnosis or procedure(s).• MTF staff must implement the use of Englishlanguagetext.Patient Clinical Information• Referring providers will include pertinent clinicalinformation in the referral.• The referring provider and/or the RMC personnelhave primary responsibility in coordinatingthe transfer of information to the civilianprovider(s).Medical Necessity and Covered BenefitDeterminations• The MCSC will review all referrals to the networkfor medical necessity and covered benefitdeterminations, including the associatedappeals processes within the PCS. However, theMTF is responsible for all referrals for ADSMsand for the MTF appeal process.• No preauthorization is needed for the first eightvisits of non-ADSM patients who seek mentalhealth care with network providers. There is norequirement for MTFs to manage the care ofpatients who self-refer. Mental health care forADSMs needs to be preauthorized.Utilizing Military Treatment Facility Capabilityand Right of First Refusal ReportsMTF staff must:1. Provide the MCSC with accurate, current listingsof the MTF’s capabilities so ROFR reports can beforwarded for MTF care, as appropriate.o MTF staff will regularly update MCSCcapability listings.2. Review all incoming referrals before the closeof the following business day for routine ROFRrequests.o Urgent ROFRs will include personaltelephone contact initiated by MCSCsand near-immediate (not to exceed 30minutes) acceptance or declination by MTFrepresentatives.MTFs must notify the MCSC of receipt of a routinereferral within one business day when the referralhas been accepted. However, if the MTF does notrespond to an ROFR, either negatively or positively,the MCSC will assume an implied declinationand the patient will be appointed to the network(TMA Memorandum, Policy Guidance for ReferralManagement, 2004). It is the MTF’s responsibilityto provide clinical feedback to the referring civilianprovider within 10 business days.Additional InformationThe MCSC does not provide referral services forTRICARE Standard, TRICARE Plus (T-Plus) TRICAREfor Life (TFL), or North Atlantic Treaty Organization(NATO) patients, or for those covered by otherhealth insurance (OHI). The RMC is responsible forassisting with these referral requirements.

Page 44Utilization Management Version 3.0Medical Management GuideReferrals may be required for urgent care deferred tothe network. Routine primary care in the local areawithout a referral could generate point-of-servicecharges for the beneficiary.MTFs are required to track and account for all initialspecialty care referral requests going out of/into theMTF on their way to resolution for TRICARE Primeand ADSM referrals, including those not trackedby the MCSC (e.g., T-PLUS, OHI). For network carearranged through the MCSC, network specialtycare providers will provide CLRs to the MCSCwithin 10 business days of the patient encounterfor “Evaluation Only” referrals and within 30 daysof the patient encounter for “Evaluate and Treat”referrals, except where exempted by MCSC contractmodification. The MCSC is contractually requiredto forward CLRs to the RMC, which will annotatereferral receipt and forward the CLR to the referringprovider.The referring provider/PCM team is responsiblefor acknowledging the results by review/signatureand for forwarding the results for filing in thepatient’s medical record. The RMC is responsiblefor reconciling outstanding referral results with theMCSC. Prior to the MCSC reconciliation, the RMCshould first review MCSC Web-based tools and filedclaims, and conduct in-house retrieval (e.g., fromclinics or the mail room).RMCs should also provide to the PCM on a regular,recurring basis a list of referrals without results,which indicate that no patient appointment wasmade and/or that no report was received.The Grievance and Appeal ProcessOverviewAccording to DoDI 6000.14, Patient Bill of Rights andResponsibilities in the Military Health System (2007),MHS patients have the right to an efficient processfor resolving differences with their healthcareproviders, MTFs, or MCSCs; this includes beingable to rely on a system of internal and externalreview. The directive states that the patient begiven an opportunity to appeal the MTF’s decisionregarding medical necessity determinations. It alsorequires the MTF appeal process be consistent withthe reconsideration procedures under CFR Title32, National Defense, Chapter 1, Section 199.15— Quality and Utilization Review Peer ReviewOrganization (PRO) Program; and Section 199.10— Appeal and hearing procedures.The PRO Program is required by Title 10 of the U.S.Code (U.S.C.) 1079(o). Medical benefits authorizedby TRICARE in civilian facilities are required bythis regulation to be the same as those benefitsauthorized in facilities of the Uniformed Servicesfor patients under Title 10 1077(a), except as maybe specifically limited by other statutory provisionsunder Chapter 55 of Title 10.The DCS uses CFR Title 32, National Defense,Chapter 1, Part 199 — Civilian Health and MedicalProgram of the Uniformed Services to determinethe scope of the medical benefit in MTFs. The scopeof the benefit is relevant in determining whether arequested healthcare service is medically necessary(an appeal issue) or a covered benefit (a grievanceissue).

Medical Management GuideVersion 3.0Utilization ManagementPage 45The grievance and appeal processes are applicableto all TRICARE beneficiaries, subject to thelimitations described in the section for uniformedpatients (see Special Considerations for ActiveDuty Service Members, later in this section). Theprovision of or denial of healthcare services forADSMs based on medical readiness requirementsor fitness-for-duty determinations is not subject tothe grievance or appeal process. Complaints may bemade through the appropriate Chain of Commandor to the Inspector General (IG). Fitness-for-dutydeterminations are addressed through the MedicalEvaluation Board (MEB) and Physical EvaluationBoard (PEB) processes (see Section III, CaseManagement, Disability Evaluation System).The grievance process applies for complaints aboutspecific treatment or coverage (benefit) decisionsother than medical necessity. It is therefore essentialfor MTFs to determine whether the patient’s disputeinvolves a grievance or an appeal.provide appropriate and timely healthcare services,access, or quality; or to deliver the proper level ofcare or service. The grievance process allows theopportunity to report in writing any concern orcomplaint regarding healthcare quality or serviceto which the patient believes he/she is entitled(TRICARE Operations Manual, 6010.51-M, Chapter12, Section 9).Examples of grievances include:• Coverage determinations.• Factors related to quality assurance.• Length of the waiting period to obtain anappointment.• MTF determinations of space-availablecare (including availability of services,pharmaceuticals, equipment, or other items).• Undue delays at an office when an appointmenthas been made.• Refusal of a PCM to provide access to servicesor to refer a patient to a specialist.The appeal process applies when healthcareservices are denied by an MTF based on thedetermination that the services are not medicallynecessary. In such cases, the MTF will neitherprovide nor authorize TRICARE payment forservices.GrievancesTRICARE defines a grievance as a written complaintor concern about a non-appealable issue regardingthe perceived failure by any member of thehealthcare delivery team, including TRICAREauthorizedproviders, military providers, regionalcontractors, or subcontractor personnel, toFiling a GrievanceTo initiate the grievance process, the patient orpatient’s representative submits his/her grievance inwriting through the Customer Service department,the patient advocate, or a similar mechanismdeveloped by the particular MTF for review by theMTF Commander. The Commander (or designee)appoints an “investigator” (most likely the actingChief of Medical Staff) to review the grievance.Within 60 days of the date of the written grievancerequest, the MTF Commander (or designee)forwards a written reply to the patient that includesfindings regarding the grievance.

Page 46Utilization Management Version 3.0Medical Management GuideThe MTF Commander’s (or designee’s) decisionis final. The reply includes the name of a contactperson who can address questions regarding thereview findings.• The external chain includes the third andfourth levels of appeal to the National QualityMonitoring Contractor (NQMC) and TMA,respectively.AppealsAn appeal is an administrative review of programdeterminations regarding the medical necessity ofhealthcare services (including behavioral services)made under the legal and regulatory provisions(TRICARE Operations Manual 6010.51-M, Chapter13, Appeals and Hearings). MTF staff are responsiblefor protecting the rights of appealing parties atall levels of the appeal process. That responsibilitybegins with the initial denial determination and endswhen a final resolution is achieved. Further levels ofappeal should progress only if the patient wants tocontinue the process (i.e., if the patient disagrees oris dissatisfied with the decision) or if the reviewingauthority upholds the initial denial.The MTF appeal process involves three levels ofreview followed by three levels of appeal. Therationale for multiple levels is twofold:1. The process allows for a check and balancewithin the system.2. The process provides for objective decisionmaking,progressing from the lowest to thehighest level in the appeal Chain of Command.Fig. 11 summarizes the MTF review and appealprocess, including reviewer qualifications andguidelines.Filing an AppealAppealing PartyThe appealing party is the patient affected by theinitial denial determination. Participation in anappeal is limited to any party associated with theinitial denial determination, as well as the authorizedrepresentative(s) of the appealing party. The patientmay appoint a representative (in writing) to act onhis/her behalf during the appeal process.The MTF provider is not generally an appropriateappealing party for a dependent patient. Adependent denied services may appoint his/hersponsor or any other person as his/her representativesubject to the limitation in CFR Title 32, NationalDefense, Chapter 1, Section 199.10 — Appeal andhearing procedures. Following the representative’sappointment, he/she may file an appeal on behalf ofthe patient.The process also provides for internal and externalchains of responsibility.• The internal chain begins with the first level ofreview, at the MTF; and ends with the first levelof appeal, to the MTF Commander.In cases where the patient is a child under the ageof 18 (i.e., a minor), the presumption is the sponsoris the appointed representative who can appeal onbehalf of the child without a specific designation orappointment, as long as the sponsor is the custodialparent.

MTF Review and Appeal: Internal ReviewFig. 11 – MTF Review and Appeal Process: Internal ReviewLevel ofReview/AppealFirst-level ReviewSecond-levelReview(Initial DenialDetermination)Third-levelReview (MTFReconsideration)ReviewerQualifications• Non-physician reviewer• Usually registered nurse or licensed practicalnurses trained in utilization review• Non-physician reviewer• Licensed practitioner with a current, valid,unrestricted license in the same or similarspecialty as the attending physician orprovider. Examples:o Referral Managemento Physician Reviewero Senior Physiciano Chief of the Medical Staff• Medical/Surgical/Specialty• Clinical Peer:o Licensed doctor of medicine, osteopathy,or oral surgery with a current, valid,unrestricted license to practice in the U.S.o Holds active staff privileges and patientcare responsibilities in an MTFo Certified by a board recognized by theAmerican Board of Medical Specialties orosteopathic equivalent and practice in thesame specialty of the physician providerwhose services are under review.Review Process(Reviewer Actions)• Utilizes criteria as a toolto review for medicalnecessity.• May approve requestedservices based oncriteria.• May not deny services.• Contacts PCM orattending physician and/or provider for additionaldocumentation orpertinent medicalinformation.• Approves or denies therequested services basedon medical standardof care and availableinformation.• Contacts attendingphysician or healthcareprovider for additionalinformation.• Makes decision basedon medical standards ofcare and documentationand/or additionalinformation obtainedfrom the attendingphysician or provider.Outcome Timelines Appealing• Approves requestedservices;OR• Cannot approve;forwards to the secondlevelreviewer formedical standard of caredecision.• Approves requestedservices;OR• Denies requestedservices. Notifies patient,his/her representative,and/or attendingphysician/PCM, inwriting, of:o Upheld denialdeterminationo Reason for denialo Patient’s rightso Steps to appeal denialif patient chooses todo so• Recommendsreconsiderationdetermination approvingor denying benefits.• Forwards determinationto MTF Commander forreview and issuance.• Admission: By noon ofday following admission• Concurrent: Withinthree (3) business daysof initial review request• Prospective: Within30 days of initial reviewrequest• Retrospective: NotapplicableNotification• Admission: By noon ofday following requestedadmission• Concurrent: Withinthree (3) business daysof initial review request• Prospective: Withinthree (3) business daysof initial review request• Retrospective: Within30 days of initial reviewrequest• Refer to timelinessrequirements for MTFCommander notification(under First Level ofAppeal)PartyNotapplicableNotapplicableNotapplicableMedical Management Guide Version 3.0Utilization ManagementPage 47

Fig. 11 (cont.) – MTF Review and Appeal Process: Internal Review/AppealLevel ofReview/AppealThird-levelReview (MTFReconsideration)First-levelAppeal (MTFReconsideration)ReviewerQualifications• Behavioral Health Clinical Peero Physicians must meet the above criteriawith board certification by the AmericanBoard of Psychiatry and Neurology.o Cannot be the same individual as in theprevious review.Examples:o Internal Reviewer (if available)o External Reviewer (clinician in the samemarket or region)Not applicableMTF CommanderMTF Review and Appeal: Internal Review/AppealReview Process(Reviewer Actions)• Consults with othermedical staff (e.g., Chiefof the Medical Staff) forguidance, as needed.• Contacts attendingphysician or healthcareprovider for additionalinformation.• Makes decision basedon medical standards ofcare and documentationand/or additionalinformation obtainedfrom the provider andprevious levels of review.Outcome Timelines Appealing• Approves requestedservices and reversesdenial determination;OR• Upholds initial denial.Notifies patient, his/herrepresentative, and/orattending physician/PCM, in writing, of:o Upheld denialdeterminationo Reason for denialo Patient’s rightso Steps to appeal denialif patient chooses todo soRequest for appeal:Must be filed within30 days following thedate of the initial denialdetermination.• Reversal;OR• Upheld DenialNotification• Admission: By noon ofday following admission• Concurrent: Withinthree (3) business daysof reconsiderationreview request• Prospective: Withinthree (3) business daysof reconsiderationreview request• Retrospective: Within30 days reconsiderationreview requestPrior to an appeal leaving the internal MTF Appeals Process, it is recommended that the case be forwarded to an external entity within the Service’s chain of Command. Thisintermediate level of review between the internal and external Appeals Process will vary depending on each Service’s specific processes.PartyNotapplicableNotapplicablePage 48 Utilization Management Version 3.0 Medical Management Guide

Fig. 11 (cont.) – MTF Review and Appeal Process: External AppealLevel ofReview/AppealSecond-levelAppeal (NQMC:Appeal Requested)Third-levelAppeal (NQMCReconsideration)Fourth-level Appeal(TMA Hearing)ReviewerQualifications• NQMC• Includesreviewers whoare clinical peersof the healthcareprovider underreview.TMA: Hearing RequestedNot applicableMTF Review and Appeal: External AppealReview Process(Reviewer Actions)Request for Appeal to the National Quality Monitoring Contractor (NQMC)(Note: It is the beneficiary’s responsibility to initiate the appeal request directly to the NQMC)• Contacts attending physicianor healthcare provider foradditional information.• Decisions are based onmedical standards of careIAW 32 C.F.R., 199 anddocumentation and/oradditional informationobtained from the providerand previous levels of review.• Hearing Officer is assigned tothe case.• Facts relevant to the caseare presented in relation toapplicable law, regulation,policies, and guidelines.• Decision is based onmedical standards of careand documentation and/oradditional informationobtained from the providerand previous levels of reviewand testimony presented atthe hearing.There are no further appeal rights. The TRICARE Director’s decision is final.Outcome Timelines AppealingParty• Approves requested services andreverses denial determination;OR• Upholds initial denial. Notifiespatient, his/her representative,and/or attending physician/PCM,in writing, of:o Upheld denial determinationo Reason for denialo Patient’s rightso Steps to appeal denial andrequest formal hearing if patientchooses to do so• Approves requested services andreverses denial determination;OR• Upholds initial denial. Notifiespatient, his/her representative,and/or attending physician/PCM,in writing, of:o Upheld denial determinationo Reason for denialo Patient’s rightso Steps to appeal denial if patientchooses to do soRequests for reconsideration shallbe postmarked or received by thedeadline.• Reversal;OR• Upheld Denial.NotificationRefer to TOM, Chapter 13, Section 4,Paragraph 2.3.2 and 2.4.• Request shall be mailed within60 days after date of NQMCreconsideration determination.• A Hearing Officer is appointedwithin 60 days following requestfor hearing.• Reversal;OR• Upheld Denial.Notification• Hearing Officer will hold hearingand issue recommended decisionto TMA Director within 60 days ofwritten notice of assignment.• Refer to 32 C.F.R. 199.10 for moredetailed information regardingtimeliness of a hearing.• Beneficiary• Beneficiary’srepresentativeNotapplicable• Beneficiary• Beneficiary’srepresentativeNotapplicableSources: DoDD 6000.14, Patient Bill of Rights and Responsibilities in the Military Health System. TRICARE Operations Manual 6010.51-M, Chapter 13, Appeals and Hearings. 32 C.F.R. 199, Civilian Health andMedical Programs for the Uniformed Services (CHAMPUS).Medical Management Guide Version 3.0Utilization ManagementPage 49

Page 50Utilization Management Version 3.0Medical Management GuideIn such situations, the custodial parent/sponsor orlegal guardian may file an appeal and will be seenas possessing the same authority as the appealingparty, which also allows him/her to receivenotification letters.Appealable and Non-Appealable Issuesnot deny access to emergency services.)• Whether a provider is TRICARE-authorized.While these issues are not appealable, they may besubject to the grievance process.Special Considerations for Active Duty ServiceMembersOnly issues that relate directly to medical necessityare appealable. Examples of appealable issuesinclude the following:• Concurrent reviews of inpatient care denials.• Denial based on inappropriate level of care.• Denial of a PCM’s request for referral to aspecialist.• Denial of inpatient admission.• Denial of preauthorization for services.• Denial of request for professional services.• Denial of supplies and pharmaceuticals.• Denial of surgical procedures, including invasiveand non-invasive tests.• Termination of previously authorized treatmentsor services.DoDI 6000.14, Patient Bill of Rights andResponsibilities in the Military Health System,identifies ADSMs as a key beneficiary population inthe MHS. Yet the DoDI does not expand the scopeof benefits or create any entitlement inconsistentwith the medical or dental care authorized underTitle 10 U.S.C. Chapter 55, Medical and DentalCare or Chapter 47, Uniform Code of MilitaryJustice; or CFR Title 32, National Defense, Chapter1, Section 199.17 — TRICARE program. ADSMshave an obligation to comply with Service Branchrequirements for medical readiness and the specialrules and procedures under the Title 10 1074(c) andCFR Title 32, Section 199.16 — Supplemental HealthCare Program for active duty members.An issue may not be appealed unless it relates tomedical necessity. Non-appealable issues include thefollowing:• Care/service that is not a covered benefit.• Denial of a treatment plan.• Denial of unproven care.• Eligibility as a patient.• Refusal of a PCM to provide access to servicesrequested by the patient. (This is distinguishablefrom an MTF refusing to allow a patient to seekcare from a PCM or denial of a PCM’s requestfor a specialty referral, both of which aremedically necessary care in the opinion of thePCM and are therefore appealable. PCMs mayAn ADSM may not file an appeal for reasons any ofthe following examples:• A military readiness requirement to obtain avaccine.• A decision to delay or deny medical treatment(whether medically necessary or elective) whenprovision of the treatment would affect aService’s military readiness requirement. Forexample:o An ADSM desires elective surgery, whichwould adversely impact his/her fitness forduty and medical readiness status.o An ADSM requires medically necessary care,which is not available in theater.

Medical Management GuideVersion 3.0Utilization ManagementPage 51The situations described in the examples abovewould affect the ability of the ADSM or of his/herunit to deploy in a timely manner. Because providingtreatment would affect the Service’s military readinessrequirement, it would not be appealable.DocumentationIf the patient is dissatisfied with a denial decisionand wishes to pursue the next level of appeal,he/she may request an appeal of that decision.Every level of the review and appeal process isdocumented in writing, with all communicationssubmitted by the appealing party and created by theMTF kept on file.Risk ManagementMTFs should keep in mind that issuing denialsof care to patients bears a fundamental RiskManagement liability. Risk Management issuesinclude process standardization, standards of care,treatment delays, obstacles to communication(within the MTF and between the MTF and patients),record-keeping, and confidentiality.Any additional medical information the attendingphysician provides, insofar as it is pertinent to thereview and/or submitted during any one of theappeal levels, must be subsequently documentedas an addendum to the medical record.The appealing party has the burden of proof toaffirmatively establish by substantial evidencethat the healthcare issue in question is a TRICAREbenefit or entitlement that is necessary accordingto medical standards of care. All parties have theopportunity to present, obtain, and examine additionaldocumentation or information for considerationduring the appeal process.MTFs must maintain documentation related toappeals for a minimum of one year after the case isclosed, at which time the case should be transferredto the Federal Records Center, according to the TRI-CARE Operations Manual. All documentation relatedto levels of review and appeal is subject to thesame prohibitions against disclosure of informationand the same protections as other documentation,according to HIPAA. Initial determinations,reconsiderations, and notifications will follow CFRTitle 32, National Defense, Chapter 1, Part 199— Civilian Health and Medical Program of theUniformed Services.The physician/provider reviewer(s) must possessthe appropriate credentials and be precise whendetermining an appeal decision. The MTF shouldconduct inter-rater reliability testing of reviewers andthe facility should be in compliance with applicableregulations. The identity of review coordinators,physician reviewers, or consultants who assistedin the review of the case will not be disclosed, inaccordance with Title 10 U.S.C. 1102, Confidentialityof medical quality assurance records: qualifiedimmunity for participants.

Page 52Utilization Management Version 3.0Medical Management GuideUTILIZATION MANAGEMENT PROGRAMACCREDITATIONAs part of the TRICARE contract requirement,network facilities are required to obtain andmaintain URAC accreditation for their UMprograms. For more information, go to:http://www.urac.org..THE UTILIZATION MANAGEMENTPROFESSIONALQualificationsThe job description of the employee workingin the UM department of an MTF will varydepending on the size of the organizationand its internal resources. Titles include UtilizationManager, Nurse Consultant, and Clinical NurseSpecialist. The UM professional should possesssufficient clinical knowledge and breadth ofexperience in patient care to identify the clinicalrationale for procedures or tests. He/she shouldbe able to gather necessary information anddetermine the medical necessity of services andappropriateness of certain levels of care.Good communication skills are imperative. In theirgoal of providing UM information to clinicians andhospital leadership, UM professionals may interactclosely with the following roles and/or personnel:1. Population Health Nurse Consultant2. Health Care Integrator (HCI)3. Group Practice Manager (GPM)4. Coders5. Patient Administration staff6. Medical Records staff7. MCSC staff8. Provider teams9. MTF MM and Managed Care divisions10. Resource Management staffThe following are specific education and trainingrequirements for the UM position:• Licensed Registered Nurse (RN) – i.e., graduateof an accredited nursing program, Bachelor ofScience in Nursing (BSN) preferred; or possessinga bachelor’s (or higher) degree in a healthcarerelatedfield from an accredited educationalinstitution (position typically occupied by an RNwith a BSN).• A minimum of three years of progressivelyincreasing managed care responsibilities, with afocus in UM and/or a minimum of three years ofbroad-based clinical nursing experience (UM/URfocus preferred).• Current Basic Life Support (BLS) certification.• Knowledge and experience (or comprehensionduring training) of software and databasescurrently employed at the MTF (e.g., CompositeHealth Care System [CHCS], Armed ForcesHealth Longitudinal Technological Application[AHLTA] — see Section V, MedicalManagement Tools).• Familiarity with customer-focused and processimprovement principles.• Full-time employment for the past twelvemonths in a healthcare-related field.• Valid unrestricted clinical license to practice fromthe state where the MTF is located or licensedthrough the Nurse Licensure Compact (NLC)if the UM professional is not Active Duty. Formore information and a list of states, visit thejoint website of the Nurse Licensure Compact

Medical Management GuideVersion 3.0Utilization ManagementPage 53Administrators (NLCA) and the National Councilof State Boards of Nursing (NCSBN): http://www.ncsbn.org.Desirable qualifications are as follows:• Certification by a UM-specific program (mostdesirable) or a professional organizationrecognized by an accrediting body for UM, suchas:o American Nurses Association (ANA):http://www.ana.org/ancco American Nurses CredentialingCenter (ANCC):http://www.nursingworld.org/ancc/o National Association of Healthcare Quality(NAHQ) Certified Professional in HealthcareQuality (CPHQ): http://www.nahq.orgo McKesson: http://www.mckesson.com/o McKesson Certified Professional inUtilization Review (CPUR) TMo McKesson Certified Professional inUtilization Management (CPUM) TMo McKesson Certified Professional inHealthcare Management (CPHM) TM• Experience with Microsoft Office software.• Master’s degree.• Six years of broad-based clinical experience.Staffing to Support UtilizationManagementand a link to higher-level data analysis and URfunctions. Communication and collaborationbetween UM and the RMC — as well as with theother components of CM and DM — needs to beseamless.SUMMARYAs healthcare organizations haveimplemented MM, a shift has occurred inthe UM role from its historical focus oncost containment to a more proactive approachof continuous quality improvement and evidencebasedpractice. Organizations that use UM solelyto determine services and cost (i.e., that implementbenefit management) tend to diminish their primaryfocus on the patient, which can cause interferenceor delays in coordinating patient care. Nonetheless,UR and preauthorization remain an important partof UM, wherein LOS and appropriateness of care arereviewed, so that problems can be identified earlyenough for intervention.A successful, cost-efficient, and effective UMprogram depends on skilled, well-trained staffinformed about current approaches and trends. Asthe field of UM continues to evolve, every UM staffmember should view him/herself as a stakeholderin developing better healthcare delivery modelsthroughout the MHS.Personnel functioning separately under the RMCneed to establish a direct working relationshipwith their UM department. While RMC staff mightperform many of the tasks related to routine, dayto-dayreferral processing, there should be a UMprofessional (e.g., a UM nurse) providing oversight

Page 54Utilization Management Version 3.0Medical Management GuideCD-ROM RESOURCESUM-1 UM Plan Based on Seven-Step QI Process— TemplateUM-2 UM Plan Based on Seven-Step QI Process— Completed ExampleUM-3 Screenshots of Milliman Care GuidelinesResourcesUM-4 Memorandum: Interim Guidance on ReferralManagement – ArmyUM-5 Memorandum: Interim Guidance onReferral Management – NavyUM-6 MTF Referral Management Center (RMC)User’s Guide (V 6.0, 2008) – Air Force‘

Medical Management GuideVersion 3.0Case ManagementPage 57Case ManagementSECTIONIIIINTRODUCTIONThe Military Health System (MHS) incorporatesCase Management (CM) as a component ofa comprehensive Medical Management (MM)strategy to:• Support patients through transitions of care.• Decrease fragmentation of healthcare services.• Support patient safety, education, and selfdeterminationby establishing an activepartnership with patients, their families, andthe entire healthcare team to achieve optimalhealthcare outcomes.Fig. 12 highlights the role of CM over the variousstages of health care (see also Section I, MedicalManagement Essentials). Specifically, as the focusof healthcare delivery moves along the PopulationHealth continuum from secondary toward tertiaryprevention, a more individualized approach isrequired to manage the unique circumstances ofpatients with a particular disease/illness/injury.Fig. 12 — Case Management within the Integrated MM Model (IM3)*See also Section I, Medical Management Essentials: Fig. 4, Integrated Medical Management Model (IM3) with Key info, page 14.

Page 58Case Management Version 3.0Medical Management GuideThe MHS has established wounded, ill, and injured(sometimes referred to as WII) Service memberrequirements, which provide a unique level ofintensive CM services for Active Duty Servicemembers (ADSMs) with complex medical needsserving in the Army, Navy, Air Force, Coast Guard,and Reserve components.Management (DM), which is based on populations(see Section IV, Disease Management). Onesignificant aspect of CM is care for patients withspecial needs, which may be physical, behavioral,emotional, or educational in nature and may requireintense coordination and collaboration amonghealthcare team members.Definition, Goals, and PurposeThe TRICARE Management Activity (TMA) utilizesthe definition of CM employed by the CaseManagement Society of America (CMSA, 2002),as follows: A collaborative process of assessment,planning, facilitation, and advocacy for optionsand services to meet an individual’s health needsthrough communication and available resources topromote quality cost-effective outcomes. (See alsoAppendix C, Definitions.)Military case managers have adopted the CMSA’sdefinition of CM but broadened its application byplacing CM under the Population Health continuum(see Fig. 12, above). CM services, which are focusedon the individual patient, may overlap with Disease“Complex CM” may be delivered to patientswith chronic illness resulting from disease orcomplex injuries. The National Committee forQuality Assurance (NCQA) defines complex CMas follows: The coordination of care and servicesprovided to members who have experienced a criticalevent or diagnosis requiring the extensive use ofresources and who need help navigating the systemto facilitate appropriate delivery of care and services.The goal of complex CM is to help members regainoptimum health or improved functional capability, inthe right settings, and in a cost-effective manner. Itinvolves a comprehensive assessment of the patient’scondition; determination of available benefits andresources; and development and implementation ofa CM plan with performance goals, monitoring, andfollow-up.Case Management is acollaborative process ofassessment, planning,facilitation, and advocacy foroptions and services to meet anindividual’s health needs throughcommunication and availableresources to promote quality,cost-effective outcomes.Originally, CM almost exclusively targeted inpatientswith catastrophic illnesses or injuries. However, anumber of developments have served to change thatstrategy; notably:• The emergence of the National Committee forQuality Assurance (NCQA): http://www.ncqa.org/.• The development of accreditation standards bythe Utilization Review Accreditation Commission(URAC): http://www.urac.org.

Medical Management GuideVersion 3.0Case ManagementPage 59• The enrollment of Medicare and Medicaidpopulations in managed care plans.• New legislation mandating CM services (seeSections 1611 and 1615 of the National DefenseAuthorization Act [NDAA] of 2008 and theDoD/VA response to those recommendations,Executive Summary CD-ROM ResourcesES-3 and ES-4).While CM continues to focus on catastrophic illnessor injury, CM practices are also intensely directed ataddressing chronic conditions that are more prevalentin the general patient population. Case managerscan affect patient outcomes through proactiveinterventions across multiple healthcare settings.Additionally, case managers are expected to engagecommunity resources and facilitate ongoing andconsistent patient education.The MHS has three primary goals for CM:• Improve the care, management, and transitionof recovering Service members.• Broaden the application of CMto include beneficiaries withcomplex needs and at-riskbeneficiaries before theyrequire complex care.• Evaluate the impact of CM onthe quality and efficiency ofmilitary health care.1. CommunityResources and Policiesbetween facilities or between outpatientmedical and BH services.• Assist the recovering Service member and his/her family in understanding the recommendedtreatment (including BH services) and inreceiving timely access to that treatment.The goal for patients coping with chronic disease isself-management and patient empowerment. Whiledisease managers provide the medical care neededfor the patient’s specific disease, the hand-off tocase managers supports much-needed, ongoingholistic coping and management strategies aspatients strive to achieve optimal functioning andquality of life. Fig. 13 is a useful representation ofactivities involved in Chronic Care Management.The purpose of CM is to:• Promote quality, safe, and cost-effective care.• Promote utilization of available resources toachieve clinical and financial outcomes.• Facilitate appropriate access to care.3. Self ManagementSupport2. Health SystemHealth Care Organization4. DeliverySystemDesign5. DecisionSupport6. ClinicalInformationSystemsAdditional goals applicable to caringfor wounded warriors are to:• Assist the recovering Servicemember in receiving qualitymedical and behavioral health(BH), which may include lengthyinpatient stays and transistionsInformed,ActivatedPatientProductive InteractionsFig. 13 – Chronic Care Management ModelPrepared,ProactivePractice Team

Page 60Case Management Version 3.0Medical Management Guide• Collaborate with the patient/family, physician,healthcare providers, and others to develop andimplement a plan that meets the needs and goalsof the patient.• Develop individualized patient plans of care.• Offer objectivity, healthcare choices, and selfmanagementsolutions.PhilosophyThe case manager’s experience in patient education,support, and advocacy makes him/her an idealintegrated health manager — a role that maintainscommunication with all providers and facilitatescommunication between all providers. Further,the case manager is involved in all aspects of careby continually assessing the patient, providinginformation and education, supporting treatmentadherence, and evaluating the patient’s response.The philosophical key component of CM addressescare that is holistic and patient-centered, with mutualgoals that allow for stewardship of resources forboth the beneficiary and the healthcare system. Byworking collaboratively with the healthcare team,case managers help patients identify care options thatare acceptable to those patients and their families.This approach promotes adherence to the treatmentplan, increasing the rate of successful outcomes andreducing fragmentation of care. Effective CM in theMHS directly and positively affects the social, ethical,and financial well-being of DoD populations as well asthe greater communities served by the MHS.The Military Case ManagerRelationship building is a key factor in reducingstress when a patient is faced with life-alteringevents, as well as in helping him/her successfullyattain treatment goals. A common strategy forcase managers in managing ADSM care is to keeppatients informed and help them resolve care-relatedissues. This inspires confidence in the patient and his/her family that the case manager is the go-to personfor guidance and assistance. For example, ADSMfamilies may be required to move frequently as dutystations change; case managers can be proactive inhelping them secure access to medical services bycoordinating the CM assessment and the patient’streatment plan with the receiving case manager priorto the move date.The military case manager’s primary role is asadvocate for the patient and his/her family withinthe MHS. This is a vital support function for youngADSMs coping with complex medical conditions,particularly during deployment. Case managers mustknow how to recognize and ease symptoms of stressand anxiety from illness and injury in ADSMs as wellas the associated effects on family members. One ofthe most important roles a case manager can play inthe military environment is to educate the ADSM andhis/her family about how to become their own bestadvocates.The military case manager must remain in closecommunication with the Managed Care SupportContractor (MCSC) to facilitate a smooth transitionwhile avoiding duplication and fragmentation ofservices (see also Section I, Medical ManagementEssentials, TRICARE and Other BenefitPrograms, Working with Managed CareSupport Contractors). MTF CMs work closely withMCSC CMs to exchange feedback and clinical dataon the patient’s status and to promote uniformdocumentation of that data.

Medical Management GuideVersion 3.0Case ManagementPage 61Given the environment in which the ADSM isemployed and the various regulations that governa Service member’s employment, military casemanagers need to be knowledgeable about:• Characteristics of the beneficiary populationcompared with the general U.S. population.• Military regulations and policies —operational requirements may affect internalCM processes, locations for care, or caredelivery timelines.• The transient nature of the military populationworldwide and within different Services.• The presence of multiple MCSCs.• Special populations that require CMintervention (i.e., wounded warriors).Further, military-specific designations, programs,and offices may influence CM processes (examplesare listed in Fig. 14).Military case managers also must understand theTRICARE benefit and how other health benefitprograms interface with TRICARE (see SectionI, Medical Management Essentials, TRICAREand Other Benefit Programs). Case managerscan help patients secure the greatest possiblebenefit by demonstrating knowledge of eligibilityrequirements associated with these programs;patient/family preferences, financial situation, anddegree of access to services; and expected level offamily/caregiver support.CD-ROM Resources CM-1 and CM-2 presentarticles related to military CM. See also RecoveryCoordination Initiatives, later in this section.Military-Specific Programs*• Active Duty Medical Extension (ADME) – Army,Reserves• Active Duty member casualty/Wounded WarriorProgram – All service branches• Assignment to Medical Hold• Command-directed programs• Convalescent leave• Special Needs Assignment IdentificationCoordination (SNAIC) – Air Force• Extended Care Health Option (ECHO)• Fitness for Duty• Geographically Separated Units (GSUs)• Limited Duty - Navy• Line of Duty (LOD) investigations – All servicebranches• Mandatory TRICARE enrollment requirements• Medical Evaluation Board (MEB)• Physical Evaluation Board (PEB)• Medical Retention Processing/ReserveComponent –Army• Military Medical Support Office (MMSO)• Non-traditional beneficiaries entitled to militarymedical care (i.e., secretarial designees, refuges,NATO members)• Patient tracking relative to absent sick status– Army• Post-Deployment Health Assessment (PDHA)• Post-Deployment Health Re-assessment (PDHRA)• Temporary disability retired list (TDRL)• Warrior Transition Unit (WTU) – Army• Warrior Transition Battalion / WTB*See also Appendix C - DefinitionsFig. 14 – Military-Specific Designations, Programs, andOffices

Page 62Case Management Version 3.0Medical Management GuideCASE MANAGEMENT COMPONENTSCase Management begins with theidentification of individuals with chronic,catastrophic, or complex, high risk, and/orhigh-cost health issues who meet applicable CMcriteria and would likely benefit from CM services.This identification process involves the followingthree steps:• Beneficiary Identification/Case Finding• Case Screening• Case Selection1. Beneficiary Identification/Case Findingfunctioning.• Cases affected by family and/or military circumstances.• Catastrophic, extraordinary conditions (e.g.,transplants and head injuries) that incur highcosts or require substantial resources.• Chronic conditions complicated by traumaticevents.• High-risk, multiple, or complex conditions ordiagnoses.• Whether there is a need for closer coordinationand interaction between the patient andhealthcare team.• Requirements for extensive monitoring.Beneficiaries may be identified and referred for CMservices at any point in the healthcare continuum.When trying to identify potential candidates forCM, military case managers should consider thefollowing:• Cases complicated by psychosocial or environmentalfactors that can affect the patient’sability to achieve optimal health or maintainThe case manager may also identify posthospitalizationcare requirements candidates forCM by participating in preadmission programs ordischarge planning meetings, or by interfacing withward or clinic staff.Sources for case finding include, but are not limitedto, the items listed in Fig. 15.Potential Sources for Case FindingAdmission and Disposition (A&D) listsDaily inpatient census reviewComposite Health Care System (CHCS) adhoc reportsDaily inpatient ward roundsEmergency Department (ED)/Urgent CarerostersExceptional Family Member Program(EFMP)/Special Needs Identification andAssignment Coordination (SNIAC) ProgramPrimary Care Manager (PCM) orspecialty care reports/referralsSelf/family membersUtilization Management (UM)/DiseaseManagement (DM)Referral/Consult Management (RM)Managed Care Support Contractor (MCSC)Unit Manning Document (UMD)Other sources, as necessary, per MTFFig. 15 – Potential Sources for Case Finding

Medical Management GuideVersion 3.0Case ManagementPage 63The case manager evaluates referrals using criteriaidentified in the CM plan to ascertain whether thebeneficiary has either CM or care coordinationneeds. One way for providers to refer patients isthrough completion of Standard Form (SF) 513,which may be sent electronically through the ArmedForces Health Longitudinal Technology Application(AHLTA) or other approved electronic systems (seeSection V, Medical Management Tools).CD-ROM Resources CM-3 and CM-4 provideblank and completed versions of SF 513.An approach known as “predictive modeling”(Meek, 2003) may be used to identify a narrowlydefined group of patients for CM (see Section I,Medical Management Essentials, andCD-ROM Resources MME-2 and MME-3).The John Hopkins Adjusted Clinical Groups (ACG)Case-Mix System measures morbidity by, amongother things, forecasting healthcare utilization. TheACG system evaluates patient populations based ondisease patterns, age, and gender.More specifically, the Johns Hopkins ACGmethodology is used to:• Predict high-risk users for inclusion in CM.• Determine government- or employer-budgetedpayment to health plans.• Allocate resources fairly within programs.• Set capitation payments for provider groups.• Evaluate access to care.• Assess the efficiency of provider practices.• Improve quality.• Monitor outcomes.For more information, go to: http://www.acg.jhsph.edu/html/AboutACGs.htm.Triggers for Potential ReferralThe MHS supports a population-based approachto CM, which coordinates care and services forgroups with similar characteristics. Coordinatingcare for groups of people before they are at riskis a key preventive measure in Population Healthimprovement. (See Executive Summary,CD-ROM Resource ES-1, 2001 DoD PopulationHealth Improvement Plan and Guide, or go to:http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf. Publication of the next iteration ofthe Guide is expected in summer 2010. See alsoSection I, Medical Management Essentials,The Link between Medical Management andPopulation Health.)The following are appropriate triggers for referral toCM (see also Section II, Utilization Management,Referral Management). Sometimes referral isbased on a diagnosis, condition, or family situation,but other factors include:• Spinal cord injury.• Head injury – traumatic and non-traumatic.• Serious trauma.• Psychological disorder (including suicide risk).• Multiple chronic illnesses.• Cancer diagnosis.• Neonatal Intensive Care Unit (NICU) admission.• Transplant* or burn.• Dual diagnosis.• Blindness.• Amputation.• Poly-substance abuse (can be a result ofpolypharmacy — when the patient hasbeen prescribed seven or eight concurrentmedications).

Page 64Case Management Version 3.0Medical Management Guide*May not be based on regional contract. Mosttransplant contracts occur in the civilian system. Inthe MTF, the case manager may coordinate with theMCSC on this type of referral.Additional factors that may trigger a referral to CMare:• Non-adherence to the medical treatment plan.• A need for care coordination between multipleproviders/facilities.• Complicated family dynamics that interfere withrecovery and maintenance of wellness.Case managers working in an Air Force MTF shouldcontact their Health Care Integrator (HCI) anddisease manager to coordinate efforts. Army orNavy case managers should contact their PopulationHealth department.2. Case ScreeningA beneficiary may qualify for CM if that patientrequires close collaboration and/or communicationbetween healthcare team members, due to thecomplexities of his/her condition/disease and/orsocial situation. If the beneficiary does not meetscreening criteria for CM enrollment, the casemanager contacts the original referral source tocommunicate the reasons and offer alternativeassistance, if available. Nonetheless, the casemanager may provide disposition planning andassistance to the patient and act as a referencesource for immediate, pressing issues.(Refer to CD-ROM Resource CM-5 for CMscreening criteria.)MTFs should target specific patient populations forCM based on the local CM or MM plan and policiesgoverning MCSC contracts. Case managers shouldgive priority to ADSMs. As noted in the TRICAREPolicy Manual (available at http://manuals.tricare.osd.mil/), some of the more common conditions/diagnoses that require CM in the MHS includetraumatic brain injury (TBI), burn patients, andinfants admitted to the NICU. When performing dataanalysis of utilization rates, frequent or prolongedhospitalizations and treatments (e.g., chemotherapy,pain management, use of monitoring equipmentfor uterine conditions or apnea) may be a “red flag”indicating patients who could benefit from CMservices. The utilization manager can obtain andanalyze relevant data and make referrals to CM (seeSection II, Utilization Management).3. Case SelectionIf the beneficiary meets the screening criteria, thecase manager will meet with the beneficiary andoffer him/her enrollment into CM. If the beneficiaryaccepts the offer for CM services, the casemanager will provide his/her contact informationto the beneficiary. As part of the process ofdeveloping a treatment plan, the case managershould also perform an assessment/risk appraisalof the level of severity of the beneficiary’scondition and/or the complexity of care required(see CD-ROM Resource CM-6).Case managers should also provide the beneficiaryand his/her family with an introductory letter,enrollment form, and/or marketing brochureexplaining CM (see Promoting Your Program,later in this section, and CD-ROM Resource

Medical Management GuideVersion 3.0Case ManagementPage 65CM-23). The introductory letter should explain thecircumstances in which information is released toother entities, and how and when the beneficiarywill receive written notification of the plan ofcare (refer to CD-ROM Resource CM-7 for asample introductory letter).When a beneficiary agrees to be case managed,the case manager must obtain written consentfrom either the beneficiary or his/her legal guardianprior to acting on the beneficiary’s behalf. Writtenconsent is a legal requirement that allows the casemanager to discuss and arrange the beneficiary’streatment plan with other parties. (Refer toCD-ROM Resource CM-8 for a sampleauthorization form for disclosure of medicalinformation and CD-ROM Resource CM-9 foran original informed consent form.)If the beneficiary or his/her legal guardian declinesCM services, or if the beneficiary is not acceptedinto CM, the case manager should document thedeclination or reason for non-acceptance in thebeneficiary’s outpatient medical record. The primarycare manager (PCM) and the individual who madethe initial referral should also be notified of thedecision. The beneficiary can be re-referred if his/her status or environment changes. (Refer toCD-ROM Resource CM-10 for a non-acceptanceletter and CD-ROM Resource CM-11 for aninability to contact form.)As part of the enrollment process, the case manageradds the beneficiary to the CM caseload database,which allows for efficient beneficiary tracking,continuity of care, outcome measurement, andreporting.The Six-Step Case Management ProcessAfter completing the preparatory steps ofbeneficiary identification/case finding, casescreening, and case selection, the case managerperforms the six basic steps of CM:1. Assessment2. Planning3. Implementation4. Coordination5. Monitoring6. EvaluationFig. 16 illustrates the six-step CM process.These essential steps constitute key activities thatare systematic, yet dynamic. Your individual ServiceBranch will have established timelines for how longyou have to contact a patient and to complete apatient plan of care, and for how often you mustfollow up with your patient and document theplan. For more information on the specific policiesof your Service Branch, contact your supervisor ordepartment head.6. Evaluation5. Monitoring4. Coordination3. Implementation2. Planning1. AssessmentFig. 16 — The Six-Step CM Process

Page 66Case Management Version 3.0Medical Management GuideThe six steps of CM are described in more detailbelow.decision. If a CM case is opened for the patient, thenext step is to develop a plan of care.1. Assessment2. PlanningAssessment is a systematic, ongoing activity thatinvolves collecting comprehensive information abouta patient’s situation, including all relevant sources(military and civilian) to identify individual needs.This includes speaking with the patient, caregivers (ifappropriate), and healthcare providers — especiallythe PCM. Fig. 17 describes categories of assessment.According to the NCQA (July 2007), case managersneed to address the following areas pertaining totheir patients:• Current health status, including conditionspecificissues and co-morbidities• Clinical history, including medications• Activities of daily living (ADLs)• Caregiver resources• Available benefits• Mental health status• Advanced directives• Cultural and linguistic needs, preferences, orlimitations• Financial considerationsBecause the assessment process may require thecase manager to make multiple contacts, it cantake several days to complete an assessment. Oncethe assessment is complete and problems havebeen identified, determination is made whetherCM criteria have been met and whether to open aCM case. If the decision is not to open the patientto CM, the patient is provided with appropriateresources and the referring party is notified of thePlanning involves determining specific objectives,goals, and actions designed to meet the patient’sneeds as identified during assessment. Once thepatient is accepted into CM, a plan of care isdeveloped. The purpose of the plan is to:• Address problems.• Set short- and long-term goals.• Identify barriers to reaching the stated goals.• Identify actions that can be taken (i.e.,interventions) to resolve any barriers to achievingthose goals.Problems may include:• Lack of patient access to appropriate specialistsor community resources.• An inadequate patient support system.• Inappropriate pain management.Goals may include:• Short-term goals — e.g., patient access toappropriate specialists or community resources.• Long-term goals — e.g., the patient’s ability toeffectively self-manage pain.A time frame is assigned for meeting each goal.It is important to keep the following considerationsin mind:• CMSA standards of practice state thatmeasurable goals must be established. Goalsthat promote cost-effective, quality outcomesmust be included in the plan of care and createdin collaboration with the patient and family.

Medical Management GuideVersion 3.0Case ManagementPage 67Assessment SubjectDemographicInformationMedical HistoryVocational InformationHealth Status/Systems ReviewCurrent/ProjectedResource UtilizationPsychological StatusCommunity/SocialSupportHealth Risk AssessmentHome/EnvironmentAssessmentCategories of AssessmentDescription• Name, social security number (SSN)• Service branch• Cultural considerations• Financial class (e.g., TRICARE, other health insurance, other benefits)• List of treating physicians, specialties, addresses, telephone numbers• Spiritual needs• Advanced directives/living will/power of attorney• Ancillary services• Pharmacology/use of pharmacy services• Education• Impact of health on work status• Occupation• Age-specific considerations• Health status perception• Learning abilities/comprehension• Community/workplace reintegration• Custodial care needs (activities of daily living)• Durable medical equipment (DME) requirements• Home environment/living arrangements• Medical/functional/disability/rehabilitation status• Beneficiary’s diagnosis/prognosis, short/long-term goals• Rehabilitation potential• Skilled and less-than-skilled nursing needs (hrs/day, days/week, daily visits, intermittentvisits)• Beneficiary’s/family’s emotional status• Beneficiary’s mental status• Compliance issues• Substance abuse issues• Understanding/acceptance of current problem• Age-specific considerations• Assessment of interrelationships between family members• Beneficiary/family propensity for support• Caregiver support system• Cultural considerations, including language barriers• Family members’ perception of their care/support role(s)• Marital status• Need for community resources• Spiritual support• Support system (beneficiary, caregiver, community, faith-based)• Clinical practice guideline (CPG) screening questions• Clinical preventive services• Fall risk• Beneficiary’s living arrangements• Presence of primary caregiverFig. 17 — Categories of Assessment

Page 68Case Management Version 3.0Medical Management GuideGoals/outcomes must also reflect input from theentire healthcare team.• Goals for the individual patient are defined aftera thorough patient assessment is completed.At that point, the case manager addresses theproblems that have been identified. Goals/outcomes are defined based on the resolutionof those problems.o For example: Patient A needs specialtycare that is not readily available in thearea where he/she lives. The goal is toprovide access to the needed specialist.The case manager's interventions aretargeted toward linking the patient withthe specialist in a manner that is accessible,affordable, and reliable. When the linkbetween specialist and patient is validated,the problem is resolved and the goal ismet. The outcome is appropriate and timelyspecialty care, when needed.• Individual goals must be re-evaluated whenpsychosocial, medical, or financial changesoccur. Treatment and plans of care must beadjusted accordingly.Multiple actions/interventions may be assigned inresponse to each barrier; these may include:• Providing research on appropriate and availablespecialists within the MTF/network who canmeet the patient’s medical needs.• Obtaining a list of all medications the patientis taking, including name of prescriber(s) andpharmacy(ies) dispensing the medications.• Requesting referral to a pain clinic.The plan of care must be agreed to by the patientand the PCM, and all parties must sign it. The planshould include contacts for medical/behavioralhealth providers; resources to be explored;verification of medications to be taken; and anassessment of housing needs, transportation, andlevel of caregiver support.The plan of care is meant to optimize Direct CareSystem (DCS) and Purchased Care System (PCS)resources, special health-related programs, and otherfederal/national/state/local agencies and resources.3. ImplementationBarriers may include:• Transportation not being available for patientvisits to a specialist.• Multiple prescribed medications from variousproviders (i.e., polypharmacy), with the patientunable to manage his/her pain.• The patient being unaware of availablecommunity resources.There are usually several barriers associated witheach problem, which in turn serve to further definethat problem.Implementation involves executing actions/interventionsidentified in the plan of care that willlead to accomplishing stated goals. This processstep necessitates communication betweenhealthcare team members, including the patientand his/her family or caregiver(s). At the outset ofimplementation, the case manager should discussthe goals of the plan of care with the patient andhis/her caregiver(s). This includes advising them theywill continue to be a resource for the case manageruntil such time that problems have been resolved

Medical Management GuideVersion 3.0Case ManagementPage 69and goals met — at which point, the patient/caregiver(s) can self-manage.The case manager activates the actions/interventions described in the plan of care, anddocuments the following types of information:• Date(s) of contact.• Who was contacted.• The purpose of the contact(s).• What was discussed.• The outcome of the discussion(s).• The specific plan for next action/intervention,including the scheduled date.During implementation, all elements of CMstandards of practice must be adhered to alongwith other applicable guidelines, including clinicalpractice guidelines (CPGs). The following resourcesmay be useful in this effort:• VA and DoD CPGs: https://www.qmo.amedd.army.mil/pguide.htm.• The Agency for Healthcare Research andQuality (AHRQ): http://www.ahrq.gov/. TheAHRQ has published and disseminated nationalCPGs for more than 19 clinical subjects. Theseare accessible through the National Library ofMedicine’s Medline service: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi.Refer to Section IV, Disease Management, formore information on CPGs.4. CoordinationCoordination involves organizing, securing,integrating, and modifying the necessary resourcesto accomplish the goals set forth in the plan ofcare. This step directs the patient to appropriateservices to achieve seamless and timely continuityof care. Coordination is achieved by identifyingpatient needs and applying appropriate actions/interventions (see also Step 2, Planning).Coordination of activities helps case managers:• Avoid duplication of services.• Ensure timely and appropriate provision ofservices.• Identify barriers to care delivery and exploredelivery alternatives.• Match patient needs with available resources.• Optimize healthcare resources in the MTF andlocal community.• Organize and manage the activities outlined inthe plan of care.• Ensure all care providers receive necessaryinformation in a timely manner.Depending on the availability of services or agenciesin the local area, the MTF case manager may needto coordinate with the MCSC. Access to communityresources from all levels — local, state, and national— will facilitate coordination of services.5. MonitoringMonitoring involves gathering information fromrelevant sources on an ongoing basis with regardto healthcare activities and services, and to patientadherence to the treatment plan. Case managersconduct monitoring to determine whether plannedpatient goals have been achieved and how effectivethe process is for achieving them.

Page 70Case Management Version 3.0Medical Management GuideDuring monitoring, the case manager:• Ensures timely and appropriate care is providedbased on the patient’s changing health statusand/or environment.• Ensures timely patient/family and healthcareprovider contact and follow-up.• Establishes and documents progress towardsmeeting plan-of-care goals.• Identifies variance(s) from the plan of care andrevises the plan accordingly.• Monitors the result of actions/interventions andcare delivery.• Monitors utilization of healthcare resources.The case manager will continually assess andmonitor the patient’s response and adherence totreatments, and decide whether services shouldcontinue or new services should be implemented. Inthis respect, monitoring dovetails with assessment.Monitoring also includes collecting and trackingdata.6. EvaluationEvaluation is a continuous step in which the casemanager measures the patient’s response to thehealthcare services being delivered. The casemanager uses critical thinking skills to analyze thedata obtained during monitoring and revises theplan of care to respond to the patient’s ongoingneeds.As part of this step, the case manager must make acomprehensive routine assessment of the patient’sstatus and progress toward meeting the goals statedin the plan of care. If no progress is noted, the casemanager should determine the reason and revisethe plan of care to include interventions that willpromote the identified goals.Other measures of care may include patient/caregiver and healthcare team satisfaction, as well ascost savings.Case ClosurePlanning for case closure begins at the time thepatient is accepted into CM. The consistent goaland measure of success of a plan of care is that thepatient/caregiver(s) be able to self-manage — thatis, to advocate for themselves. Early in a case, it isappropriate for a case manager to make referrals,contact providers, and research resources. As thecase progresses, that responsibility needs to betransferred to the patient/caregiver(s), as appropriate.As the case manager works with the patient/caregiver(s), he/she acknowledges successes in thepatient’s progress toward greater self-sufficiency.As the case manager assesses a patient’s progresstoward meeting the goals established in the plan ofcare, the case progresses toward closure.Sometimes not all goals are achieved. A case mayappropriately be closed based on circumstances suchas failed adherence to treatment regimes, changein eligibility, or even death. In some circumstances,it may be useful to conference with another casemanager in making the decision about whether toclose.When the decision to close a case is made, the casemanager undertakes the following steps:

Medical Management GuideVersion 3.0Case ManagementPage 71• Communicates the patient’s status withthe patient/caregiver(s), provider, and othermembers of the healthcare team; and informsthem of the reason for the closure decision.• Documents a summary CM note in the patient’soutpatient record and documents the closureon the CM tracking log. (Refer to CD-ROMResource CM-12 for a sample case closuresummary form.)• Documents the closure on the CM tracking logor an electronic form such as the ones availablethrough the Air Force’s Access ImprovementModel (AIM). (Refer to CD-ROM ResourcesCM-13 and CM-14 for sample AIM forms.)DocumentationAs with all other parts of the medical record, documentationis critical in providing a legal record ofpatient care. The case manager should documentall activities of the plan of care and CM process,including interventions with healthcare teammembers, health status updates and progress, newproblems, and changes in goals. Most importantly,all encounters with the patient and family shouldbe documented, whether those communicationsare face-to-face, by phone, by e-mail, or throughanother virtual method.Documentation guidelines vary depending on localor Service-specific policies. Complete and correctdocumentation must meet standards established byThe Joint Commission (TJC) and other professionalorganizations (see Appendix D, Resources). It isrecommended that the documentation occurs inthe Armed Forces Health Longitudinal TechnologyApplication (AHLTA) and is coded appropriately.(See Section V, Medical Management Tools,CD-ROM Resource MMT-1 for more informationon AHLTA, sample screenshots of AHLTA templates,and guidance on how to appropriately code patientencounters.)It is recommended that a satisfaction survey be sentto the patient/caregiver(s) and to provider(s) as anoutcome measure for feedback on CM services.Other outcome measures would be performed atthis time, including on how the CM services affectthe population health of the MTF ( CD-ROMResources CM-15 and CM-16 provide samplesurveys). See also Outcome Measurement andManagement, below.Outcome Measurement and ManagementMM outcomes are measured based on quality,cost, access, and readiness (see Section I, MedicalManagement Essentials, including Fig. 2, MHSMedical Management Model). In CM, patient andprogram outcome evaluation should be performed.Patient outcome evaluation is an integral part of theCM process and measures patient outcomes usingclinical, functional, and/or satisfaction indicators.Program outcome evaluation focuses on how CMaffects healthcare delivery.Patient-level evaluation usually involves outcome-basedmeasurements, while program-level evaluation usuallyinvolves process-based measurements. Fig. 18 describessample patient and program evaluation outcomes.

Page 72Case Management Version 3.0Medical Management GuideSample Patient and Program Evaluation Outcomes (Local Level)Patient Outcomes• ClinicalMedication compliance (refills, blood pressure, labvalues)Reduced LOSReduce readmissionsUse of more appropriate levels of careCost avoidance• Psychosocial• Functional• QualityPain and comfortCondition state — functional, cognitive, quality oflife, physiologic indicators• FiscalCost per visitSpecific cost reductions• Lab tests• Medical supplies• PharmaceuticalsProgram Outcomes• Difference between the number of acute careadmissions before and after CM is initiated• Difference between the number of clinicappointments before and after CM is initiated• Difference between the number of ED visits beforeand after CM is initiated• Efficiency• Fiscal impact• High utilizers• Quality• WorkloadNumber of patients initiated into CM per monthNumber of CM cases closed per monthNumber of referrals to DM per monthNumber of referrals (accepted/denied) to MCSC permonth• Prevention InitiativesNumber of women/men who have receivedprevention screening (e.g., Paps, prostate screenings)Number of children with current immunizations• ServiceNurse staff satisfactionInterdisciplinary staff satisfactionPatient satisfaction• Follow-up call• Increased access• Increased trust and confidence in the MHS• Reduced patient complaints• Reduced wait timesFig. 18 – Sample Patient and Program Evaluation Outcomes

Medical Management GuideVersion 3.0Case ManagementPage 73Patient Outcome EvaluationSuccessful patient outcomes are based on what isexpected to happen as a result of the course of thedisease and the effect of CM interventions. Whenthe case manager focuses on patient needs anduses a carefully constructed collaborative plan ofcare, individual goals will be met and the outcomewill be cost-effective, high-quality care.As discussed in Section I, Medical ManagementEssentials, there is a preventive model to measurecause and effect in MM interventions that includesthree phases: primary prevention, secondaryprevention, and tertiary prevention. Based on thismodel, success (achievement of outcomes) can beunderstood as slowing, halting, or reversing either a)advancement within the same phase or b) transitionto the next phase.outcome classification system. This system aims atevaluating the CM model used. That model must bestandardized across the MTF and used by all casemanagers (Cesta, et. al.).There is no best system for measuring outcomeindicators. Organizations should identify the onethat works best for their providers and customers.Indicators must be measurable — i.e., basedon cost per case type or episode of care/illness.Organizations also must delineate the frequencyof data collection, the sample, the formulas to beapplied in the analysis, and the reporting format.Some organizations may classify the patient’sfunctional ability as independent from clinicalindicators, while others may combine the twoaspects in conducting their analysis. It is importantto define whether the indicator is a patient/family orhealthcare organization-related indicator.Regardless of which CM model is implemented, itis essential to have a measurement system in place.In addition to measuring outcomes, this systemmust also identify the process of data collection,aggregation, analysis, and reporting (Cesta, Tahan,Fink, 2002). Because of their responsibilities, casemanagers should make sure to track outcome datafor the patients in their caseload to determinethe effectiveness, efficiency, and efficacy of CMservices.The success of a CM system depends to a greatdegree on how well case managers employoutcome data to manage, plan, facilitate, expedite,advocate, coordinate, and evaluate the delivery ofpatient care. To enable case managers to executethis role, it is important for the MTF to establish anFig. 19 presents examples of patient-relatedoutcome classification.Program Outcome EvaluationCM program outcomes should be measured basedon CM program goals and the MTF’s strategic plan.Once specific outcomes have been determined,the data must be reported through the Chain ofCommand in order to gain value. (Refer toCD-Resource CM-17 for sample CMmeasurement reporting tools, including preventableadmissions, two quantitative cost avoidance/savingsreports, and qualitative savings — see differenttabs in file.) Fig. 20 presents examples of healthcareorganization-related outcome classification.

Page 74Case Management Version 3.0Medical Management GuideClassificationPatient/Family-Related OutcomesClinical• Improved patient care outcomes, such as reduced/controlled pain, morbidity, and mortalityrates.• Reduction in signs and symptoms of disease and degree of progression of the disease.• Prevention of adverse effects of treatments and complications of illness.• Reduction in practice variation.Financial• Optimal and appropriate use of resources and services.• Provision of care in appropriate setting(s) level of care.• Maximal coordination of care among providers.• Streamlining of diagnostic and therapeutic tests and procedures.Quality of Life• Improved/maximized physical abilities and level of independence.• Improved psychological, physiological, and social functioning.• Improved state of well being.• Improved perception of health status.• Enhanced self-care abilities/skills.• Enhanced knowledge of healthcare needs.Satisfaction• Increased patient/family satisfaction with care.• Improved continuity of care.• Improved patient-nurse and family-nurse relationships.Source: T Cesta, H Tahan (2003): Case Manager’s Survival Guide Winning Strategies for Clinical Practice, 2nd Edition, p. 100-103(Seminar Nurse Manager), Mosby.Fig. 19 – Example of Outcomes Classification: Patient-RelatedOther program measures may include preventable admissions rates, a measure that can be stratified bydiagnosis. For example, a potential enterprise measurement for DM is the preventable admission rate forCM patients with a primary diagnosis of asthma, diabetes, or congestive heart failure (CHF) compared to thepreventable admission rate for non-CM patients with the same diagnoses.CM outcome measures should be patient-centered and within the context of the organization’s overall businessplan. If care decisions are challenged by constraints within the facility’s business plan, the case manager shouldcollaborate with UM to resolve the dilemma in the most cost-effective manner without compromising quality.These circumstances may warrant a CM team meeting or case conference with other MM professionals andmembers of the healthcare team. In such cases, it is important to document any variances in the patient’s planof care that will have a direct impact on the outcome measure.

Medical Management GuideVersion 3.0Case ManagementPage 75ClassificationHealthcare Organization-Related OutcomesClinical• Standardization of care processes (establishing standards of care/case management plans).• Streamlined care processes and delineation of responsibilities.• Improved turnaround time of tests, treatments, and procedures.• Increased compliance with standards of regulatory and accreditation agencies.FinancialQuality of LifeSatisfaction• Appropriate changes in staff mix/skill mix.• Reduced cost (e.g., reduction in length of stay, reduction in or elimination of fragmentationand duplicate services).• Improved reimbursement and revenue.• Reduction in denials of claims.• Improved communication among providers and healthcare staff.• Prevention of inappropriate hospitalizations.• Reduction in inappropriate utilization of Emergency Department services.• Provision of a safe environment of care.• Provision of programs that meet patient and family needs.• Improved accessibility to care/services.• Improved staff satisfaction.• Reduced rates of burnout, turnover, attrition, and absenteeism.• Enhanced states of communication, collaboration, and teamwork among providers anddisciplines (interpersonal, interdisciplinary, and interdepartmental).Source: T Cesta, H Tahan (2003): Case Manager’s Survival Guide Winning Strategies for Clinical Practice, 2nd Edition, p. 100-103(Seminar Nurse Manager), Mosby.Fig. 20 – Example of Outcomes Classification: Healthcare Organization-RelatedFig. 21 lists examples of CM outcome measures.Measuring program outcomes allows CM to support and objectively track improvements in healthcareprocesses or any decline in patient progress. Outcome measurement enhances compliance with regulatoryand accreditation requirements and standards of practice; and reduces risk by demonstrating compliance withhealthcare quality guidelines.Cost-Benefit AnalysisCM activities can have a significant impact on an organization’s business plan. When case managers developeffective outcome measures, they demonstrate value to their MM department and the organization as a whole.

Page 76Case Management Version 3.0Medical Management GuideExamples of CM Measures• Timeliness of service• Cost avoidance to the Direct Care System(DCS)• Relative Weighted Product (RWP)/RelativeValue Unit (RVU) impact of a CM intervention• Recaptured care as a result of CMcoordination• Access to specialty care services as a result ofCM coordination• Beneficiary satisfaction• Reduced hospital admissions• Patient knowledge of the healthcaretreatment plan and benefits• Improved provider/patient interaction• Measures of clinical improvement• Appropriate utilization after CM intervention• Hospital readmissions rate before and afterCM interventionFig. 21 – Examples of CM MeasuresOutcome measures validate:• What is effective.• What is not effective.• The cost of an intervention.• Return on investment (ROI).A cost-benefit analysis is performed to helpdetermine a) whether to make a change or b) howwell a planned action (e.g., implementation of aprogram) may turn out.A cost-benefit analysis relies on adding up positivefactors and subtracting negative ones to determinea net result. The technique is to simply add up thebenefits of an action/intervention and subtractthe costs associated with that action/intervention.The cost-benefit analysis is closely linked to the“evaluation” aspect of the CM process. As thecase manager coordinates services and makesrecommendations for care options, he/she shouldconduct an ongoing cost-benefit analysis regardingthose choices.Another method of demonstrating value is totrack and calculate costs that were avoided.Using a log to collect data of your caseload is astraightforward method for expressing quantity andcost effectiveness. (Refer to CD-ROM ResourcesCM-18, CM-19, and CM-20 for examples of CMcaseload logs.)According to Kongstvedt (2001), a cost-benefitanalysis report for CM should include the followingelements:• Overview of CM intervention (a brief narrative).• Summary of intervention.• Actual charges.• CM fees.• Savings (e.g., avoided or potential charges;discounted and negotiated reductions;reductions in services, products, and/orequipment).• Gross savings (potential charges minus actualcharges).• Net savings (gross savings minus CM fees).• Status of the case (opened or closed).

Medical Management GuideVersion 3.0Case ManagementPage 77CM Hard and Soft SavingsHard Savings or Avoided Costs*• Change in the level of care facilitated by CM• Change in the patient’s length of stay (LOS)• Change to a contracted PPO provider• Finding unauthorized charges that are notwarranted• Negotiation of duration of services• Negotiation of frequency of services• Negotiation of price of services, supplies, equipment,or per diem rates• Prevention of unnecessary bed days, supplies,equipment, services, or chargesSoft Savings or Potential Savings**• Avoidance of potential acute care days• Avoidance of potential costs, equipment, andsupplies• Avoidance of potential ED visits• Avoidance of potential home health visits• Avoidance of potential hospital admissions• Avoidance of potential legal exposure• Avoidance of potential medical complications• Improved patient/family satisfaction with CM• Improved patient compliance• Improved quality of care or quality of life*Measurably saved or avoided costs when facilitatedby the case manager.**Less tangibly measurable than hard savings.If no case manager was assigned to the patient,the potential costs incurred could have beenmuch more than with CM; they represent coststhat were avoided most likely because of CMintervention.Source: Powell and Ignatavicius, 2001Fig. 22 – CM Hard and Soft SavingsCost-benefit analysis takes into account both hardand soft costs incurred as a result of a selectedoption for care or a choice in service delivery.hours of care, preventing unnecessary bed days,or reducing the unnecessary use of supplies andequipment.Hard costs (or hard savings), also known as “avoidedcosts,” are measured in actual dollars when costsare measurably saved or avoided (Powell andIgnatavicius, 2001). Examples of hard costs mayinclude such items as hospital bills, physician fees,and medical supplies in which the case managerfacilitated a change in the level of care, the patient’slength of stay (LOS), or negotiated the frequencyor duration of services. Hard costs can show clearsavings as a result of eliminating duplication ofservices, reducing Emergency Department (ED)visits, transferring to lower levels of care, reducingSoft costs (or soft savings), also referred to as“potential savings,” are factors that may not havean exact dollar measurement but that incur a socialor personal cost to the patient. Examples of softcosts are lost duty time, avoided ED visits, reducedproductivity, and improved quality of life.Fig. 22 describes CM hard and soft savings.

Page 78Case Management Version 3.0Medical Management GuideESTABLISHING A CASE MANAGEMENTPROGRAMOrganizational FrameworkThere are multiple types of organizationalstructure for CM program assignmentin inpatient or ambulatory care facilities.Integrating all case managers within one designateddepartment or cost center before assigning themto individual duty throughout the inpatient andoutpatient areas is just one model that may add valueto the CM program. Hospital or facility size, availableservices, resources, and staff qualifications oftendetermine the program’s structure.The organizational structure of a CM program shouldabove all serve to support the practice of quality care.This includes ensuring there are a sufficient numberof:• Qualified case managers to service the population(see The Case Management Professional, laterin this section).• Data management systems to meetdocumentation and data mining requirements.• Support staff to assist the case managers in theirclinical management of patients.The program should also support national CMstandards of practice and encourage CM certification.Access to physician consultation, benefits advisors,decision support criteria (e.g., McKesson ® InterQual ®evidence-based clinical support criteria, MillimanCare Guidelines ® — see Section II, UtilizationManagement), decision support staff, andeducational resources are essential.GoalsMHS CM program goals include:• Establishing processes to proactively identifywounded, ill, or injured Service members whomeet the criteria for assignment to clinical CMas determined by Directive-Type Memorandum(DTM) 08-033, Interim Guidance for ClinicalCase Management for the Wounded, Ill, andInjured Service Members in the Military HealthSystem (Draft) —http://www.dtic.mil/whs/directives/corres/dir3.html. (See also CD-ROMResource CM-21.)• Creating and implementing comprehensiveperformance measures to facilitate appropriateand successful execution of clinical CM, asoutlined in DTM 08-033.• Establishing processes that will be used toimprove care as patients and their familiestransition along the continuum of care, ensuringseamless hand-off during transitions of care(TOCs) — see Transition/Coordination ofCare, Transition of Care, later in this section.• Establishing processes to proactively identifyother patients who meet the criteria for CM.• Ensuring services are rendered in a timely andcost-effective manner without compromisingquality of care.• Assisting patients in maintaining the maximumamount of autonomy and human dignity whilehelping minimize the impact of long-termchanges in living and occupational status, as wellas disability level.To successfully administer CM services, the MTFmust establish processes critical to the program. ACM program must target the right population for

Medical Management GuideVersion 3.0Case ManagementPage 79CM services. The “80/20 rule,” that 20 percentof the population is responsible for 80 percentof healthcare costs, should be a key conceptin directing CM interventions. MTFs shouldsystematically identify and analyze their populationto find high-risk and high-volume patients beforethey become high-cost patients.ImplementationWhen preparing a plan for CM programimplementation, you should address the followingquestions:• What is the process for case finding, screeningcriteria, and selection; and for deciding to enrolleligible beneficiaries into CM?• Which tools (i.e., clinical pathways, guidelines)will be used to track patient progress?• Which forms, computer software, or paperworkwill be required for documentation or charting?It is also important to be aware of challenges relatedto:• Patient safety during transition.• The degree to which collateral programs thatdirectly affect CM are integrated within theMTF.• The ability to secure reliable connectivitythrough technology.• The degree to which practices are standardizedamong case managers.The MTF’s program will be dynamic and evolvingas it matures from its initial stages. To assist inlaunching a new program, the Web-based MHSLearn CM modules course library provides a varietyof useful forms and tools for the case manager. Formore information, go to: https://mhslearn.csd.disa.mil.QualityAs discussed throughout this section, it isparticularly important to consider:• Care coordination procedures.• Case manager qualifications, roles, responsibilities,and job descriptions.• Discharge planning procedures.• Intra/interregional transfer policies.• Outcomes reporting.• Plans for process improvement.• Processes for local and regional networking.• Staff and beneficiary educational programs.• Standardized beneficiary screening criteria.• Problem resolution methods.• Unique ADSM requirements.Each CM department and program supports thequality program of the MTF Command. CM qualityprograms are geared toward process improvement,with CM departments offering Command-specifictraining and professional development programs forcase managers. Certification is one mechanism forenhancing quality by standardizing the individual/professional knowledge base for CM practice (seeThe Case Management Professional, later in thissection).Quality-based outcomes may include performanceindicators such as improved functional or healthstatus, enhanced quality of life, patient/family/provider satisfaction, adherence to the treatmentplan, improved patient safety, appropriate use of

Page 80Case Management Version 3.0Medical Management Guidehealthcare services, cost savings/avoidance, andpatient/caregiver self-management.Quality measures can be applied internally orexternally. For example, an internal qualitymeasure might involve supervisor review of casedocumentation to encourage standardization.External quality control measures can be establishedby Service-specific governing bodies. For example,Navy CM at the Bureau of Medicine and Surgeryprovides documentation reviews for quality andcompliance, which helps standardize documentationpractices among Navy MTFs and medical clinics.Performing a quality review supports the concept of“best practice.” The OCMO Healthcare InnovationsProgram is an excellent source for benchmark andprocess improvements: www.tricare.mil/ocmo/innovations.cfm.CaseloadThe various responsibilities involved in MM-relatedactivities can affect the case manager's ability toprovide comprehensive services. A major factor isthe number of case managers required in an organization,which depends on the composition (casemix/acuity) of the membership. A case manager’scaseload is dependent on many concurrent factors,including:• Characteristics of the patients served.• Complexity of the plan of care.• Geographical area covered.• Amount of administrative support.• Availability of community-based services.• Experience and competency of the casemanager.• Control over funds used in the delivery of care.Caseload assignment may also be influenced by:• The clinical needs of the patient.• The psychosocial needs of the patient/family.• Cognitive challenges to the patient.• Treatment adherence issues.• The demographics of the population served.• Geographic factors.The 2008 Case Management Caseload ConceptPaper, a joint publication of the CMSA and theNational Association of Social Workers (NASW),asserts that the clinical practice setting affects thepatient-to-case-manager ratio (refer to CD-ROMResource CM-22). For example, an experienced casemanager providing telephonic CM in an outpatientsetting can manage a higher caseload than an onsitecase manager in an acute inpatient setting. Page 22of the CMSA’s concept paper features a caseloadmatrix.Specifics in determining caseload assignmentsinclude:• Intensity of involvement by the case manager.• Frequency of interventions by the case manager.• Case acuity.• Skill training, roles, competencies, andexperience of case managers.• Breadth of the case manager’s responsibility.• The 2007 Dignified Treatment of WoundedWarriors Act (H.R. 1538), which determinescaseload assignments for the Medical Care CaseManager (MCCM).o No more than 17 wounded warriors inan outpatient setting are assigned to theMCCM.

Medical Management GuideVersion 3.0Case ManagementPage 81Assigning caseloads is a labor-intensive processthat includes creating and implementing the planof care, as well as maintaining documentation ofprogress toward target goals. Managing the balanceof tasks is a critical factor in helping case managersexperience job satisfaction in their day-to-dayresponsibilities. More specifically, assigning a genericratio of patients to a case manager (a “one ratiofits all” approach) does not support case managers’ability to consistently reach optimal outcomes fortheir patients. When determining what constitutesa manageable caseload, applying the CMSA’sresearch and lessons learned from implementinga CM program can generate an environment thatsupports the most desirable patient outcomes.Discharge PlanningDischarge planning helps sustain or enhancethe gains achieved from hospitalization for thecontinued health and welfare of patients andtheir families following discharge. Mullahy (1998)describes discharge planning as “assessing thepatient’s need for treatment after hospitalizationin order to help arrange for the necessary servicesand resources to affect an appropriate and timelydischarge.” Discharge planning can be providedin multiple settings, whether transitioning thepatient from an inpatient hospitalization to anotherinpatient facility or residential treatment facility; orfrom an inpatient to skilled nursing facility, homehealth care, or high-intensity outpatient services.Discharge planning is critical, as shorter hospitalLOS are typical. Ideally, discharge planning begins atpreadmission. In planning the appropriate discharge,the case manager must spend time speaking withpatients/caregiver(s) to determine what they needand are willing to do at the next level of care, andwhich resources are available at home. Supportcan range from video teleconferencing with aDepartment of Veterans Affairs (VA) polytraumacenter to holding conference calls with the family orfacilitating site visits.The staff nurse may perform discharge planningactivities when caring for the patient on theinpatient unit. However, the case manager isresponsible for overseeing discharge planningactivities and for executing the plan as designed.The discharge planning process includes thefollowing steps.1. Assessment. The discharge planner isresponsible for assessing every patient onadmission for discharge planning needs — ata minimum every 72 hours until discharge, perMcKesson InterQual guidelines (see SectionII, Utilization Management). The dischargeplan must align with the TRICARE benefit andpolicies. Therefore, it is also important forthe discharge planner to obtain informationregarding the patient’s enrollment status, as thisaffects the authorization of plan of care upondischarge.2. Referral. Consideration must be made if referralsneed to be sent to a social work case managerto address patient/family social issues or to makearrangements such as nursing home placement.Referral can also mean obtaining TRICAREreferrals and authorizations to execute thedischarge treatment plan. For example, a patientmay require assistance with home IV infusiontherapy. In this case, referrals and authorizations

Page 82Case Management Version 3.0Medical Management Guidewould need to be obtained for infusion therapyservices. Communication among home healthcompanies, the coordinating case manager, andthe ordering provider further serves to reconcilethe treatment plan with the service order.3. Formulation. Discharge planning can be verysimple or highly complex. It is best accomplishedusing an interdisciplinary approach to determinethe best plan for each patient. In Active Dutycases, the patient’s Command may have inputon the discharge plan.4. Implementation. The case manager will revieweach patient’s discharge plan with the patient/caregiver prior to discharge and enter theappropriate documentation in the patient’smedical record.5. Monitoring. Monitoring the quality andeffectiveness of the discharge planning processis a cumulative effort. The importance of timelyfeedback from providers, patients/caregivers,case managers, and discharge planners cannotbe overstated.Prior to discharge, the case manager mayrecommend a home assessment to anticipate allenvironmental needs in conducting a safe discharge.This is an important intervention, especially whenthe patient is coping with a severe disability thatmay involve complex mechanical assistance. Ifthe discharge is likely to be complicated, the casemanager may convene a pre-discharge planningmeeting to verify that both family members andhome care providers understand their roles, and thateveryone shares similar expectations and goals.The discharge plan should be family-centered andshould take into consideration:• Patient/family preferences.• Consideration of existing DoD/VA memorandaof understanding (MOUs).• TRICARE benefit parameters.• Qualifications for entitlement programs (e.g.,ECHO).• Previous experience with existing providers andfacilities.• Most appropriate provider/facility for thepatient.• Location of facility and providers, and theirability to meet patient/family needs.• Understanding of patient-specific goals.• The parent Command and PatientAdministration departments (if the patient is anADSM).• Impact on medical readiness and the DisabilityEvaluation System (DES) process.Barriers to effective and timely discharge planninginclude delays in completing discharge details,duplication of services, lack of patient focus, andinvolvement of available patient transport resources.Some root problems in discharge planning includelack of patient involvement/understanding of thedischarge plan, poor coordination/communicationwith the patient/family and/or caregiver(s), andpoor communication within medical providers.The patient must agree with the discharge plan tosupport maximum adherence.

Medical Management GuideVersion 3.0Case ManagementPage 83Care CoordinationCare coordination is a function of CM that involvesassisting individuals with complex circumstances (i.e.,circumstances that place them at risk for diminishedindependence) in gaining access to needed medical,social, educational, financial, and other servicesacross various organizations and providers. Theprocess coordinates the continuum of care forbeneficiaries whose needs exceed routine dischargeplanning but do not meet the requirements for longtermCM.Examples of patients who might benefit from carecoordination include those who:• Are at risk for a failed inpatient discharge plan.• Have special needs (e.g., children, the elderly,newly diagnosed diabetics, individuals withcatastrophic injuries).• Require extensive short-term coordination andmanagement.• Have greater-than-average needs identifiedduring pre-discharge planning that do not meetthe criteria for formal CM.• Have needs that require medium-intensityinteraction with the case manager.• Have acute, immediate needs that are notexpected to require continuous treatment inthe long term (e.g., patients receiving a hipreplacement).AccreditationWhile MCSC CM programs may be accreditedby URAC, the contract is not contingent onaccreditation. For more information on URAC’s mostcurrent CM program accreditation guidelines, go tohttp://www.urac.org/.The CMSA provides program accreditationinformation at http://www.cmsa.org/.Promoting Your ProgramWhether a CM program is being established or isalready in place, the key to sustaining the programis to optimize the department through marketing.Once your marketing strategy is established, you willwant to build a caseload (see Caseload, earlier inthis section). Here, the key decision is to expand theservices offered to other areas or sustain existingservices. CD-ROM Resource CM-23 provides asample CM marketing brochure. You may also wantto take advantage of promotional opportunitiesin Nurses Week, Social Workers Week, and CaseManagers Week to market your CM services.See Section I, Medical Management Essentials,Program Sustainment, for more details onpromoting MM programs.LEGISLATIVE GUIDANCE SPECIFICTO INTEGRATING PHYSICAL ANDPSYCHOLOGICAL REHABILITATIONTitle XVI of the National Defense AuthorizationAct (NDAA) of 2008, Wounded WarriorMatters, Section 1611, addresses thechallenges associated with caring for wounded,ill, and injured ADSMs and their families (seeExecutive Summary, CD-ROM Resource ES-4).In this section of the law, the NDAA outlines specificscreening, referral, and management requirementsfor identifying the signs of post-traumatic stressdisorder (PTSD), TBI, and BH conditions such assubstance abuse and suicide risk. The law placesparticular emphasis on identifying and reactingto these conditions in response to the increase of

Page 84Case Management Version 3.0Medical Management Guidethe increase of incidences of severe physical andpsychological trauma among Service membersserving in Global War on Terror (GWOT) missions,specifically, Operation Enduring Freedom (OEF) andOperation Iraqi Freedom (OIF) (see also AppendixC, Definitions).The ongoing deployments related to the GWOThave taken a disproportionate toll on ADSMsand their families. The incidence of PTSD hasincreased, especially in ADSMs experiencingmultiple deployments. TBI has been describedas the “signature injury” of OEF and OIF. Ofteninvisible, particularly in those with mild to moderateinjury, many of these cases were missed in theearly days of the conflict. Today, identification andtreatment of this condition is much improved. Nowall returning ADSMs are screened for blast exposureand TBI. It is not uncommon for an ADSM to bediagnosed with both PTSD and TBI, each of whichrequires treatment and intervention. These ADSMsneed and benefit from CM during their recovery,but early recognition and intervention are key tosuccessful rehabilitation.The intent of the NDAA is to ensure that allwounded, ill, and injured ADSMs have the benefitof both clinical and non-clinical CM, and that casemanagers working with wounded, ill, and injuredADSMs receive appropriate training, includingtraining on PTSD and screening for TBI. Becausepatients’ psychological health often affects theirphysical recovery, case managers must be trainedto recognize behaviors that may indicate substanceabuse, depression, or other psychological crisis. Inthis respect, case managers should become familiarwith normal coping mechanisms and the stages ofloss and grief.In many managed care models, physical andbehavioral services and care are segregated. Thisalso means that physical illnesses are assessed andmanaged independently of psychosocial conditions.Yet for those suffering from chronic or complexconditions, a common profile for wounded, ill,and injured Service members, segregated careresults in poor outcomes, higher utilization ofhealthcare services, and increased impairment anddisability.A patient with chronic disease is more likely to havebehavioral or psychosocial co-morbidities. Further,medical and behavioral complexities affect overallhealth outcome, use of healthcare services, qualityof life, and treatment adherence (Steifel, 2006).PTSD and TBI can place great stress on the ADSM’sfamily as well. The case manager plays a critical rolein identifying additional resources and programs thatenhance the ability of family members to cope withand manage the challenges associated with a PTSDor TBI diagnosis.Additionally, the case manager’s body ofknowledge should include an understanding of thefollowing factors that can affect ADSM patients:• Cultural issues, including those faced by patientsliving in foreign countries.• Family dynamics and the impact of the militarylifestyle on families.• Health expectations and behaviors, includingdemands placed on fit warrior expectations.• Psychological and neuropsychologicalassessments, especially post-deployment anddepression screening.• The psychological impact of chronic illness anddisability.

Medical Management GuideVersion 3.0Case ManagementPage 85• Substance use/abuse/addiction, including theuse of dietary supplements.Disability Evaluation SystemWhen an ADSM suffers from an injury or a chronicillness, the MTF’s primary responsibility is to providemedical treatment, with the ultimate goal ofreturning the ADSM quickly to duty. However, someof these patients may be unable to perform theirduties and will be required to enter the DisabilityEvaluation System (DES). The DES has two distinctstages: the Medical Evaluation Board (MEB) and thePhysical Evaluation Board (PEB).Medical Evaluation BoardThe MEB is typically made up of two or threephysicians who evaluate the ADSM’s injury orillness and plan of care to make a determinationon whether the ADSM can adequately perform theassigned duties of his/her position. The ADSM istypically referred to the MEB by the primary careprovider or the unit Commander; or the referral maybe based on a higher-Command recommendation.If the ADSM is found fit for duty, the MEB will clearthe ADSM and return him/her to duty. If the MEBfinds that the ADSM may return to Active Duty andperform his/her duties within a reasonable period oftime (typically between eight and 16 months withtreatment), the Board may recommend TemporaryDuty (TDY) for the ADSM. If the MEB determinesthat the ADSM is unfit for continued duty, the Boardrefers the patient to the PEB.Physical Evaluation BoardThere are two types of PEB: informal and formal.The informal PEB (IPEB) is the first step in the PEBprocess and is defined by the following aspects:• It includes three voting members — one mustbe a physician and one must be a nonmedicalofficer.• The ADSM may not be physically present.• The ADSM may agree with the recommendationof the IPEB or request reconsideration at aformal PEB.The formal PEB is defined by the following aspects:• It includes three voting members — one mustbe a physician and one must be a nonmedicalofficer.• It allows the ADSM to appear before the board,present evidence and testimony, call witnesses,review all documents used by the board, andprovide any additional documents he/she deemsimportant to his/her case.• The ADSM is generally represented by anattorney.A final determination from the formal PEB will beone of the following:• Separation without Benefits• Separation with Severance Pay• Permanent Disability Retirement (PDR)• Temporary Disability Retirement List (TDRL)• Return to DutyThe ADSM has a right to appeal the formal PEBdetermination through his/her Service’s appellatereview agency. Certain ADSMs who are determinedto be unfit for duty may be able to remain on Active

Page 86Case Management Version 3.0Medical Management GuideReturn toDutySeparationService memberidentified with injury orchronic disease.Case ManagementInterventionMedicalEvaluationBoardCare Coordinationand CounselingPhysicalEvaluation/DisabilityBoardLegalReviewDisposition(Outcomes)Care Coordinationand Transition of CareTemporary DisabilityRetirement ListRetirementFig. 23– Disability Evaluation System (DES)Duty through the Continuation of Active Duty(COAD) program. The ADSM must complete theCOAD application process with his/her PEB LiaisonOfficer (PEBLO).Fig. 23 illustrates the DES.retirement or separation. Members released fromActive Duty, National Guard, or Reserve service havethe option of requesting a REFRAD physical whenchanging from Active to Reserve status. The militaryunit coordinates the REFRAD physical exam, whichshould be performed at the MTF.For more information on the MEB/PEB process andspecifics for each Service Branch, refer to Methodsand Actions for Improving Performance of theDepartment of Defense Disability Evaluation System(Marcum, Emmerichs, Sloan, Thie, 2002). See alsoAppendix C, Definitions.Other Types of EvaluationAs the basis for DoD/VA rating their disabilitycompensation, Active Duty, Guard, or ReserveService members who are separating or retiringfrom service should undergo one physical exam.Combining the DoD’s separation physical exam withthe VA’s Compensation and Pension (C&P) examhelps streamline the process and minimize costs.The case manager should be aware of the processesregarding military physical examinations for Servicemembers on Release from Active Duty (REFRAD)status or who are leaving the Service due to

Medical Management GuideVersion 3.0Case ManagementPage 87RECOVERY COORDINATION INITIATIVESIn September 2008, the DoD and VA respondedto the NDAA requirements on wounded warriormatters in their Report to Congress on theComprehensive Policy Improvements to the Care,Management, and Transition of Recovering ServiceMembers (NDAA Section 1611 and 1615) (seeExecutive Summary, CD-ROM Resource ES-3).The DoD/VA report outlines provisions implementedby the two departments that affect MTF casemanagers.Federal Recovery Coordination ProgramNDAA 2008 requires the Services (Army, Navy, AirForce, Marines) to establish a recovery coordinationprogram for wounded, ill, and injured Servicemembers who have significant illness or injury suchthat they may be medically retired or separated fromthe military.In January 2009, the Under Secretary of Defenseissued Directive-Type Memorandum (DTM) 08-049,Recovery Coordination Program: Improvements tothe Care, Management, and Transition ofRecovering Service Members (RSMs): http://www.dtic.mil/whs/directives/corres/pdf/DTM-08-049.pdf.See also CD-ROM Resource CM-24.DTM 08-049 states the purpose of the DoDRecovery Coordination Program (RCP), as follows:• Provide for improvements to the care,management, and transition of RSMs and theirfamilies.• Develop and implement standardized policies,processes, personnel programs, and tools toaccomplish comprehensive care coordination.• Adjust policies and operational procedures, asnecessary, based on data collected during thefirst six months after the signature date of theDTM.The Services have since established the FederalRecovery Coordination Program (FRCP), which isoperated by the VA. Service members participatingin this program are expected to have lifelong careneeds. ( CD-ROM Resources CM-25 throughCM-32 provide more detailed information on theFRCP, including program descriptions, forms, and anational resource directory.)Recovery Care CoordinatorsReferral for the FRCP is through a screening processperformed by the Services that considers acuityin both medical and nonmedical (e.g., financial,housing, family support) areas. The VA programprovides senior-level clinical nurses and socialworkers, designated as federal Recovery CareCoordinators (RCCs), to provide oversight of therecovery plan for catastrophically injured ADSMs.If the ADSM meets the criteria, he/she is referred toan RCC who:• Develops a Federal Individual Recovery Plan(FIRP) with the ADSM along with his/her familyand recovery team.• Provides oversight of the FIRP to help meet theADSM’s and his/her family’s needs.

Page 88Case Management Version 3.0Medical Management GuideRecovery Coordination ProgramRecovery, Rehabilitation, Reintegration (R3)FOUR CORNERSTONESNew Roles for CM in the NDAARecovery Care Coordinators– Responsible for assistance to Service member (i.e., access)– Employed by Military BranchRecoveryPlanRecoveryCoordinatorMedical Care Case Managers (MCCMs)– Licensed, healthcare professional– Understand Rx and receive appropriate careNon-Medical Care Managers (NMCMs)– Finance, personnel, admin, transitional, family supportRecoveryTeamNational ResourceDirectoryFederal Recovery Coordinators– Primary responsibility/oversight for R3– Employed by Veterans Administration: LCSW or RNsSource: National Defense Authorization ActFig. 24 – Recovery Coordination ProgramFig. 25 – New Roles for CM in the NDAAThe FIRP plan should track with the plan of caredeveloped by the recovery team as a whole.The RCC continues to work with the ADSM and his/her family throughout the recovery, rehabilitation,and transition process to meet their needs. For bestoutcomes, the RCC is treated as a member of theoverall outpatient recovery team that includes clinicaland non-clinical staff. The RCC participates in teamdiscussions and plan-of-care development.Additional resources specific to wounded warriorcare are found in the June 2008 provision of theNDAA (H.R. 5658 — see Appendix D, Resources).Figs. 24 and 25 describe aspects of woundedwarrior care coordination under the NDAA.TRANSITION/COORDINATION OF CARETransition of CareIn the military, unique transitions of care (TOCs)occur when patients move:• From the DCS to the PCS.• From MHS care to VA care.• Among multiple Service-level settings— for example: An injured Marine receivesemergency care in an Air Force ED, istransferred to a Navy medical center for limbsavingsurgery, is rehabilitated in an Armysetting, and is moved jointly between his/herhome base primary care and the VA for PEBpurposes.• From one TRICARE regional case manager toanother.

Medical Management GuideVersion 3.0Case ManagementPage 89• Between Commands.• Between facilities (e.g., rehabilitation hospitals,psychiatric hospitals, skilled nursing facilities).• From one hospital unit to another.• From one level of care to another (e.g., acutecare to outpatient care or to home health care).• From overseas to stateside.Case managers need to maintain awarenessthat care transitions and care coordinationsrequire continuous monitoring, and to develop orrefine processes that support patient TOCs. Anorganization’s CM program should empower staffto create tools and tracking mechanisms that allowfor enhanced communication, monitoring, andfollow-up. Performance measures of success arenot only essential to documenting outcomes; theyprovide secondary value in “forcing” patient CMfollow-up.heart, and spirit and on transition back to dutystatus or civilian life. Each Service has its ownintegrated care transition program, as follows:1. Warrior in Transition Program (WT) and ArmyWounded Warrior Program (AW2): https://www.aw2.army.mil/index.html, http://mhs.osd.mil/WoundedWarrior.aspx2. Navy Safe Harbor: http://www.npc.navy.mil/CommandSupport/SafeHarbor/3. Air Force Wounded Warrior Program (AFW2):http://www.woundedwarrior.af.mil/4. Wounded Warrior Regiment (WWR): http://www.woundedwarriorregiment.org/WWR.aspxAppendix D, Resources, provides more detailon Service-level wounded warrior recoverycoordination programs and related CM roles, suchas the Warrior Transition Unit (WTU) Nurse CaseManager.Effective and safe transitions depend on effectivecommunication between the transferring facility(where the transition originates) and the receivingfacility (where the patient is sent). In additionto the healthcare team, the patient/caregiversneed to actively participate in the TOC process.( CD-ROM Resource CM-33 provides a TOCimplementation plan.)For more information on TOCs, visit the NationalTransitions of Care Coalition (NTOCC) website:http://www.ntocc.org.Service-Specific Care Transition ProgramsCM services for Warriors in Transition (WTs) arecentered on holistic healing of the body, mind,Inter/Intra-Regional TransferWhen a beneficiary enrolled in CM within the MTFrelocates to another region, the MTF case managerin the originating MTF (“transferring” case manager)is responsible for ensuring continuity of care and asmooth transition for the patient and family to thecase manager at the relocation site (“receiving” casemanager).The process for transfers includes the following:• Once it is determined that a beneficiary in CMis moving to a new location, the transferringcase manager requests/documents writtenpermission to communicate with the receivingcase manager in the new location, from eitherthe beneficiary or his/her legal representative.

Page 90Case Management Version 3.0Medical Management Guide• The transferring case manager contacts thereceiving case manager as soon as possible toinitiate and coordinate the transfer.• The transferring and receiving case managerscollaborate on a transition plan to verify thatservices are available and in place at the newlocation.• If the beneficiary’s relocation is imminent anda receiving case manager cannot be identified,the transferring case manager contacts the CMpoint of contact (POC) at the TRICARE RegionalOffice (TRO) before the Service memberdeparts.• The case manager uses the Inter/intra RegionalTransfer Form to document information. Theform will include identification of any specialneeds or programs that address specialneeds, such as EFMP or ECHO. ( CD-ROMResources CM-34 and CM-35 provide inter/intra-regional transfer documents for ADSM andMHS-eligible, non-ADSM beneficiaries.)• When a transfer involves an organ transplant, enroute aeromedical evacuation (AE) services (seeAeromedical Evacuation, below), complextransportation arrangements, or a high visibilitycase, the transferring case manager coordinateswith the TRO case manager.• The transferring case manager providesinstructions for expediting the medicalrecord transfer and identifying caregiver(s),special needs issues, transportation, or otherassistance, as required. A cost/benefit analysis isrecommended, particularly if the transfer is fromthe DCS to the PCS.• Prior to the transfer, the transferring casemanager documents the beneficiary’s healthstatus, case manager contact information, andactions (including the rationale).• The receiving case manager also documents thecommunication (including transfer instructionsor requests) in the appropriate hard copy or electronicmedical record.• The transferring case manager continues toprovide CM services until the beneficiary hastransferred enrollment to the receiving casemanager at the new location.Additional responsibilities for the transferring casemanager may involve:• Arranging medically appropriate patienttransport.• Coordinating care with the provider at thetransferring/receiving sites and with the patient’sfamily.• Ensuring availability of supplies/equipmentduring transport and at the receiving location.• Confirming an initial appointment with thereceiving MTF for EFMP families.• Identifying and ensuring availability of resourcesto accomplish the transfer.Aeromedical EvacuationAeromedical evacuation (AE) is the transportation ofpatients under medical supervision to and betweenmedical treatment facilities by air transportation.This includes timely evacuation of patients from acombat zone.The Health Service Support (HSS) patient movementmission in joint operations is designed to minimizethe effects of wounds, injuries, and disease byrapidly evacuating affected personnel from thelocation of wounding, injury, or illness in a combattheater to a hospital in the continental United States(CONUS). The patient movement system operates

Medical Management GuideVersion 3.0Case ManagementPage 91worldwide to regulate all Service component patientmovements and is supported by the following:• Global Patient Movement Requirements Center• U.S. Transportation Command (USTRANSCOM)• Aeromedical Evacuation Coordination Center• Defense Medical Regulating Information System• Theater patient movement requirements centers• Joint patient movement teams• In-transit visibility• Service component evacuation assetsThe transferring MTF is responsible for transportingpatients between the MTF and the aerial port ofembarkation. The movement of patients from onelevel of treatment to another for more definitivetreatment, or between and within levels oftreatment, requires in-depth planning, adequateresourcing, and skillful execution (Joint Publication4-02.2 — Joint Tactics, Techniques, and Proceduresfor Patient Movement in Joint Operations).Fig. 26 illustrates how AE services are coordinated.Aeromedical Evacuation ModelDetermine requirement for patient evacuation.AE liaison/MRO Requests patient evacuation.Prepare patient for movement.Ensure adequate supplies.Transport to on-load airfield.Determine Eligibility.Validate medically and administratively.Identify destination options.Assign to Service Component.Coordinate patient movement requirements with User.Validate patient preparation.IAW applicable instructions.Identify resources.Collaborate with PMRC.Decide appropriate aircraft.Send ATO for lift, crew, etc.Follow mission execution.Stage patient for evacuation.Provide supportive patient care.Brief AE medical crew on patient load.Load patient on aircraft.Inform AELT, AMD/AECT of aircraft departure.Receive ATOTask aircrew(s)Launch aircraft to on-load airfieldFig. 26 – Aeromedical Evacuation (AE)

Page 92Case Management Version 3.0Medical Management GuidePatient movement has advanced to support criticalcare capabilities via the AE system. Patients returningto CONUS MTFs with complex and catastrophicinjuries and/or complicated medical sequelae(abnormal condition resulting from a previousdisease) will likely require CM services and maybenefit from enrollment into one of the Services’warrior care programs. Case managers need a basicunderstanding of patient movement through the AEsystem, as it offers perspective on patients’ medicaland psychosocial health needs from onset of injuryor illness to definitive treatment in stateside MTFs.For more information, contact your MTF PatientAdministration office.Coordination of CareCoordination from the MHS to the Departmentof Veterans AffairsDepending on eligibility (i.e., Service-connectedcondition or disability), Active Duty, retired, orseparated Service members may receive health carefrom the VA’s Veterans Health Administration (VHA).In 1996, Congress established Public Law 104-262,the Veterans Health Care Eligibility Reform Act, inwhich enrolled veterans are entitled to a medicalbenefits package that emphasizes preventive andprimary care. For more information on eligibilityand enrollment, refer to the VA website: http://www.va.gov/healtheligibility/coveredservices/StandardBenefits.asp.The DoD and VA (VHA and Veterans BenefitsAdministration [VBA]) continue to partner toimprove the dialogue and collaboration between thetwo departments at all levels, focusing on the abilityto identify and serve all ADSMs who have sustainedinjuries or illnesses in combat operations.When the transition of healthcare services isrequired between an MTF and a VA medicalcenter (VAMC), the MTF case manager (or patientadministrative staff, as appropriate) is responsiblefor coordinating the transfer with the VHA Liaisonlocated at the MTF and/or the OEF/OIF CareManagement Team located at the VAMC. To locatethe appropriate VHA Liaison for referral, refer to thecontact list table on CD-ROM Resource CM-36(this list is continuously updated).When the MTF case manager identifies the requirementto transfer care to the VA, he/she completesa referral packet to include the DoD/VA LiaisonReferral Form ( CD-ROM Resource CM-37) witha discharge plan and medical record documentation.Once the VHA Liaison receives the referral form andmedical record documentation, he/she initiates thereferral with the accepting VAMC. Depending onthe urgency and request for healthcare services, thetransition time may occur as quickly as a few days.Coordination for Active Duty Service Membersin the TRICARE Prime Remote ProgramThe Military Medical Support Office (MMSO) is aTri-Service agency providing CM services for the followingpopulations:• ADSMs enrolled in the TRICARE Prime Remote(TPR) program.• Reserve and National Guard members injured inthe line of duty (LOD).• New accessions awaiting the start of training.

Medical Management GuideVersion 3.0Case ManagementPage 93• Any ADSM en route to a first school, training, orpermanent duty station who is not yet enrolledin the TPR or in an MTF.While the organization and scope of responsibilityfor the MMSO may change over time, its mainmission will continue to directly support thehealthcare needs of ADSMs in TPR. For moreinformation, visit the MMSO website at http://www.tricare.mil/tma/MMSO/.Through clinical review, oversight, preauthorization,and coordination for all specialty care referrals,the MMSO verifies that remote and non-enrolledADSMs are receiving needed medical care withinTRICARE standards. MMSO staff identify fitnessfor-dutyissues and make recommendations toCommands for referral to MTFs or the MEB. Staffedby a team of registered nurses (RNs), the CM divisionidentifies cases and plans of care that include noncoveredbenefits or experimental procedures, andconsults with specialty advisers to obtain clinicalopinions and recommendations. Based on therecommendations of those advisers and the patient’scondition, the nurses will either continue the care inthe remote area or make a referral to the nearest,same-Service MTF.The MMSO’s primary CM responsibilities relate to:• Chronic and complicated cases.• Long-term care for remotely located Servicemembers and those who have sustained a TBIor spinal cord injury (SCI), or have been blinded.When an ADSM sustains a TBI, SCI, or has beenblinded, and it has been decided to refer the patientto the VA program under the national MOU, theMTF case manager should contact the MMSO casemanager as soon as possible to facilite authorizationfor admission to a VAMC. The MMSO case managercan also answer questions regarding processes forcare once the patient is released from the VA.As a conduit between the beneficiary and TRO, theMMSO can act as an information resource to assistMTF case managers with problems or complicatedissues. Although case information can be faxed tothe MMSO, it is recommended that the CM divisionbe contacted directly by telephone for assistance.Coordination for Exceptional Family MemberProgram and Special Needs FamiliesEnrollment in the Exceptional Family MemberProgram (EFMP), also referred to as Special NeedsIdentification and Assignment Coordination(SNIAC), is used during the assignment process toidentify ADSMs whose family members have specialneeds. Special needs range from medical, dental,and mental health concerns to educational ordevelopmental requirements.The purpose of early identification is to verify thatnecessary services are available upon change ofduty stations. The EFMP proactively considers a familymember’s special requirements while assistingfamilies in finding and using appropriate servicesand programs with the dual goal of increasing familyself-sufficiency and improving self-advocacy skills.(Note: Not all EFMP families require CM; however, allCM families with qualifying special needs should beenrolled in the EFMP.)

Page 94Case Management Version 3.0Medical Management GuideEach Service administers the program differently(e.g., point of contact [POC] titles may vary;program responsibilities may be located in differentdepartments). The sponsor of the family memberwith special needs must also enroll in the program.Families usually self-identify, but medical personnelmay also identify eligible members during routinehealthcare visits.ooooAdditional programs the family is currentlyengaged or enrolled (e.g., ECHO).Case history and current treatmentplan, including stability of condition andrehabilitation, if indicated.Discovery date and summary of medicalcondition.Support system at home.EFMP eligibility should be re-evaluated on a regularbasis, since a family member’s status may change.Case managers or special needs coordinatorsshould assist the EFMP member; especially duringthe coordination of overseas screening, processing,and enrollment. Since there is minimal medicaloversight in the EFMP, case managers may providethe necessary structure to promote standardization,uniformity, connectivity, and transferability ofbenefits from one TRICARE region to another.When an ADSM is notified of potential dutyrelocation or must complete a move expeditiouslyand a dependent family member has special needs,the following steps should occur:• The transferring case manager obtainsauthorization from the sponsor or legalguardian for release of information from theadult beneficiary with the special need(s) priorto discussing healthcare arrangements with theADSM.• The transferring case manager consults thereceiving case manager to determine availablemedical care and special needs resources in thelocation of possible assignment.• The transferring case manager provides thenecessary clinical data so the receiving regioncan make a determination on the availability ofresources. This may include, but is not limited to:If the family member’s needs cannot be met in thereceiving region/location and the ADSM proceedswith assignment to that region/location, the casemanager must discuss with the ADSM the potentialor actual impact on the family member’s care andthe need for coordination with regions/locations onthe availability of medical care. In such cases, thefollowing process applies:• The transferring case manager will documentthe following in the CM transition plan:o Current needs, services, and medicalcondition(s) of the affected familymember(s).o Communication with the TRO informing thereceiving case manager of the potential/actualshortfalls in healthcare resources required bythe beneficiary.o Discussion with the receiving case managerregarding the identification of potential gapsor shortfalls in local healthcare resources.o The Service member’s decisions on the planof care and follow-up plan.• The receiving case manager will:o Assist family members in coordinating thecare needed upon arrival to the new dutystation.o Coordinate with schools to transferIndividual Education Plans (IEPs).o Document interventions and decisions made.

Medical Management GuideVersion 3.0Case ManagementPage 95Transition/Coordination ChallengesThe World Health Organization (WHO) incollaboration with TJC and TJC International agreedin April 2007 on a list of nine National Patient SafetyGoals (NPSGs). Based on the list of current NPSGs,the most important challenges to seamless TOCidentified by the Commission include:• Communication. It is critical to share current,comprehensive information within and amongcare providers and delivery systems. Theacronym SBAR, for Situation-Background-Assessment-Recommendation, is an easy-toremembermechanism for communicatingon issues that require a clinician’s immediateattention and action. SBAR is recommendedas a tool in one of the NPSGs used in hospitalsettings when patients are transferred from oneunit to another (http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution3.pdf).• Medication accuracy/reconciliation. Transitionsare the most common situation in whichmedication errors occur. Medication accuracy/reconciliation is a process designed to preventmedication errors at patient transition points(http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution6.pdf).• Accountability and responsibility. Healthcareprofessionals involved in a patient’s care, bothclinically and administratively, are responsible forbreaking down barriers that impede TOCs. Casemanagers may face legal accountability whenpatients are not transitioned appropriately or ina timely manner.• Role clarification. It can be difficult to assignaccountability if there is confusion about theroles of various healthcare team members in thetransition of care for a patient in CM. Ongoingcommunication via all available systems (e.g.,telephone, secure e-mail, paper documents) andcare conferences can minimize confusion whenspecific roles are identified.• Follow-up. This is one of the most effectiveactions a case manager can take in promotingsafe and complete TOC. Case managers shoulduse caution when relying on the patient orfamily/caregiver(s) to be entirely responsible forfollow-up. The patient’s condition may be alimiting factor, impeding his/her ability to securecare as part of the medical plan. Conversely, thefamily/caregiver(s) may be subject to stressorsunrelated to healthcare issues that are impedingeffective follow-up or maintenance of the careplan.For more information, go to http://www.who.int/.Other Types of Transition/CoordinationTitle XVI of the National Defense Authorization Act(NDAA) of 2008, Wounded Warrior Matters, Section1615 (refer to CD-ROM Resource ES-4), focuseson facilitating the transition of Service members fromActive Duty status to civilian life. In the MTF, the casemanager arranges for housing modifications, assistivedevices, or adaptive equipment. As previouslydiscussed, this may involve collaboration with the VAto identify the best options for an ADSM’s physicaland behavioral rehabilitative care.Case managers strive to help patients return toactivities that are productive, meaningful, andrewarding to them, which is extremely importantfor their recovery and quality of life.

Page 96Case Management Version 3.0Medical Management GuideAspects of this process include:• Disability compensation (e.g., worker’scompensation and auto insurance).• Ergonomics.• Job analysis, job modification, job accommodation,and job hardening.• Job development and placement.• Life care planning.• Military boards and medical retirementprocedures.• Other military programs.be familiar with individual countries’ arrangementswith the United States before arranging care.Depending on the scope of any signed agreements,ADSMs or their family members may only be eligible,for example, for outpatient direct care medicaltreatment. To understand enrollment and eligibilityrequirements in individual countries, the casemanager should access the following websites:• http://www.tricare.osd.mil/recip• http://www.nato.int/structur/countries.htmOutside the Continental United States(OCONUS) and TRICARE Global RemoteOverseas (TRGO) ProgramCM plays an important role in supporting Servicemembers Outside the Continental United States(OCONUS). Specifically, case managers workingat specialty treatment centers or MTFs may becalled on to assist in the acceptance and transfer ofcomplex patients from other MTFs for specializedtreatment.ADSMs serving overseas must be enrolled in theTRICARE Global Remote Overseas (TRGO) program,where available. For more information, go to: http://www.military.com/benefits/tricare/tricare-overseas/tricare-global-remote-overseas.North Atlantic Treaty Organization (NATO)CM also comprises an important UM role when itcomes to understanding and working within theboundaries of agreements between the UnitedStates and other NATO countries. Depending on thehealthcare utilization patterns and practices (medicaland/or dental) of an individual NATO membercountry, case requirements can quickly escalate.The case manager needs to manage the access andutilization of care while liaisoning with the ADSM’sembassy staff for authorization.In non-NATO cases, only ADSMs are eligible for care;their family members are not covered. However,because ADSMs often move between varioustheaters of operation and because internationalagreements continually change, it is recommendedthat case managers consult with their PatientAdministration departments on a case-by-case basis.Members of the North Atlantic Treaty Organization(NATO) Armed Forces occasionally call upon MTFs ortheir host Service Branch medical clinics to providecare to their overseas Service members and/orfamilies. In such cases, the case manager needs to

Medical Management GuideVersion 3.0Case ManagementPage 97THE CASE MANAGEMENT PROFESSIONALQualificationsThe job description of the employee workingin the CM department of an MTF will varydepending on the size of the organizationand its internal resources. Titles include CaseManager, Health Care Integrator (HCI), NurseClinical Case Manager, Medical Care Case Manager(MCCM), and Licensed Clinical Social Worker(LCSW).The following resources can aid in understandingthe essential skill sets required for successful casemanagers:• Nursing Case Management from Essentials toAdvance Practice Applications, 4th Edition.• The Case Manager’s Survival Guide, WinningStrategies for Clinical Practice, 2nd Edition.• CMSA Core Curriculum for Case Management,2nd Edition.See Appendix A, References, for publicationinformation.Knowledge of key CM skill sets and assistancefrom the Human Resources and/or Personneldepartments can help case managers prepareappropriate interview questions to determinewhether your candidates possess these skill sets.The CM professional:• Should have sufficient clinical knowledge andbreadth of patient care experience to identifythe clinical rationale for procedures or tests.• Should be able to gather necessary informationand determine the medical necessity of servicesand the appropriateness of care.• Must have knowledge in the area of CM andexpertise applying his/her professional skills tothe full range of bio-psychosocial health-relatedproblems in the provision of CM services.• Must have a patient- and family-centeredapproach to performing assessments and plansof care.The case manager will have knowledge of humanbehavior/dynamics and motivation, healthcareservice delivery, healthcare financial systems andfunding sources, professional ethics, and clinicalstandards and outcomes. He/she should alsopossess knowledge of accreditation standardsfrom organizations such as TJC and privacy andconfidentially requirements as detailed in the HealthInsurance Portability and Accountability Act (HIPAA).CD-ROM Resource CM-38 is a Privacy ActStatement for Health Care Records form. (See alsoSection I, Medical Management Essentials; andAppendix C, Definitions.)Education and Experience RequirementsCM professionals must possess the following specificeducation and experience credentials:• Licensed Registered Nurse (RN) – i.e., graduateof an accredited nursing program, Bachelor ofScience in Nursing (BSN) preferred; or bachelor’s(or higher) degree in a healthcare-related fieldfrom an accredited educational institution(position typically occupied by an RN with aBSN).

Page 98Case Management Version 3.0Medical Management Guide• Valid unrestricted clinical license to practice.• Social worker case managers — current licensefrom a U.S. jurisdiction and must be LicensedMaster’s Social Worker (LMSW).• A minimum of two years of recent experience(within the last four years) in professionalnursing, social work, or CM for adults, children,families, seniors, or groups.• Employed for the past 12 months in ahealthcare-related field.• Current basic life support (BLS) certification.• Knowledge and experience, or comprehensionduring training, in the performance of core CMactivities (i.e., patient advocacy, assessment,planning, implementation, coordination,monitoring, evaluation).• Demonstrated expertise in resolving complicatedhealthcare, social, interpersonal, and financialpatient situations.• Experience in program planning and conductingindividual, family, group, and communityassessments.CertificationValid desirable qualifications are certification by aCM-specific program upon hire or within 24 monthsof employment. Refer to the following resources:• Commission for Case Manager Certification(CCMC): http://www.ccmcertification.org/.• American Nurse CredentialingCenter (ANCC): http://www.nursecredentialing.org/.• CMSA: http://www.cmsa.org.Ethical Practice StandardsEthics address the judgment of right and wrongand good or bad. Per the CMSA’s 1996 statementon ethical CM practice, case managers adhere tothe code of ethics for their profession of licensure.CM is guided by the ethical principles of autonomy,beneficence, non-maleficence (not harming others),justice, and veracity (Beauchamp and Childress,1994/2008).The patient is always the primary considerationwhen making CM decisions. This means thepatient must be involved in all aspects of decisionmaking,including being informed of options andconsequences prior to making decisions. The casemanager works closely with the patient duringthis process in order to help him/her achieve selfmanagement.The case manager is obliged to promote for thegood of the patient (beneficence) and refrainfrom doing harm to the patient (maleficence).The case manager is intimately involved with thedissemination of services and resources on anindividual basis (justice). Truth-telling (veracity) isimperative for development of trust with a patient,and must be built among patients, case managers,and healthcare providers.The case manager must follow the regulationsset forth in his/her state licensing body, as well asthose practice guidelines published by nationallyrecognized organizations in the industry of managedcare, particularly the CMSA and URAC. In 2002, theCMSA published standards of practice delineatingguidelines for the CM profession.

Medical Management GuideVersion 3.0Case ManagementPage 99The standards require that the case managerprovide services within the scope of practice definedby their community, licensure, and publishedpractice standards. Case managers are potentiallyliable if they do not follow these CM standards ofpractice. DoD and Service Branch-specific policiesand directives concerning the provision of healthcare also apply.Resources for Orienting and Trainingthe New Case ManagerWeb-based learning modules to assist in orientingand training newly hired staff are available at MHSLearn: https://mhslearn.csd.disa.mil. MHS-requiredCM training includes the following topic areas:1. Case Management2. TRICARE Fundamentals3. Military Medical Support Office4. Traumatic Brain Injury5. Post-Traumatic Stress Disorder6. Suicide Awareness7. Homicide Awareness8. Substance Abuse9. Clinical Decision Support Tools10. Introduction to the Veterans Administration11. Disability Evaluation System12. Federal Recovery Coordination Program13. Recovery Care CoordinatorsEach Service and MTF may offer its own requiredor optional training opportunities. For moreinformation, contact your Education and Trainingmanager.A “continuity binder” — also called a standardoperating procedure (SOP), orientation, or resourcemanual — specific to individualized CM role(s) canbe a useful tool. The binder may be in paper orelectronic form, and can help personnel coveringanother staff member’s position in his/her absenceunderstand the responsibilities of that staffmember’s position(s). The binder provides:• Descriptions of daily, weekly, and monthlyresponsibilities and related tasks.• A list of personnel in the organization and theircounterparts within the TMA region.• A hard copy of any forms or logs used, in case ofcomputer system failures.• A list of scheduled meetings.• Other relevant information.The continuity binder should be updated on aregular basis.In addition to possessing the basic educationalbackground for the position, it is also crucial for CMpersonnel to maintain practice competency.( CD-ROM Resource CM-39 provides a SampleCase Manager Core Competencies Form.)As part of the CM orientation process, casemanagers are required to complete and pass allrelevant MHS Learn modules prior to providingpatient care. It is also vital for personnel to havea basic knowledge of each position within theirdepartment, as MM roles are often interdependent.

Page 100Case Management Version 3.0Medical Management GuideSUMMARYClinical CM moves beyond the historical practiceof coordinating systems and brokering for costreduction. It is a personal involvement in themedical, behavioral, psychosocial, and functionalaspects of a patient’s health care. The casemanager’s span of influence encompasses thecontinuum from health to impairment, requiringan integrated approach that involves collaborationwith utilization managers and disease managers foreffective coordination across healthcare settings.Military CM practice requires licensed healthcareprofessionals who are experienced in PopulationHealth, the MHS and related benefits, payormechanisms, community resource models, anddisease states. With appropriate education andtraining, nursing or social work professionals arewell equipped to support patients and their familymembers in the pursuit of optimal wellness.Case managers seek to promote self-managementeducation and an optimal quality of life whileimplementing cost-effective resourcing and thetimely resolution of clinical and system issues.Specifically, case managers serve as catalysts,facilitators, and communicators when advocatingfor patients who are unable to meet or unsuccessfulin meeting their own healthcare needs. Casemanagers serve not only as “connectors” offragmented systems; they also function as the“hub” in a wheel of coordinated, multiple-caredelivery systems, acting as a central POC forpatients.Case managers facilitate and ensure that “one handknows what the other hand is doing.” This visibilityfosters timely and appropriate interventions from amyriad of providers who may be delivering care tocomplex and chronic care patients.CM plays a crucial role in supporting the MHSdespite a financially challenging environment andthe high operational tempo of military missions. Assuch, it is an excellent resource for patients, families,providers, and military Commands when advancedMM interventions are required to meet healthcareand mission goals.CD-ROM RESOURCESCM-1 Article: Reineck, C. A., Farris, P.: CaseManagement: Conserving the FightingStrength in the U.S. Military — CareManagement (August 2003)CM-2 Article: Lewis-Fleming, G., Laing, D.,Whiting, D. (CDR), Dawe-Gillis, C. (CAPT):Case Management and the Active DutyService Member — Care Management(February 2001)CM-3 Standard Form (SF) 513 – BlankCM-4 Standard Form (SF) 513 – CompletedCM-5 Case Management Screening CriteriaCM-6 Severity/Complexity Index – ArmyCM-7 Sample Introductory LetterCM-8 Sample Authorization Form for Disclosureof Medical Information – ArmyCM-9 Original Informed ConsentCM-10 Non-Acceptance LetterCM-11 Inability to ContactCM-12 Sample Case Closure Summary LetterCM-13 AIM Screenshot, CM Plan of Care – AirForce

Medical Management GuideVersion 3.0Case ManagementPage 101CM-14 AIM Screenshot, Initial Assessment – AirForceCM-15 Patient/Family Satisfaction Survey– SampleCM-16 Provider Satisfaction Survey – SampleCM-17 CM Measurement Reporting Tool– SampleCM-18 CM Caseload Log Sample #1CM 19 CM Caseload Log Sample #2CM-20 CM Caseload Log Sample #3CM-21 Directive-Type Memorandum (DTM) 08-033, Interim Guidance for Clinical CaseManagement for the Wounded, Ill, andInjured Service Members in the MilitaryHealth System – DRAFTCM-22 CMSA CM Caseload Concept PaperCM-23 Sample CM Marketing Brochure – Patient/ProviderCM-24 Directive-Type Memorandum (DTM) 08-049 – Recovery Coordination Program:Improvements to the Care, Management,and Transition of Recovering ServiceMembers (RSMs)CM-25 Federal Recovery Coordination Program– OverviewCM-26 Federal Recovery Coordination Program– Care Coordination Office (Mission)CM-27 Federal Recovery Coordination Program– DescriptionCM-28 Federal Recovery Coordination Program– Care Coordination Office (NationalResources Directory)CM-29 Federal Recovery Coordination Program– Enrollment FormCM-30 Federal Recovery Coordination Program– Comprehensive Needs AssessmentCM-31 Federal Recovery Coordination Program– Comprehensive Recovery PlanCM-32 Federal Recovery Coordination Program– Category Assignment ToolCM-33 Transitions of Care Implementation PlanCM-34 Inter/Intra-Regional Transfer Form– ADSMsCM-35 Inter/Intra-Regional Transfer Form – non-ADSMsCM-36 VHA Liaison Contact ListCM-37 VHA Liaison Referral FormCM-38 Privacy Act Statement for Health CareRecords FormCM-39 Sample Case Manager Core CompetenciesFormCM-40* Wounded Warrior Regiment Brief for NewPersonnel (February 2008)CM-41* Department of the Army WarriorTransition Unit (WTU) ConsolidatedGuidance (July 18, 2008)CM-42* Frequently Asked Questions (FAQs) andanswers pertaining to the Army MedicalAction Plan (AMAP) and United StatesArmy Europe (USAEUR) WTUs*Not referenced in text‘

Medical Management GuideVersion 3.0Disease ManagementPage 105Disease ManagementSECTIONIVINTRODUCTIONDisease Management (DM) is focused onoptimizing health in specific populations.It should be noted that all componentsof MM — Utilization Management (UM), CaseManagement (CM), and Disease Management(DM) — blend together when they areoperationalized. The lines of distinction betweenUM, CM, and DM programs may become lessdefined as UM, CM, and DM personnel collaboratewith Military Treatment Facility (MTF) providers andstaff to achieve the best healthcare benefit possiblefor the patient and the organization.Fig. 27 highlights the role of DM over the variousstages of health care (see also Section I, MedicalManagement Essentials). Specifically, as the focusof healthcare delivery moves along the PopulationHealth continuum, when the focus of health care isprimary prevention, interventions are most effectivefor groups of people with similar characteristics. Thesame is true when providing healthcare services atthe level of secondary prevention for people whoFig. 27 – Disease Management within the Integrated Medical Management Model*See also Section I, Medical Management Essentials: Fig. 4, Integrated Medical Management Model (IM3) with Key info, page 14.

Page 106Disease Management Version 3.0Medical Management Guideare at risk for exacerbating or complicating theirdisease.In the Department of Defense (DoD), MTFs havesuccessfully implemented DM programs for anumber of conditions and disease states. Inaccordance with the National Defense AuthorizationAct (NDAA) of 2007, the Military Health System(MHS) was tasked with developing DM programsfor a variety of diseases and chronic conditionsincluding asthma, chronic obstructive pulmonarydisease, diabetes, depression and anxiety disorders,cancer, and heart disease. Thus, MTFs and ManagedCare Support Contractors (MCSCs) have begun tosystematically incorporate these disease states intotheir DM programs.system of coordinated healthcare interventions andcommunications for populations with conditions inwhich patient self-care efforts are significant.”The DMAA has broadened its focus from strictlyDM to a Population Health model, of which DMis a component. This model promotes a proactive,accountable, patient-centric approach featuring a“physician-guided” healthcare delivery approachdesigned to “develop and engage informed andactivated patients over time to address both illnessand long term health” (DMAA, 2009). The MHSPopulation Health model (see Section I, MedicalManagement Essentials, Fig. 3) is based on ahealthcare delivery approach that incorporates sixkey components illustrating this paradigm from aprovider-guided approach.Definition, Goals, and PurposeDM is an organized effort aimed at achievingdesired health outcomes in populations withprevalent, often chronic, diseases for whichhealthcare delivery may be subject to considerablevariation (Kongstvedt, 2007) (see also Appendix C,Definitions). In contrast to CM’s focus on individualpatients, DM is aimed at sub-populations of patientswith a specific condition, disease, or set of comorbidities(e.g., the metabolic syndrome associatedwith diabetes, hypertension, and hyperlipidemia).The principles of DM are applicable to all venuesof healthcare delivery, including the inpatient andoutpatient settings in both the primary and specialtycare arenas.According to the Disease Management Associationof America (DMAA, 2009): The Care ContinuumAlliance (hereafter referred to as DMAA), DM is “aDM program goals are to improve clinical outcomes,increase patient and provider satisfaction, andpromote appropriate utilization of resourcesthroughout the MHS. The purpose of DM isto improve the quality of life for individuals bypreventing or minimizing the impact of a disease orchronic condition. This purpose is accomplished byactivities such as implementing more standardizedcare and improving patients’ ability to care forthemselves.Per the DMAA (2009), a DM program:• Emphasizes prevention of exacerbations andcomplications by using evidence-based practiceguidelines and patient empowerment strategies.• Supports the healthcare provider/patient relationshipand plan of care.• Evaluates clinical, humanistic, and economicoutcomes on an ongoing basis with the goal ofimproving overall health.

Medical Management GuideVersion 3.0Disease ManagementPage 107The Current State of DiseaseManagementProviders have long strived to return patients tooptimum health. It has only been since the mid-1990s that DM became the program of choice formanaging patient populations (Sprague, 2003).Several driving forces (e.g., congressional mandates,TMA policy, increasing costs) have influenced theMHS’ move to adopt more robust DM practices.There is strong evidence for efficacy of health promotion,disease prevention, and condition managementprograms in both the MHS and the civilianhealthcare arena.Effective DM is a cost-effective approachto enhancing quality of life, postponing thedevelopment of complications, and consistentlyimproving health outcomes for all beneficiarypopulations in the MHS. DM should no longer beviewed as a burden to healthcare teams but ratheras an effective means for improving the futurehealth of defined populations.Managing Chronic Disease in the MilitaryHealth SystemIn the MHS, the incidence of chronic disease inActive Duty Service members (ADSMs) is approximately21 percent (Armed Forces Health SurveillanceCenter, 2009). However, the vast majority of chronicillnesses in the MHS are present in the retiree andfamily member population. Approximately 30percent of military members remain in the Serviceuntil retirement and become lifetime beneficiaries(Force Readiness and Manpower InformationSystem, 2003). Therefore, the long-term carecoordination and resulting program benefits for thispopulation can be maximally realized in the MHS byleveraging MM resources.In 2005, 133 million people — almost half ofall Americans — lived with at least one chroniccondition (e.g., heart disease, cancer, diabetes).These diseases cause major limitations in dailyliving for almost 1 in 10 Americans (Agency forHealthcare Research and Quality [AHRQ], 2009). Infact, chronic diseases account for 70 percent of alldeaths in the U.S., or about 1.7 million each year(National Center for Chronic Disease Prevention andHealth Promotion [NCCDPHP], 2008). These diseaseshave a severe impact on quality of life, resulting insignificant increases in individual healthcare costsand the development of conditions that lead to ahigh rate of morbidity.Supporting the link between clinical and businessoperations and evidence-based health care (e.g.,asthma, diabetes, and cancer screening) is includedas one of eight critical initiatives in Tri-Servicebusiness planning (described in Section I, MedicalManagement Essentials). In accordance with theNDAA of 2007, the MHS placed a greater emphasison integrating DM programs for a variety of diseasesand chronic conditions with enterprise activities.Consequently, the incorporation of evidence-basedmedicine practices and programs has assumeda higher priority in the administration of currentTRICARE contracts. (For more on the link betweenclinical and business operations, see Section I,Medical Management Essentials. For moreinformation on Tri-Service business planning, seeSection V, Medical Management Tools.)To support the objectives of their business plans,

Page 108Disease Management Version 3.0Medical Management GuideMTFs have implemented the clinical practiceguidelines (CPGs) established by the Departmentof Veterans Affairs (VA) and the DoD for numeroushigh-cost and high-volume conditions, includingdiabetes and asthma. However, significant gaps inquality still exist for conditions covered by theseCPGs, requiring further emphasis and continuedevaluation.Employer-Funded Health PlansEmployer funding of healthcare plans has been adriving force in civilian DM efforts, as employersseek to control healthcare program costs.According to a study in the American Journal ofManaged Care (Welch et. al., 2002), DM programswere most likely to focus on three main diseases:diabetes, asthma, and congestive heart failure. Thestudy found that medical directors perceived theirDM programs to be highly effective not only inreducing mortality and morbidity and improving thefunctional status of patients, but also in loweringcosts. This highlighted the need for DM programsto undergo critical evaluation for quality and costeffectiveness. In a survey by the Kaiser FamilyFoundation (KFF) and the Health Research andEducational Trust, 55 percent of large employers(those with 200 or more employees) offering healthbenefits included one or more DM programs. Thesame survey found that 62 percent of large firmshad one or more wellness programs, including injuryprevention, fitness, smoking cessation, and weightloss (KFF, 2006).A report by America’s Health Insurance Plans (AHIP)examined a variety of civilian health programs aimedat improving the quality of life for members withchronic disease (AHIP, 2007). Important trends inchronic care included:• Providing health coaching for behavior change:Healthcare professionals, usually nurses or healthpromotion staff, coach high-risk members onlifestyle changes.• Harnessing advancements in informationtechnology (IT): Technology, such as electronicmedical records and electronic registries, is usedto improve effective care.• Caring for the whole person: Rather thantargeting individual diseases (such as oneprogram for asthma, one for diabetes, and onefor depression), the needs of the whole personare addressed.• Offering a continuum of care: Health outcomesare improved by the provision of a variety ofservices, ranging from wellness and preventionto acute, chronic, and end-of-life care.Cost Savings for Disease ManagementAs previously discussed, cost control is an importantfocus for DM. Medical expenditures in 2006 forindividuals with one or more chronic diseases totaledabout $1.58 trillion, or 75 percent of total U.S. healthspending (Partnership to Fight Chronic Disease,2008).An analysis on the economic burden of chronicdisease in 2003 demonstrated:• The highest treatment expenditures for chronicdiseases were $64 billion for heart disease,$45.8 billion for mental disorders, and $45.2billion for pulmonary conditions.

Medical Management GuideVersion 3.0Disease ManagementPage 109• Direct costs per person were $3,381 for heartdisease, $1,977 for diabetes, $1,509 for mentaldisorders, and $919 for pulmonary conditions(DeVol, Bedroussian, 2007).As recently as 2003, costs for seven commonchronic diseases, cancer, diabetes, heart disease,hypertension, stroke, mental disorders, andpulmonary conditions, were $277 billion withlost productivity totaling $1.1 trillion (DeVol,Bedroussian, 2007). This lost productivity includedabsenteeism, missed work days, and presenteeism.Presenteeism, defined as being at work but notperforming optimally, was identified as causing thelargest share of lost economic output (Partnership toFight Chronic Disease, 2008).According to the Centers for Disease Control andPrevention (CDC), the approach of focusing onvarious risk factors not only helps prevent chronicdisease; it is cost effective. Reducing cholesterollevels for U.S. adults by 10 percent can reduce thenumber of heart attacks and stroke overall by 30percent. U.S. adults lowered blood pressure andhigh cholesterol during the 1980s, which reducedcosts associated with coronary heart disease byabout 9 percent — from about $240 billion in 1981to about $220 billion in 1990 (CDC, 2009).For Americans with diabetes, foot care examinationsand improved self-care as a result of patienteducation could prevent up to 85 percent ofdiabetes-related amputations. Blood pressurecontrol among people with diabetes reduces therisk of heart disease and stroke by up to 50 percentand the risk of eye, kidney, and nerve diseases byapproximately 33 percent. Blood pressure controlalone for this population can result in a concomitantcost savings of $1,200 over a lifetime for a personwith Type 2 diabetes. In addition, self-managementtraining for diabetics prevents hospitalizations: every$1 invested in training reduces healthcare costs byup to $8.76 (Capital District Physicians’ Health Plan[CDPHP], 2008).DISEASE MANAGEMENT COMPONENTSThere are six essential components to effectiveDM:1. Population identification processes.2. Evidence-based clinical practice guidelines(CPGs) to reduce practice variation and improvecare.3. Collaborative practice models, includingproviders and interdisciplinary healthcare teammembers.4. Patient self-management education.5. Process and outcome measurement, evaluation,and management.6. Feedback and reporting to stakeholders,including patients, the healthcare team, andCommand leadership.Full-service DM programs must include all of theaforementioned elements. Programs not inclusiveof all six components are considered “DM supportservices” (DMAA, 2009).1. Population Identification ProcessesDM begins with a thorough assessment and analysisof the population served by the healthcare system.This assessment includes, at a minimum, knowledge

Page 110Disease Management Version 3.0Medical Management Guideof population age distribution, gender, beneficiarycategory, risk factors, and disease burden. Diseasemanagers will also be interested in any knownhealthcare utilization patterns (e.g., high utilizers,inpatient admissions, Emergency Department [ED]visits).Tools to identify population demographiccharacteristics include:• Defense Eligibility Enrollment Reporting System(DEERS)• MHS Management Analysis and Reporting Tool(M2)• MHS Population Health Portal (MHSPHP)• Armed Forces Health Longitudinal TechnologyApplication (AHLTA)For more information, refer to Section V, MedicalManagement Tools.Armed with a thorough knowledge of theirpopulation, disease managers can risk-stratify thatpopulation and its healthcare needs in order todetermine the priority of interventions. This riskstratification includes identifying chronic diseaseconditions and required treatment along withdefining unhealthy behaviors within specific subpopulationsor cohorts.2. Evidence-Based Clinical Practice GuidelinesFundamentalsEvidence-based practice forms the foundation ofDM. DM programs use CPGs to guide patient care.What is the Military Health System Population Health Portal (MHSPHP)?The MHSPHP is a centralized, secure, Web-based Population Health management systemused by Army, Navy, and Air Force healthcare teams. The MHSPHP transforms Department ofDefense (DoD) and Network healthcare administrative data into actionable information.Military Treatment Facility (MTF) TRICARE Prime enrollees in need of potential clinicalpreventive services, Disease Management, or Case Management are identified on healthcareaction lists. MHSPHP documentation defines specific data sources and methodologiesthat are based on HEDIS ® parameters. Using the MHSPHP, all MTF healthcare teams canproactively manage the health status of their patients over the Web.

Medical Management GuideVersion 3.0Disease ManagementPage 111(CM and UM may also use CPGs as part of theirwork flow and patient care processes.)CPGs are systematically developed, evidencebased,nationally recognized statements to assistpractitioners and patients in making decisionsabout appropriate healthcare services for specificclinical circumstances (Field & Lohr, 1990). UsingCPGs as a tool is an important strategy in anyhealthcare organization, particularly where there isan opportunity to improve the quality of care andindividual patient quality of life, reduce variationin clinical practice, and decrease costs. CPGshelp standardize DM processes and may be usedas a framework for evaluating interventions byspecifying treatment goals and outcome measures(i.e., metrics). When successfully implemented,CPGs offer the opportunity for improving bothpatient clinical outcomes (by decreasing the rate ofcomplications) and financial outcomes (by reducinginappropriate utilization of healthcare services).In contrast to practices reflecting expert consensusor the anecdotal experiences of individual providers,evidence-based CPGs are explicitly linked to thestrength of evidence established after extensive andsystematic review of all relevant literature. CPGsmust be:• Clinically applicable and flexible.• Developed through an interdisciplinary process.• Reviewed on a scheduled basis.• Based on valid, reliable, and reproducibleevidence.• Well documented.CPGs are frequently displayed as an algorithm — aflowchart format providing step-by-step decisionsupport and care guidance for a specific diseaseor condition. CPGs are seen by many as a potentialsolution to inefficiency and inappropriate variationsin the quality of care. However, it is acknowledgedthat the use of guidelines must always be appliedin conjunction with a provider’s clinical judgmentfor the care of a particular patient. For that reason,CPGs may be viewed as an educational toolanalogous to textbooks and journals but presentedin a more user-friendly format.The MHS rationale for adopting CPGs is that theyprovide practitioners with a clinical decision-supporttool for determining appropriate evidence-basedhealth care for specific clinical conditions. A welldesignedguideline offers a broad approach tosupporting interdisciplinary, coordinated care forpatients with a variety of conditions. However,providers should be able to deviate from a guidelinewithout incurring sanctions or jeopardizing coveragefor services when, in their judgment, the healthcareneeds or desires of the individual patient indicatesuch a deviation.The Joint Commission (TJC, 2009) acknowledgesthat CPGs can “improve the quality, utilization, andvalue of healthcare resources.” The Commission hasincorporated their use into its standards for 2009,which state that leaders in hospitals (LD.4.240through LD.4.270) and ambulatory care facilities(LD.4.280) will use CPGs to design or improveprocesses that evaluate and treat specific diagnoses,conditions, and/or symptoms.The 2006 Department of Defense Instruction (DoDI)6025.20, Medical Management Programs in theDirect Care System (DCS) and Remote Areas (seeSection I, Medical Management Essentials,

Page 112Disease Management Version 3.0Medical Management GuideCD-ROM Resource MME-1) describes therequirement for MTFs to identify and select at leastone clinical process each year for improvementthrough the application of a CPG. Furthermore, oneof the critical initiatives informing Tri-Service businessplanning (see Section I, Medical ManagementEssentials and Section V, Medical ManagementTools) calls for increasing the use of evidence-basedhealth care (EBHC), including the incorporationof CPGs, to address clinical quality and outcomesfor specific diseases and conditions. ( CD-ROMResources DM-1 and DM-2 provide Service-specificpolicy guidance on incorporating CPGs.)Department of Defense/Department ofVeterans Affairs Clinical Practice GuidelinesMTFs are encouraged not to create CPGsthemselves, but rather to adopt or adapt an existingCPG, ideally with a rigorous, evidence-reviewfoundation. Creating a CPG is a labor- and timeintensiveprocess. CPGs created at the national levelare developed by well-supported teams of subjectmatter experts (SMEs) who are experienced in theevidence review process.The VA and DoD have partnered since 1998 todevelop evidence-based CPGs that are pertinentto the DoD population’s needs while also freefrom pharmaceutical and industry bias. In effect,these CPGs serve to standardize care for specificconditions across federal healthcare systems. TheVA/DoD Evidence-Based Practice Working Groupdevelops CPGs for select high-volume, high-costconditions specific to VA and DoD populations. TheWorking Group reports to the Assistant Secretary ofDefense for Health Affairs (ASD [HA]) and the UnderSecretary for Health, Veterans Health Administration(VHA). The Army Medical Department (AMEDD) hasassumed the responsibilities as Executive Agent forthe DoD.The scientific rigor of the VA/DoD evidence reviewprocess has been acknowledged by a multitudeof civilian healthcare organizations that havevolunteered to collaborate with the two agencies onfederal CPG development. The rigorous process forselecting and developing a VA/DoD CPG is outlinedbelow.1. Selection — A condition for CPG development isselected by the VA/DoD Work Group based onrelevant high-volume, high-cost conditions.2. Development — Reviewing guidelines already inexistence, a VA/DoD CPG is developed or revisedbased on a current review of research-basedliterature, with a focus on implementing thatguideline in primary care settings.3. Toolkit — Educational materials specific toproviders and patients are developed andpackaged in a toolkit to aid in CPGimplementation.4. Dissemination — The CPG is launched toMTFs using a variety of modalities, such asdirect mail, Web-based programming, and siteassistance visits.5. Implementation — MTF facility champions andaction teams are identified and empowered toimplement the CPG.6. Maintenance — CPGs and toolkits are updatedevery two to four years based on currentevidence and feedback from VA and DoDfacilities. Patient outcomes are monitored atthe local, Service, and MHS levels to assessthe impact of CPG implementation on patienthealth.

Medical Management GuideVersion 3.0Disease ManagementPage 113CPG and toolkit development involves bringingtogether VA and DoD SMEs as well as patients,providers, and support staff to develop process toolsthat support patients, providers, and the healthcaresystem as a whole. By developing and deploying thetoolkits centrally, items are standardized throughoutthe MHS and resources are conserved. Resourcessupporting CPG implementation include:• Patient self-management tools encompassing avariety of resources, such as self-care brochures,wallet cards, care cards, posters, videos, andCD-ROMs.• Clinical support tools that streamlineand standardize clinician assessment,documentation, and treatment of patients(e.g., algorithms, medical education videos,posters, exam room cards, and pocket cards).• System support tools, including AHLTAtemplates, disease registries such as the MHSPopulation Health Portal (MHSPHP), Servicespecificscorecards, and suggested processoutcome measures (refer to Section V, MedicalManagement Tools).CPGs developed by the VA/DoD collaboration aredisplayed in Fig. 28. These CPGs, available supportingmaterials, and ordering information are available atthe U.S. Army Medical Command (USA MEDCOM)Quality Management Office (QMO): https://www.qmo.amedd.army.mil/ (see also Appendix D,Resources). VA/DoD CPGs are frequently underdevelopment or undergoing routine updates, so it isimportant to check the website regularly for the mostcurrent version.VA/DoD Clinical Practice Guidelines (CPGs)• Amputation*• Asthma*• Chronic Heart Failure*• Chronic Kidney Disease• Chronic Obstructive Pulmonary Disease• Diabetes Mellitus*• Disease Prevention• Dyslipidemia*• Dysuria• Gastroesophageal Reflux Disease• Hypertension in Primary Care*• Ischemic Heart Disease*• Low Back Pain*• Management of Pregnancy* (formerlyUncomplicated Pregnancy)*Supporting toolkit available• Major Depressive Disorder* (includesSubstance Use Disorder and SuicidePrevention)• Medically Unexplained Symptoms(Chronic Pain and Fatigue)*• Mild Traumatic Brain Injury (mTBI)• Obesity*• Opioid Therapy for Chronic Pain• Post-Deployment Health Evaluation andManagement*• Post Traumatic Stress Disorder (PTSD)*• Post-Operative Pain*• Psychoses*• Stroke Rehabilitation*• Substance Use Disorder*• Tobacco Use Cessation*Fig. 28 – VA/DoD Clinical Practice Guidelines

Page 114Disease Management Version 3.0Medical Management GuideThe AMEDD enlisted the assistance of the RANDCorporation in developing the best method forimplementing VA/DoD CPGs (Nichols, 2001). Thatcollaboration resulted in an implementation guidepublished in 2001, titled Putting Practice Guidelinesto Work in the Department of Defense MedicalSystem: A Guide for Action ( CD-ROM ResourceDM-3). This document is also available at the ArmyQMO website: https://www.qmo.amedd.army.mil(see also Appendix D, Resources).and use. A template of attributes is completed foreach guideline included in the NGC; and the NCGverifies the currency of all guidelines representedin the database. The NGC website allows users toview more than 2,000 guidelines by clinical specialty,disease/condition, target population, treatment/intervention, or issuing organization. The websitealso features comprehensive structured summaries,full-text guidelines, guideline syntheses, guidelinecomparisons, and PDA downloads.From its work with RAND, the AMEDD developedthe current plan for implementing CPGs withinprimary care. That plan, the VA/DoD Manual forFacility Clinical Practice Guideline Champions (referto CD-ROM Resource DM-4) includes thefollowing steps:1. Know the Guideline (CPG)2. Assess Current MTF Practice Patterns3. Compare Practice Patterns with CPGRecommendations4. Identify "Gaps" in MTF Practice Patterns5. Develop an "Action Plan" to Close the Gaps6. Implement the Plan7. Develop a System to Monitor Practice ChangeNational Guideline Clearinghouse – http://www.guideline.gov/The National Guideline Clearinghouse (NGC) isa joint effort among the AHRQ, the AmericanMedical Association (AMA), and AHIP. The NGCis a comprehensive database of evidence-basedCPGs and related documents. The NGC websiteprovides an easily accessible mechanism forobtaining objective, detailed information on CPGsand furthering their dissemination, implementation,U. S. Preventive Services Task Force – http://odphp.osophs.dhhs.gov/pubs/guidecps/uspstf.htmThe U. S. Preventive Services Task Force (USPSTF)is an independent panel of primary care andprevention experts who systematically reviewcurrent evidence for effectiveness and developrecommendations for clinical preventive services.USPSTF recommendations, while not technicallyCPGs, are firmly based in evidence and deservemention because of their common use andacceptance. USPSTF recommendations and theirevidence reviews are routinely used by the TMAas the basis for determining TRICARE benefits.The USPSTF aims to:• Create age-, gender-, and risk-basedrecommendations regarding services that shouldbe a routine part of primary care.• Evaluate the benefits of individual services.• Identify a research agenda for clinical preventivecare.The USPSTF has provided recommendations forpreventive interventions related to screening,

Medical Management GuideVersion 3.0Disease ManagementPage 115counseling, immunizations, and chemoprophylactictreatments for more than 80 conditions anddisorders, including in the following areas:1. Cancer (oncology)2. Cardiovascular3. Infectious disease4. Injury and violence5. Mental health and substance abuse6. Metabolics, nutrition, and endocrinology7. Musculoskeletal8. Obstetrics and gynecology9. Pediatrics10. Vision and hearingClinical protocols and pathways are tools thatdelineate the optimal sequencing and timing ofinterventions by providers for a particular diagnosisor procedure. They are designed to minimize delaysand resource utilization and maximize the qualityof care. (Refer also to Appendix C, Definitions.)They often have a role in the clinical setting, inboth the inpatient and outpatient arenas. Althoughthey may be evidence-based, these protocols aredistinguishable from CPGs in that they do not havethe full complement of support resources. They areadjunct tools that may be leveraged by healthcareteams to streamline patient care processes.3. Collaborative Practice ModelsThe MHS has a wide variety of practice modelsin place. The most effective are those that fostercollaboration and communication among healthcareteam members, including providers, support/ancillarystaff, and Command leadership, as well as patientsand their families. Examples of ancillary staff whomay be involved in patient care include pharmacists,nutritionists, physical therapists; and dental, healthpromotion, health benefits, and laboratory staff.Deployment health services, health promotion, andmedical counterparts in the field should also beconsidered as potential partners. Other military andcivilian resources include organizations such as familysupport services, local health departments, and localfitness centers. To maximize the use of resourcesand increase efficiencies, it may be advantageous tocollaborate with MCSCs, the Multi-Service MarketOffice (MSMO), and the TRICARE Regional Office(TRO) (see Appendix D, Resources).The United States are divided intothree TRICARE regions. Each ofthe regions has a regional civiliancare partner, the Managed Care SupportContractor (MCSC), who helps administerthe TRICARE benefit plan. The MCSC workswith the TRICARE Regional Offices(TROs) to manage the benefit at the locallevel and receives overall guidance fromTRICARE Management Activity (TMA)headquarters.A Multi-Service Market Office (MSMO) isa TRICARE area with more than one Servicewith a Military Treatment Facility (MTF). Adesignated MTF Commander is appointedto serve as Senior Market Manager foreach MSMO. This role is responsible fordeveloping a single, consolidated, integratedbusiness plan for the Direct Care System(DCS) and Purchased Care System (PCS) forall services located within the MSMO. Thereare currently 12 MSMOs.

Page 116Disease Management Version 3.0Medical Management GuideThe most effective processes have beendemonstrated in teams whose members exercisejoint accountability. This means that qualifiedstaff are expected to be involved in direct careactivities and patient/family education, and inadding patient information to the medical recordand correcting such information. Commandersassist team members by clarifying expectations,prioritizing responsibilities, and allocating resourcesto provide care. Providers should strive to know thehealthcare needs of their entire panel, documenttheir interventions accurately in AHLTA, and provideleadership in the clinical arena.In addition to providing patient care and education,providers, nurses, and support staff within the clinicshould critically evaluate their program and takeaction, as necessary, to improve clinical processes.These stakeholders should be involved not only indirect care activities but also in MTF outreach andmarketing activities to promote patient educationand awareness.The good physiciantreats the disease;the great physiciantreats the patientwho has thedisease.Sir William OslerOpen and ongoing communication among teammembers enhances the effectiveness of teamactivities and allows all members to be involvedin patient care to the fullest extent possible.Communicating with patients and families clearlyand consistently serves to strengthen the patienthealthcareteam relationship and to maximize patientsafety. Communication patterns must be clear — notonly in the clinic, but also during patient transitionsto other clinics, facilities, healthcare services, or theinpatient setting.Clinic reengineering to facilitate patient flow andpatient care activities is integral to the successof collaborative practice models. Strategies tostreamline patient care and improve communicationamong healthcare team members can includeutilizing group visits, promoting standard order sets,and implementing nurse-run clinics.4. Patient Self-Management EducationSelf-management (also referred to as self-care) is abroad term describing interventions targeted towardpatients with a chronic disease and condition andtheir families. The goal of self-management is to helppatients with chronic disease(s) learn to incorporatethe skills to lead an active and satisfying life (Loring,1993). DM programs empower patients withinformation and self-management plans to enablethem to participate directly in decisions related totheir own health care. Because individual patientslive within a context that includes their familiesand/or their immediate environment, selfmanagementincludes the family as an integralparticipant in the patient’s education and skillbuildingprocess.

Medical Management GuideVersion 3.0Disease ManagementPage 117Self-management may include:• Health promotion activities (e.g., tobaccocessation) and clinical preventive services (e.g.,cancer screenings) as recommended by theUSPSTF.• Behavior modification, where indicated, toreduce chronic disease complications (e.g.,dietary monitoring for patients with diabetesor obesity). Examples of specific programstargeting behavior modification include healthyeating and menu planning and exercises formanaging blood glucose.• Compliance monitoring (e.g., review ofhypertension daily blood pressure logs).The benefits of patient self-management are manyand include reduced hospital admissions, reduceddemand for clinical services, improved clinician andpatient satisfaction, improved health outcomesand standard of living, and improved medicationadherence. Clinical outcomes for diseases such asdepression, asthma, hypertension, and diabetes onlyimprove when patients are involved in their owncare (Weingarten, 2002).While patient education may teach diseasespecificinformation and skills, self-managementeducation implies that the patient not only learnsthe information but also acquires the skills tobetter manage his/her health. It includes exposingpatients to problem-solving skills that will help themhandle issues that affect their lifestyle, regardlessof whether or not those issues are directly relatedto their condition or disease. Whereas the goalof general patient education is compliance withtreatment regimes, the goal of self-managementeducation is to increase a patient’s confidencein the ability to manage his/her own health.The underlying assumption in patient education isthat knowledge will create a change in behavior,possibly because it is demanded by the educator.In contrast, self-management education empowersthe patient to achieve a change based on a strategythat combines knowledge and his/her own self-careskills. A patient’s health is more likely to improvewhen the patient is confident of his/her ability toadapt to change.To support patients in managing their lifestylechoices to better adapt to living with a condition ordisease, the healthcare professional needs to assessa patient’s self-management knowledge, behaviors,abilities, confidence, and barriers. Armed withthis assessment, the healthcare professional canprovide behavior change information and ongoingsupport. This allows the patient to understand theeffect of personal behavior on his/her own health,enabling that patient to develop strategies for healthimprovement to meet his/her lifestyle expectations.According to the Institute for HealthcareImprovement (2008), typical failures found inpatient/family self-management education include:• Assumptions that the patient is the key learner.• Confusion regarding self-care instructions,particularly medication use.• Non-compliance, resulting in repeat clinic visitsor hospitalizations.When developing, selecting, and providing specificpatient self-management education, it is critical thateducation efforts target both the patient and his/herfamily. Challenges in working toward patient selfmanagementinclude low patient education level,language barriers, cultural barriers, lowsocio-economic status, and lack of family support.

Page 118Disease Management Version 3.0Medical Management GuideEach of these should be considered when planningcare with patients.Education materials should reflect an appropriatelevel of understanding for the patient/family and bepresented in their preferred modality and learningstyle. Education strategies include:• Individual and group classes on wellness or onspecific diseases or chronic conditions.• Patient-friendly written handouts.• Audio and video libraries.• Disease-specific telephone information centers.• Telephone prompts for screening or healthcareneeds.CD-ROM Resource DM-5 shows the WISEDisease Self-Care Model, which was developed bythe HealthSciences Institute (HSI) as a framework forpatient self-management.5. Process and Outcome Measurement,Evaluation, and ManagementThe critical evaluation of current programs andprocesses is an important element of both MM andPopulation Health. This evaluation can be appliedto all clinical departments within MTFs as diseasemanagers assess the health of the population, theimpact of clinical practices on care rendered, andthe quality and cost effectiveness of the deliverysystem.Quality of care can be measured by any number ofmeans, including:• Inpatient admission rates.• Emergency Department (ED) utilization.• Surgical outcomes.• Immunization rates.• Patient satisfaction.• Compliance with preventive health assessments.• Provision of recommended clinical preventiveservices.Process and outcome measures allow the diseasemanager to understand how the DM programis performing and to evaluate the impact ofimplemented actions on patient health.• Process measures evaluate specific aspects ofthe healthcare delivery practice, such as thepercentage of patients with diabetes with anA1c test completed in the past 12 months or thepercentage of patients with asthma who are onlong-term controller medication.• Outcome measures assess the results ofa specific test or how many patients areexperiencing a particular outcome (e.g., thenumber of patients with diabetes who had anLDL level less than 100 mg/dl).Clinical outcome measurements, such as processor outcome measures help gauge the progressof a DM program by improving specific aspectsof healthcare quality in the MTF. They areespecially useful in determining the effectivenessof a new program or of a specific aspect ofthat program. Tracking outcomes within anorganization provides a basis for modifyingprocesses to improve future outcomes and offersa mechanism for identifying barriers to desiredoutcomes.Disease managers should use standard, nationallyrecognized measures to enable goal-setting andbenchmarking — the review of processes, services,and clinical practices to compare performanceand gauge whether and where clinical processes

Medical Management GuideVersion 3.0Disease ManagementPage 119may need to be improved (see also Appendix C,Definitions). Benchmarking enables the followingcomparisons:• Among clinics/MTFs/services throughout anorganization.• Between the MHS and its civilian counterparts.• Against individual DM programs over time.These comparisons often allow for readyidentification or adoption of best practices whichmay prompt the re-engineering of clinical processesto ultimately improve the health of a population.Tools to readily collect healthcare information forspecific diseases or preventive services includethe MHSPHP, M2, AHLTA, and Clinical Data Mart,as well as Service-specific sites (see Section V,Medical Management Tools).Clinical Quality MeasuresA longstanding approach within the MHS hasbeen to leverage nationally recognized measuresto make comparisons to civilian benchmarks andorganizations. Numerous civilian organizations andgovernmental agencies have developed measuresof clinical quality and business efficacy. Theseorganizations include the CDC, TJC, NationalCommittee for Quality Assurance (NCQA), andAgency for Healthcare Research and Quality(AHRQ).The requirements for centralized MM measuresare developed through the MHS Clinical MeasuresSteering Panel, which includes representatives fromthe Services, MCSCs, and TMA.Healthcare Effectiveness Data and InformationSet (HEDIS ® ) —http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2009/2009_Measures.pdfHEDIS ® is sponsored by the NCQA. As the mostwidely utilized set of measures of clinical qualityin health care, HEDIS ® is used by more than 90percent of managed care organizations throughoutthe United States. Using very explicit methodology(including age/gender/enrollment restrictions andinclusion/exclusion criteria), this set of standardizedmeasures specifies how health plans collect andreport data on quality of care. HEDIS ® measuresare frequently utilized by organizations to create a“report card” on the quality of services and careprovided by healthcare plans. These measures donot necessarily reflect the standard of care; rather,they serve to provide objective comparisons acrossorganizations.The HEDIS ® measures assess various dimensionsof care and services and are organized in eightdifferent domains encompassing more than 70different measures (refer to Fig. 29).The category the MHS leverages most to report onthe quality of care delivered to DoD beneficiaries isthe Effectiveness of Care (EOC) dataset. Measuresof interest to the MHS, including cancer screening,comprehensive diabetes care, and asthmamanagement, have been incorporated into thequality and business plans of all three Services andMCSCs. For a list of HEDIS ® EOC topics,refer to Fig. 30.

Page 120Disease Management Version 3.0Medical Management GuideORYX — http://www.jointcommission.org/AccreditationPrograms/Hospitals/ORYX/facts_oryx.htmORYX is a set of objective measures to assessthe clinical quality provided by inpatient facilities.Implementation of ORYX is a requirement forhospital accreditation with TJC. Under MHS ClinicalQuality Management (CQM — https://www.mhscqm.info/),ORYX data are abstracted from medicalrecords in all bedded (inpatient) MTFs. MTFs mustchoose a combination of applicable core and noncoremeasure sets. *The USAF may not exclusivelyuse TJC for MTF accreditation, but ORYX data arestill collected and reported.Core measure sets generally reflect inpatientprocesses and outcomes, and include the following:• Acute myocardial infarction• Heart failure• Pneumonia• Pregnancy and related conditions• Effectiveness of Care• Access/Availability of Care• Satisfaction with the Experience of Care• Use of Services• Cost of CareHEDIS ® Domains of Care• Health Plan Descriptive Information• Health Plan Stability• Informed Health Care ChoicesSource: http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2009/2009_Measures.pdfFig. 29 – HEDIS ® Domains of Care• ADHD• Asthma• Cancer Screening• Chlamydia Screening• Cholesterol Management• COPDList of HEDIS ® Effectiveness ofCare Measure Topics• Diabetes• Geriatrics• Glaucoma Screening• Hypertension• Immunizations• Lead Screening• Low Back Pain• Medication Management• Mental Illness• Myocardial Infarction• Osteoporosis• Rheumatoid Arthritis• Smoking Cessation• Upper Respiratory Infections• Urinary Incontinence• Weight/Activity AssessmentsSource: http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2009/2009_Measures.pdfFig. 30 – HEDIS ® Effectiveness of Care Measure Topics

Medical Management GuideVersion 3.0Disease ManagementPage 121• Hospital-based inpatient psychiatric services(DoD does not report this data to TJC)• Children's asthma care• Surgical Care Improvement Project (SCIP)• Hospital outpatient measuresNon-core measures are generally ambulatorycare measures and include diabetes, asthma, andhypertension. For more information, visit the MHSCQM website or contact a local QM representative.The MHS publishes MTF performance data forHEDIS ® and ORYX measures on publically availableportals, including the Hospital Compare and MHSCQM websites.goals. Every 10 years, the Department of Healthand Human Services (HHS) revises this documentto account for major risks to health and wellness,evolving public health priorities, and emergingtechnologies related to our nation's healthpreparedness and prevention. Healthy People2020 is anticipated to be published in early 2010.Additional information is available at the CDCwebsite at http://www.cdc.gov/.The MHS has recently focused on the 10 LeadingHealth Indicators identified by HP 2010 (Fig. 32),with an emphasis on tobacco use, alcohol abuse,Healthy People 2010 (HP 2010) — http://www.healthypeople.gov/Healthy People 2010 LeadingHealth IndicatorsThe Healthy People 2010 measure set wasdeveloped by the CDC to serve as a road mapfor improving the health of all people in theUnited States. HP 2010 consists of 28 focus areascontaining 467 objectives with measures to assessthe health of American communities. A limitedset of 10 objectives, the Leading Health Indicators(Fig. 31), reflects the major health concerns in theUnited States for the beginning of the 21st century.Indicators were selected based on their ability tomotivate action and their importance as publichealth issues, and on the availability of data tomeasure progress.HP 2010 provides measure definitions and currentbaseline data with epidemiologic stratifications,along with desired targets. The HP 2010 websiteprovides additional resources and helpful strategiesfor implementing programs to meet the HP 2010• Physical Activity• Overweight and Obesity• Tobacco Use• Substance Abuse• Responsible Sexual Behavior• Mental Health• Injury and Violence• Environmental Quality• Immunization• Access to Health CareFig. 31 – Healthy People 2010 (HP 2010)Leading Health Indicators

Page 122Disease Management Version 3.0Medical Management Guideand overweight/obesity. Some of these indicatorshave been integrated into corporate and strategicdocuments, including the MHS Values Dashboard.National Quality Measures Clearinghouse (NQMC)— http://www.qualitymeasures.ahrq.gov/The NQMC, which is sponsored by the AHRQ, is apublic archive for evidence-based quality measuresand measure sets. It was developed to promotewidespread access to quality measures by thehealthcare community (NQMC, 2009). The NQMCwebsite allows users to view measures by disease/condition, treatment/intervention, domain, or issuingorganization. Users can also explore measuresendorsed by the National Quality Forum (NQF) orthose associated with related guidelines, housed onthe National Guidelines Clearinghouse website(refer to DM Component 2, Evidence-Based ClinicalPractice Guidelines). Other features of the NQMCwebsite include measure summaries, tutorials, expertcommentary, measure comparisons, and resources tocorrectly assess and apply quality measures.Other measure sets are available for diseasespecificconditions. Various consortia have created anationally-recognized set of measures for assessingDM programs. These consortia include the NationalDiabetes Quality Improvement Alliance (DQIA) andthe American College of Cardiology (ACC)/AmericanHeart Association (AHA) Task Force on PerformanceMeasures, which have addressed various cardiacconditions. Since these measure sets are the productof collaborative efforts, they are generally endorsedand supported by agencies such as the AHRQ, TJC,NQF, and other physician-based organizations.MHS CQM Fact Sheets• Asthma Care• Birth Trauma• Breast Cancer Screening• Cervical Cancer Screening• Childhood/Adolescent Immunizations• Chiropractic Health Care Services• Chlamydia Screening• Clinical Practice Guidelines Use• Depression• Depressive Disorder• Diabetes Mellitus Care• Dyslipidemia• Healthcare Acquired Infections• Heart Failure• Hypertension (also Pre-hypertension andBlood Pressure Measurement)• Ischemic Heart Disease• Obesity• Prenatal Access to Care• Post Deployment Health Care• Postpartum Depression• Post-Traumatic Stress Disorder• Tobacco Use CessationFor access to all NQMP Fact Sheets, please go to: https://www.mhs-cqm.info/Open/Education/Factsheets.aspxFig. 32 – MHS CQM Fact Sheets

Medical Management GuideVersion 3.0Disease ManagementPage 123Every year, MHS CQM performs special studiesto critically evaluate clinical outcomes to assessthe quality of care rendered in the MHS. CQMsummarizes these special studies in fact sheetsand provides educational opportunities for MHSstaff. Fig. 32 provides a list of fact sheet topicspublished since 2001.MM may use other Service-level, corporate, andstrategic measures, as well as national benchmarkmeasures, but the aforementioned measureshighlight the MHS’ current priorities (see alsoSection I, Medical Management Essentials,Medical Management Goals and Approach).6. Feedback and ReportingThe complete outcomes management processrequires not only defining data requirementsand obtaining outcomes, but analyzing data andreporting results. Without obtaining feedbackon the effectiveness of the current program andprocesses, it is difficult to appreciate the need forchange. Program assessments and subsequentmodifications allow for effective processimprovement using the Plan-Do-Check-Act(PDCA) cycle (Fig. 33).While some MM staff may not possess the skill setsor expertise to obtain and analyze appropriate data,they should communicate and collaborate with MTFpersonnel experienced in those areas to acquire theinformation they need.Fig. 33 – The PDCA CycleStakeholder ReportingReporting outcome measures serves to informMHS stakeholders of the progress of DM activitieson improving the health of the population.Reporting should be performed on a periodicinterval determined by the DM and MTF leadership.It should include communication with patients,healthcare providers, ancillary and interdisciplinarysupport staff, and Command leadership to facilitateprioritization of resources and planning for futureDM efforts. Reporting of individual provider orclinic outcomes to the healthcare team encouragesownership and refinement of care delivery practices.MTF-specific data and performance on HEDIS ®measures for many outpatient diseases andpreventive screenings are available on the MHSPHP.Disease registries, AHLTA, and the Clinical Data Martare other tools that can be leveraged to generateclinical data (see Section V, Medical ManagementTools).

Page 124Disease Management Version 3.0Medical Management GuideThe MHS and Services display Aggregateperformance data on MHS and Service-specificwebsites (some are CAC-enabled orpassword-protected), including:• MHS — CQM: https://www.mhs-cqm.info/• Army — Command Management System (CMS):https://cms.mods.army.mil/cms• Air Force — Surgeon General’s Executive GlobalLook (EGL): https://egl.afms.mil• Navy — Population Health Navigator Dashboard:http://www-nehc.med.navy.mil/Data_Statistics/Clinical_Epidemiology/pophealthnav.aspx(restricted access, CAC card required)See also Section V, Medical Management Tools.MTF leadership and the DM team should refer totheir DM plan on an ongoing basis to determinewhether their goals have been attained and toidentify opportunities for process improvement.ESTABLISHING A DISEASE MANAGEMENTPROGRAMIn the MHS, the DM program directly supports thestrategic priority of promoting patient choice andaccountability, building healthy communities, anddemonstrating the MHS’ commitment to safety andquality outcomes. To build an effective DM programin the MTF, a disease manager must be cognizantof the six components of DM as identified earlierin this chapter. Healthcare team members involvedin planning a DM program must consider certainquestions to provide direction for their MTFs (seeFig. 34).Implementing a Disease Management PlanOnce the DM program components are analyzedand aligned to meet the needs of the MTF’spopulation and Service-specific mission, the diseaseQuestions to Ask During Development of a DM Program• What are the MTF’s population demographics?• Which risk factors are most prevalent in your population? Which subpopulations require clinicalpreventive services?• What are the disease burdens/chronic conditions of the population served?• Which MTF resources are currently available?• Which disease or conditions should the MTF focus on? Could a CPG be adapted/applied as a tool forbetter management?Fig. 34 – Questions to Ask During Development of a DM Program

Medical Management GuideVersion 3.0Disease ManagementPage 125EVALUATEEvaluateand Refinethe ProgramASSEMBLEAssemble aTeamADOPTAdoptGuidelines andProtocolsANALYZECollect and AnalyzeOutcomesDataASSESSAssessthe TargetPopulationESTABLISHEstablish Goalsand TargetOutcomesIMPLEMENTImplementthe PlanCREATECreate aPrioritizedPlanFig. 35 – The Phases of Implementing a Disease Management Planmanager is ready to focus on implementing aspecific plan. An eight-phase approach providesa systematic construct to help stakeholdersbecome comfortable with the processes of planimplementation. Fig. 35 summarizes the phasesinvolved in setting up a DM plan.Let’s break each phase down to get a more preciseappreciation of what the disease manager shoulddo at each level:1. Assess the Target PopulationFor example, consider a chronic disease such asdiabetes mellitus: How many patients are enrolledand to which providers are they assigned? Thedisease manager may further risk-stratify thepopulation to examine glycemic control, overduelab tests, and associated co-morbidities.2. Assemble a TeamThis phase allows the disease manager to presentthe clinical data identified in Phase 1 to thehealthcare team that will be managing the diseases/conditions. Collaboration and communication arecrucial in identifying the best way to assist a patient/group of patients in adhering to the treatmentplan(s) and in taking more control and responsibilityfor their own health care. Phase 2 teams should beinterdisciplinary, including providers, nursing staff,MM, and ancillary support personnel (see Fig. 36).

Page 126Disease Management Version 3.0Medical Management GuideBased on contractual agreements, the MTF mayalso collaborate with the local MCSC in providinga seamless program between the DCS and PCS.Implementation must be a healthcare team effortthat incorporates all available resources to avoid“reinventing the wheel.”3. Adopt Guidelines and ProtocolsThe healthcare team may decide to implement adisease-specific guideline and adapt it to facilitatelocal policies, business plan initiatives, or Commanddirectives. Prior to implementing a CPG, teammembers will need education and training in theapplication of the algorithm(s) and toolkits. This willmost likely involve reengineering MTF processes tomobilize the entire healthcare team. Roles will needto be assigned so that all personnel understand theirrole(s) in the process (e.g., appointing a providerchampion). Other methods — such as the use offlow charts, lists, and the PDCA cycle (refer to Fig.33) — can help in designing, tracking, andcommunicating the processes to all participants.The steps taken in developing and/or choosing anappropriate CPG should be documented in Servicespecificexecutive/leadership functional minutes,Population Health committee minutes, or MTF policy.4. Establish Goals and Target OutcomesIn establishing goals and targets, it may be helpfulto look at prior performance, MTF trends, Commandexpectations and available resources. Targets shouldmirror the common project management approachSMART — that is, be specific, measureable,achievable, realistic, and time-bound. The diseasemanager, in collaboration with the interdisciplinaryhealthcare team, may develop a timeline formonitoring the status of the population selectedby the team. For example, a desirable goal maybegin with notifying patients overdue for diabetichemoglobin A1C testing and encouraging them tocomplete laboratory tests within 60 days of DM planimplementation.Example of an Interdisciplinary Healthcare Team• Providers (physicians, physician assistants,nurse practitioners)• Registered Nurses (RNs)• Health educators• Technicians, medics, medical assistants/clerks• Utilization management (UM) and CaseManagement (CM) staff• Any ancillary and allied healthcare staffwho participate in managing the targeteddisease/condition (e.g., pharmacists,nutritionists, dental hygienists/dentists)• Command leadership• Information management/technologyspecialistsFig. 36 – Example of an Interdisciplinary Healthcare Team

Medical Management GuideVersion 3.0Disease ManagementPage 1275. Create a Prioritized Plan6. Implement the PlanIn these two phases, the disease manager focuseson selected patient groups previously identified bythe healthcare team and helps the team determinethe decisions and tasks that need to occur and theorder in which they should be executed. Individualand family education is just one type of interventiona disease manager can use to promote patient selfmanagementin an effort to minimize complicationsand avoid unnecessary and inefficient healthcareutilization. Other strategies are to send reminderpostcards or use automated telephone messagingsystems to notify patients of the need for healthcarevisits, medication changes, or recommendedbehavior changes. These techniques offer a simpleyet effective way to collaborate with patients inreaching their desired treatment goals.7. Collect and Analyze Outcomes DataThis phase should be accomplished at regularintervals to track progress. The disease manageris encouraged to liaison with other members ofhis/her Command (e.g., business office, qualitymanagement, IT) to determine whether this datacollection is already occurring at the MTF, or toleverage existing resources or expertise.8. Evaluate and Refine the ProgramDuring this phase, the disease manager may identifybarriers that are preventing the MTF from reachingits goals and determine the necessity of developinga plan to remove those barriers. It is critical thatthe MTF perform annual reviews to determine nextsteps and follow-on goals. Benchmarking againstinternal and external outcomes (e.g., applyingHEDIS ® measures) is a good method for trackingperformance and progress.AccreditationOrganizations such as URAC, the NCQA, and TJCprovide accreditation to DM programs. Otherdisease-specific organizations, such as the AmericanDiabetes Association (ADA), provide certificationsthat recognize outstanding educational programsbased on national standards. (Based on the NDAA2007, it is the MHS’ policy to promote meetingthe standards for program accreditation but notnecessarily for programs to become accredited.The topic is included here to increase awareness ofaccreditation possibilities.)URAC has established accreditation standards forDM programs. According to URAC, DM standardspromote evidence-based practice, collaborativerelationships with providers, consumer education,and shared decision-making with consumers. Thesestandards apply to all types of entities providingservices for individuals with chronic illnesses,including health plans and freestandingDM or MM organizations.The URAC accreditation process occurs in fourphases:1. Application2. Desktop Review3. On-site Review4. Committee Review

Page 128Disease Management Version 3.0Medical Management GuideThe NCQA offers program accreditation options toinclude various patient- and practitioner-orientedprograms. The NCQA’s DM standards address keyareas for which organizations are reviewed. Thestandards are based on patient service, practitionerservice, program content, clinical systems,measurement and quality improvement, andprogram operations.TJC certifies DM programs as a complementaryprocess to MTF accreditation. TJC’s Disease-SpecificCare (DSC) Certification Program is designed toevaluate DM and chronic care services that areprovided by health plans, DM service companies,hospitals, and other care delivery settings. The evaluationand resulting certification decision is basedon an assessment of the following:• An organized approach to performancemeasurement and improvement activities.• Compliance with consensus-based nationalstandards.• Effective use of evidence-based CPGs tomanage and optimize care.For organizations, TJC accreditation is available forvirtually any chronic disease or condition. Advancedaccreditation is available for chronic kidney disease,inpatient diabetes, primary stroke centers, and otherspecialized disease states/procedures.THE DISEASE MANAGEMENTPROFESSIONALQualificationsThe job description of the DM professionalwill vary depending on the size of theMTF and the availability of resources.DM professionals should possess sufficientclinical knowledge and patient care experienceto identify appropriate use of and compliancewith CPGs, as well as conduct and/or arrangepatient care. The DM professional also needsexcellent communication skills, as he/she worksin collaboration with a range of healthcarepersonnel to promote delivery of appropriate,cost-effective care to patient populations.Typically, a candidate for the disease manager rolecan best succeed with the following qualificationsor commensurate experience:• A bachelor’s degree (or higher) in a healthrelatedfield from an accredited institution.• A valid unrestricted healthcare license.• Current basic life support (BLS) certification.• Experience with software and databasescurrently employed at the MTF.• Strong communication and organizational skills.Desirable qualifications include:• Certification by the HealthSciences Institute(HSI) through its Chronic Care Professional (CCP)certification program or another disease-specific,patient-education certifying institution (e.g.,American Diabetes Association [ADA]). (SeeCertification, next page.)

Medical Management GuideVersion 3.0Disease ManagementPage 129• Familiarity with evidence-based CPGs andUSPSTF recommendations.• Familiarity with clinical quality measures (e.g.,HEDIS ® , ORYX).• Three years of broad-based clinical healthcareexperience.• Full-time employment in a healthcare role forthe previous 12 months.• Previous DM experience.The disease burden of the MTF’s enrolledpopulation will determine the size and specificityof any DM program. CD-ROM Resource ItemDM-6 provides a list of sample contract tasks for aDM nurse, which could be adapted to either astatement of work or another type of jobdescription. CD-ROM Resources DM-7,DM-8, and DM-9 provide sample Service-specificDM position descriptions.It should be noted that, depending on the particularService or MTF, DM responsibilities or oversightmay be included as part of roles such as ClinicalStaff Nurse, Physician, or Health Care Integrator(HCI) — an Air Force-specific position ( CD-ROMResource DM-10 provides a description of the HCIrole).CertificationThe HSI has offered a CCP certification programsince 2004. In October 2007, the DMAA partneredwith the HSI and endorsed the program, whichencompasses 25 chronic diseases and late-lifeconditions. The program promotes an evidencebasedapproach to leveraging Population Healthstrategies, DM practices, and health coaching.CCP certification is valid for three years. Recertificationthrough re-examination or documentation of 15 hoursof continuing DM or chronic care education may beobtained. Additionally, organizations that requireCCP for their professional staff may include the CCPseal on their promotional materials, proposals, andwebsite documentation to demonstrate to patientsand customers that their staff have completedspecialized training and passed a national examination(i.e., to show the organization is CCP-accredited).SUMMARYClosely linked to Population Health, DMfocuses on fostering consistent, evidencebasedcare for beneficiaries with one ormore chronic diseases or conditions. While the roleof DM may have been underappreciated in the past,expanded IT capabilities and a renewed appreciationfor the impact of chronic disease on the individual andthe healthcare system have served to highlight theproactive role DM plays in improving the future healthof defined populations.To promote program goals and reduce duplicationof efforts, DM must be accomplished in concert withboth UM and CM staff and the entire healthcareteam. Strategies for implementing DM shouldincorporate other policies and program documents,such as the 2006 Department of Defense Instruction(DoDI) 6025.20, Medical Management Programs inthe Direct Care System (DCS) and Remote Areas (seeSection I, Medical Management Essentials,CD-ROM Resource MME-1), and the currentedition of the DoD Population Health ImprovementPlan and Guide (see Executive Summary,CD-ROM Resource ES-1).

Page 130Disease Management Version 3.0Medical Management GuideCD-ROM RESOURCESDM-1 DM Policy Guidance – NavyDM-2 DM Policy Guidance – Air ForceDM-3 Putting Practice Guidelines to Work in theDepartment of Defense Medical System: AGuide for Action – RANDDM-4 VA/DoD Manual for Facility Clinical PracticeGuideline ChampionsDM-5 WISE Self-Care Model – HealthSciencesInstituteDM-6 Sample Contract Tasks for the DiseaseManagement NurseDM-7 Army Disease Management PositionDescription – SampleDM-8 Navy Disease Management PositionDescription – SampleDM-9 Air Force Disease Management PositionDescription – SampleDM-10 Healthcare Integrator Job Description – AirForceDM-11* Disease Management Road Map– Narrative OverviewDM-12* Disease Management Road Map– Assessment FormDM-13* Disease Management Road Map – ActionPlan (Blank)*Not referenced in text‘

Medical Management GuideVersion 3.0Medical Management ToolsPage 133Medical Management ToolsSECTIONVINTRODUCTIONThis section focuses on tools and resourcesfor successful Medical Management(MM) programs. It complements the 2001Population Health Improvement Plan and Guide,Section IV, p. 67, Analyze Performance and HealthStatus (see Executive Summary, CD-ROMResource ES-1).As discussed in Section I, Medical ManagementEssentials and throughout this Guide, the MHSemphasizes enhanced collaboration between clinicaland business practices within Military TreatmentFacilities (MTFs), since much of the same data areused to derive both clinical and business plans.Specifically, the priorities and measures (i.e., metrics)set for the local MM plan may directly affect theassumptions and data for the local business plan,and vice versa.The tools described in this section are meant to helpsupport this collaborative approach to MM.USING INFORMATION SYSTEMS AND DATAMARTSAccessing the DataMany of the tools described here requirepasswords and/or are only accessibleat “.mil” domains. Health InsurancePortability and Accountability Act (HIPAA) standardsrequire security training and justification for systemaccess. Some tools presented here advise the userof “*Restricted access.” In such cases, please followup with your supervisor or department head formore information on accessing and utilizing thesetools.Note that some Web links may take you to a pagewarning you of a problem with the website’ssecurity certificate. This is a standard messageprior to accessing sensitive websites that may haverestricted access. To access the site when this occurs,click on the red shield icon with the X and proceed.Also note that some tools are presented withoutWeb hyperlinks, as website addresses are oftenupdated or rendered inactive due to domain namechanges.

Page 134Medical Management Tools Version 3.0Medical Management GuideUnderstanding the Methodology andLimitationsINFORMATION SYSTEMS AND DATAMARTSEach system or data mart has detailed datadictionaries, defined methodologies, and businessrules for its respective applications. It is imperativefor MM teams to understand the applicability andlimitations of the system or mart being used. TheTRICARE Management Activity (TMA) sponsors andconducts training to assist MM staff in using thesetools, including:• Data Quality Training• TRICARE Fundamentals• TRICARE Financial Management EducationProgram (TFMEP)• TRICARE Uniform Business Office (UBO)/UnifiedBiostatistical Utility (UBU) Conference• Working Information Systems to DetermineOptimal Management (WISDOM)Courses are listed under the training section on theTMA conference website at http://www.tricare.mil/conferences.cfm.Data Quality ConcernsSeveral coding validation studies conducted withinthe MHS have corroborated concerns about codingaccuracy, especially regarding outpatient care.However, initiatives to establish training programs,involve leadership in more direct oversight,employ certified coders, and deploy the 3MCoding Compliance Editor (CCE) software shouldsignificantly improve the quality of MHS data overtime. Still, it is advisable to scrutinize analyses thathave been conducted using MHS data, to identifyand minimize inconsistencies.Military Health System-Level Decision SupportTools and Executive Information SystemsArmed Forces Health Longitudinal TechnologyApplication: http://www.health.mil/ahlta/The MHS’ electronic healthcare record systemis the Armed Forces Health LongitudinalTechnology Application (AHLTA), whichinterfaces with the Composite Healthcare System(CHCS) for patient record management. CD-ROMResource MMT-1 provides step-by-step instructionson accessing AHLTA in a user-friendly visual format.Clinical Data Mart (CDM) is the clinical reportingtool for AHLTA. It allows users to measure, analyze,and manage performance of direct patient care,wellness, prevention, and DM of the MHS patientpopulation. The CDM can be used to create adhoc queries to help measure quality, safety, andefficiency. CDM accounts are created by the localMTF system administrator. Types of account (basedon demonstrated need) include MTF Access (non-Protected Health Information [PHI] and PHI levels),Enterprise Access (non-PHI and PHI levels), andProvider Access (PHI level). Contact your supervisoror department head for more information.Executive Information and Decision Support:https://dhss.csd.disa.mil/MX/Common/EIDS/mxAppHome.cfm?subMenuItem=aboutThe Executive Information and Decision Support(EI/DS) Web portal provides a centralized data store

Medical Management GuideVersion 3.0Medical Management ToolsPage 135for the MHS. EI/DS tools help provide complete,accurate information to MM staff, includingbeneficiary, provider, financial, and healthcare usedata. These data are evaluated, integrated, andmade available to MHS users through a variety ofEI/DS tools and specialized data sets developedto meet business requirements. EI/DS activelyinterfaces with more than 260 systems around theglobe and is comprised of a data warehouse andseven operational data marts supporting nearly3,000 users, including MHS managers, clinicians,and analysts.EI/DS includes the following tools, many of whichare discussed in this section:1. Military Health System Data Repository (MDR)2. MHS Management Analysis and Reporting (M2)3. Prospective Payment System (PPS)4. ESSENCE Medical Surveillance5. CDM6. TRICARE Encounter Data (TED)7. Patient Encounter Processing and Reporting(PEPR) and its reporting applications.All tools and resources provided by EI/DS require anaccount. The various tools have a limited number oflicenses; therefore, accounts must be approved bya Service representative. To become a user, contactEI/DS via email at: eids.access@tma.osd.mil.TOOLS FOR UTILIZATION, CASE, ANDDISEASE MANAGEMENT COLLABORATIONFig. 37 provides a summary of informationsystems that may be helpful for UM, CM,and DM collaboration. (For more informationon collaboration between MM components, seeSection I, Medical Management Essentials;Integrating Utilization, Case, and DiseaseManagement Functions.)Multiple source systems feed the MHS DataRepository (MDR) to create various data marts andapplications. These source systems include:• The Composite Health Care System (CHCS)— where data are gathered directly from theMTFs.• The Medical Expense & Performance ReportingSystem (MEPRS) Executive Query System(MEQS).• The Defense Eligibility Enrollment ReportingSystem (DEERS).• Managed Care Support Contractor (MCSC)systems.The data from these systems are reviewed, analyzed,and aggregated in the MDR to create the variousmarts and applications listed in Fig. 38.Be sure to see the companion CD-ROM for moreimportant Medical Management Tools and Resources.

Page 136Medical Management Tools Version 3.0Medical Management GuideSummary of Data Systems for Use in Medical ManagementData SourceUtilizationManagementCase ManagementDiseaseManagementPopulation HealthDMSSM2MCFASCDMMEWACSMHS PortalPDTSSADRSIDRTMA Purchased CareTMA-RTTOCService Sources:AFP2R2Army PASBAFig. 37 – Summary of Data Systems for Use in MMMHS Data RepositoryTRICARE Management Activity Reporting ToolsTMA Reporting Tools (TMA-RT) comprise thefollowing seven applications:1. Military Health System Management Analysis andReporting Tool: http://www.mhs-helpdesk.com/Pages/m2.aspThe Military Health System Management Analysisand Reporting Tool (M2) is used to obtain summaryand detailed views of population, clinical, andfinancial data from all MHS regions. Access isgranted at six levels of report from Level 1 (MTFleveldata) through Level 6 (personally identifiableinformation).Fig. 38 –MHS Data Repository

Medical Management GuideVersion 3.0Medical Management ToolsPage 137M2 includes MTF and commercial network claimsdata integrated with eligibility and enrollment data.It allows users to perform trend analyses, conductpatient and provider profiling studies, and conductbusiness case analyses to maximize health planefficiency. Many corporate measures are derivedfrom M2.Comprehensive data sets are compiled from varioussources including, but not limited to:• MTF data sets.• Expense Assignment System, Version 4 (EAS IV).• Standard Ambulatory Data Record (SADR).• Standard Inpatient Data Record (SIDR).• World Wide Workload Reports (WWRs).• External data sets.• Health Care Service Record (HCSR) — Networkinstitutional and professional services claims.The name HCSR has been changed to“TRICARE Encounter Data” (TED); however,any claims submitted prior to contract changesremain an HCSR record.• Pharmacy Detail Transaction Service (PDTS)— A centralized data repository that allows theDoD to build a common patient medicationprofile for all DoD beneficiaries, regardlessof the point of service they use (excludingStandard TRICARE).• National Mail Order Pharmacy (NMOP).• Patient (i.e., beneficiary) demographic data.• DEERS eligibility data.• TRICARE enrollment data.• TRICARE longitudinal enrollment data.• TRICARE Mail Order Policy (TMOP).2. Defense Medical Surveillance System: *Restrictedaccess3. Defense Medical Epidemiology Database:http://afhsc.army.mil/The Defense Medical Surveillance System (DMSS)and Defense Medical Epidemiology Database(DMED) are operated by the Armed Forces HealthSurveillance System (AFHSC).As the DoD’s premier epidemiologic resource, DMSSprovides the MHS with a longitudinal record of upto-datehistorical data related to:• Medical events (e.g., hospitalizations,ambulatory visits, immunizations, reportablemedical events, health risk appraisals,deployment health assessments).• Individual/demographic characteristics.• Military experiences (assignments, deployments,casualty information) spanning a Servicemember’s entire career.The DMSS is an excellent source for processing Tri-Service epidemiologic queries on disease burdensand injury rates, and can be used to demonstrateService trends and potential for disease/conditionmanagement initiatives. Features include the abilityto create results in tabular, line graph, or bar graphformats. DMSS also has the ability to save, export,and print query results.The DMED application enables Web-based, userdefinablequeries of de-identified DMSS datasubsets. Its user-friendly interface provides data onpopulation statistics, disease summaries, detailedqueries, and Top 10 diagnoses for Active Dutypopulations. Data can be obtained for inpatient

Page 138Medical Management Tools Version 3.0Medical Management Guideand ambulatory encounters, reportable events, anddemographic data elements.5. TRICARE Operations Center: http://mytoc.tma.osd.mil/4. Medical Expense & Performance ReportingSystem Early Warning and Control System: http://www.meprs.info/mol3The Medical Expense & Performance ReportingSystem (MEPRS) Early Warning and Control System(MEWACS) is a robust, interactive, user-friendly dataquality surveillance tool developed by the MEPRSManagement Improvement Group (MMIG) toproactively identify, investigate, resolve, or correctMEPRS data anomalies in a timely manner usingsystematic, repeatable processes. It is a valuable MMtool for monitoring resource consumption and clinicproductivity. MEWACS provides detailed informationat the MTF level and does not require a passwordfor access.MEWACS currently contains up to 24 months ofTri-Service MTF activity-level measures, including:• EAS IV Repository data status and compliancewith 45-day reporting suspense.• Interactive MTF MEPRS data profiles bythird-level functional cost code.• MTF-specific summary data outliers and varianceassessments.• A WWR vs. EAS IV Repository total ambulatoryvisit comparison.• Ancillary and support expense allocation tests.MEWACS is updated monthly and is available fordownload at the end of each month.This tool is an MHS healthcare information Webportal providing decision-makers at all levels ofthe organization with meaningful, easy-to-use,Web-based operational tools and reports. TheCenter provides useful MM resources, such as atemplate analysis tool, inpatient daily summaries,length-of-stay (LOS) analysis, provider schedules,and appointment cancellations by MTFs. Generalaccess is available through the TRICARE website;direct access to the tool requires a username andpassword.6. Patient Administration Systems and BiostatisticsActivity: *Restricted accessThe Patient Administration Systems and BiostatisticsActivity (PASBA) offers a wealth of valuableinformation for preparing MM plans. The Armyuses PASBA to post utilization reports for the MHSthat are stratified by Service, fiscal year, currentprocedural terminology (CPT) code, diagnosis-relatedgroup (DRG), and International Classification ofDiseases-Ninth Edition-Clinical Module (ICD-9-CM)codes. (See also Appendix C, Definitions.)The following is a list of available reports:• Top 100 CPT for Non-Same Day Surgery• Top 100 CPT for Same Day Surgery Report• Top 100 DRG by Case Weighted Product• Top 100 DRG by Frequency• Top 100 ICD-9-CM for Non-Same Day Surgery• Top 100 ICD-9-CM for Same Day Surgery• Top 25 CPT for Non-Same Day Surgery forActive Duty

Medical Management GuideVersion 3.0Medical Management ToolsPage 139• Top 25 CPT for Same Day Surgery for ActiveDuty• Top 25 DRG by Case Weighted Product forActive Duty• Top 25 DRG by Frequency for Active Duty• Top 25 ICD-9-CM for Non-Same Day Surgeryfor Active Duty• Top 25 ICD-9-CM for Same Day Surgery forActive DutyThese reports are available for all DoD and VAregional commands and medical facilities. Data areposted once a year, usually in January or February,for the previous fiscal year.7. Military Health System Population Health Portal:*Restricted access• Chlamydia screening• High cardiovascular risk• Lipid riskBy generating provider-level action lists of patients,the Portal enables risk stratification and targetingof provision of services to the enrolled population.The ability of the Portal to identify individuals whoare considered “high utilizers” directly supports MMactivities and encourages collaboration betweenUM, CM, and DM.The Portal also assists in the evaluation of the MMprogram by providing:• Aggregate measures (e.g., HEDIS ® ) to assess theperformance of a branch clinic or MTF.• Action lists to enable other critical analyses atthe patient, provider, clinic, or MTF level.The Military Health System Population Health Portal(MHSPHP) allows MM professionals to identifyand assess their populations, forecast and managedemand, and provide evidence-based care toindividuals needing clinical preventive services andDM. Although the tool has a common log-in page,each Service has a unique name and home pagefor its application — the Army Population HealthInformation Connection, the Navy Population HealthNavigator, and the Air Force Population HealthPortal.This tool provides patient demographic informationand identifies patients requiring clinical preventiveservices, including but not limited to:• Cancer screeningo Breast cancero Cervical cancero Colon cancerHealth Assessment Review Tool — formerlyHealth Enrollment Assessment ReviewThe Health Assessment Review Tool (HART),formerly known as the Health EnrollmentAssessment Review (HEAR), is a DoD automatedhealth assessment tool. Information from the HARTcan be used to help establish prevalence of healthrisk behaviors and to set MM priorities accordingly.CD-ROM Resource MMT-2 describes variousaspects of the tool, and CD-ROM ResourceMMT-3 records the change from HEAR to HART perthe Assistant Secretary of Defense for Health Affairs(ASD [HA]) in 2005.

Page 140Medical Management Tools Version 3.0Medical Management GuideMHS InsightMHS Insight is an exceptionally powerful yet easy-touseMHS performance management tool to supportthe periodic review of performance measures toactively manage business, operational, and clinicalactivities from the ASD (HA); the TMA; and theArmy, Navy, and Air Force medical departments(including local MTFs, intermediate Commands, andheadquarters). This Web-based solution improvesthe ability of the MHS to set, monitor, and achievestrategic performance goals; and to quickly andaccurately communicate performance informationto all levels of the MHS. Contact your supervisor ordepartment head for more information.Prospective Payment SystemThe Prospective Payment System (PPS) is a modular,performance-based budgeting system that facilitatesthe ability of the MHS to provide incentives andfinancial rewards for efficient management. Eachmodule of the application is designed to leverageinformation technology that has already been builtby the Services as part of their business planning.Protected Health Information ManagementToolThe Protected Health Information ManagementTool (PHIMT) is a Web-based application that assistsin complying with the HIPAA Privacy DisclosureAccounting requirement. It enables the MHS tosimplify its compliance tasks and reduce associatedcosts through the use of sophisticated HIPAAprocess automation features and centralized datamanagement.Information on the PHIMT is available through theTRICARE website at http://www.trow.tma.osd.mil/TMAPrivacy/hipaa/hipaacompliance/tools-training/PHIMT.htm.To obtain access to the tool, contact EIDS@mhshelpdesk.com.SERVICE-LEVEL INFORMATION SYSTEMSThe Army, Navy, and Air Force have developedService-specific websites that providemeasures supporting the Defense HealthProgram (DHP), as well as other measures of interestfor MM. The tools described below allow Service-,regional-, and MTF-level views of their respectivemeasures, to assist MM teams in extracting relevantmeasures to support their MTFs’ MM and businessplans.• Army — The Army’s Office of the SurgeonGeneral (OTSG) maintains a dashboardof clinical and business measures on theCommand Management System (CMS), and theMedical Operational Data System (MODS).MODS provides the Army Medical Department(AMEDD) with an integrated automation systemsupporting all phases of human resource lifecycle management during both peacetime andmobilization. It provides Commanders, staff,and functional managers of AMEDD organizationswith a real-time source of informationon the qualifications, training, special pay, andreadiness of AMEDD personnel. Measures areavailable from the MEDCOM level to the childDefense Medical Information System (DMIS)

Medical Management GuideVersion 3.0Medical Management ToolsPage 141level and are presented in a red-amber-greenstoplight with contributing data available fordownload. Access to the site is restricted tothose with a CAC: https://cms.mods.army.mil/.• Navy — In direct support of Tri-Service businessplanning, and of the Navy’s PerformancebasedBudget (PBB) and current MM policy, thePopulation Health Navigator (PHN) dashboarddisplays clinical quality performance datagenerated by the MHSPHP. In addition to theHEDIS-like performance measures, other clinicalPBB measures are also displayed. The PHNdashboard design allows for benchmarkingwith Navy and external standards as well as forcomparisons with children’s healthcare clinics,Navy Medicine regions, or similar MTF types.Access is restricted to those with a CAC:http://www-nehc.med.navy.mil/Data_Statistics/Clinical_Epidemiology/pophealthnav.aspx.assessment)o Financials (business plan, primecontainment).A significant innovation is the "Push Report,"a feature on the SG/EGL website that allowscustom reports to be pushed directly to Air Forcecustomers’ email inboxes. These reports contain thesame information as what is available on the EGLwebsite, but the data are sent in an attachment sousers receive updated information when the site isrefreshed.SG/EGL and Virtual Analyst have becomethe benchmarks of Web-based performancemeasurement improvement efforts within the AFMS.Access is granted through a ".mil" domain. Ausername and password are required to enable fullnavigation: https://www.egl.afms.mil andhttps://eglva.afms.mil.• Air Force — The Air Force Medical Service(AFMS) offers the Surgeon General ExecutiveGlobal Look (SG/EGL) and the SG/EGL VirtualAnalyst, which provide performance measuresfor all Air Force MTFs. Each of the SG/EGLmeasures directly supports the objectivesand initiatives of the Air Force SG and MajorCommand (MAJCOM) Surgeons General (SGs)for each MTF in the AFMS. The tool tracksmeasures such as:o Readiness (dental and individual readiness)o Quality HEDIS ® measurements on cancerscreenings, diabetic management, andchildhood immunizations)o Efficiency (access and coding)o External customer service (deliveryBUSINESS PLANNING TOOLSAs discussed throughout this Guide,developing a clear and coherent businessplan is a central function of today’sMM programs (see also Section I, MedicalManagement Essentials).Tri-Service Business PlansBusiness plans consist of the following four primarysections:1. Enrollment Forecasts2. Inpatient Demand and Workload3. Outpatient Demand4. Workload and Manpower Requirements

Page 142Medical Management Tools Version 3.0Medical Management GuideIn 2005, the MHS introduced an automated formatfor Tri-Service business plans. This format is:• Focused on MTFs that are able to receive inputand validation from MSMOs and TROs.• Automated and standardized with easy, onscreenaccess guidance.• Mapped to HA and Service-level measures.• Comprised of measures that relate to criticalinitiatives approved by all Services (modes ofexecution may vary).Fig. 39 is a sample MTF enrollment template. Thetemplate is stratified by patient (i.e., beneficiary)categories, gender, and age. The demographics ofthe enrolled population can be an indicator of futuredemand.weighted products (RWPs) by major diagnosticcategories (MDC) and is stratified by treatmentlocations. Normative demand (third column)indicates the expected RWP workload based onthe MTF’s enrolled population. The data under theEnrollee columns show the MTF’s actual workloadfor care provided in house, in other MTFs, and in thenetwork.Fig. 41 is a sample MTF outpatient demand andworkload template, which forecasts total relativevalue units (RVUs) by Service and product lines,stratified by treatment locations.The final section of the business plan is themanpower template (Fig. 42).Fig. 40 is a sample MTF inpatient demand andworkload template, which forecasts total relativeThe manpower template displays historical full-timeequivalents (FTEs) by source (i.e., contract staff,Fig. 39 – Sample MTF Enrollment Template

Medical Management GuideVersion 3.0Medical Management ToolsPage 143Fig. 40 – Sample MTF Inpatient Demand and Workload TemplateFig. 41 – Sample MTF Outpatient Demand and Workload Template

Page 144Medical Management Tools Version 3.0Medical Management GuideFig. 42 – Sample MTF Manpower Templatecivilian, and military personnel). It also documentswhether personnel are borrowed or loaned out toother facilities. The number of FTEs should correlateto productivity measures.CD-ROM Resource MMT-4 shows a screenshotof a Tri-Service business planning tool from theArmy. CD-ROM Resource MMT-5 offers aTRICARE conference presentation on businessplanning.Tri-Service business plans should also offer MTFs theopportunity to validate historical clinical informationregarding elements such as eligibility, enrollment,outpatient/inpatient workload, and outpatient/inpatient utilization.CD-ROM RESOURCESMMT-1 AHLTA Step-by-Step InstructionsMMT-2 Assistant Secretary of Defense for HealthAffairs Memorandum, Policy for TRICAREHealth Enrollment Assessment Review(HEAR) Survey (Oct. 11, 1996)MMT-3 Assistant Secretary of Defense forHealth Affairs Memorandum, PolicyMemorandum for Name Change of theDoD Automated Health Assessment Toolfrom HEAR to HART (Oct. 28, 2005)MMT-4 Tri-Service Business Planning ToolScreenshot (Army)MMT-5 MHS Business Planning, TRICAREConference (Jan. 26, 2005)

Medical Management Guide Version 3.0 Appendix A - ReferencesPage 147Appendix A – ReferencesCITED REFERENCESExecutive SummaryAn Achievable Vision: Report of the Department of Defense Task Force on Mental Health, 2007. See ExecutiveSummary, CD-ROM Resource ES-5.Department of Defense (DoD)/TRICARE Management Activity (TMA), Population Health Improvement Plan andGuide. TMA/Government Printing Office, 2001: http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.See Executive Summary, CD-ROM Resource ES-1.Honoring the Call to Duty: Veterans’ Disability Benefits in the 21st Century. Veteran’s Disability BenefitsCommission, 2007. See Executive Summary, CD-ROM Resource ES-9.Rebuilding the Trust: The Independent Review Group on Rehabilitative Care and Administrative Processes atWalter Reed Army Medical Center and National Naval Medical Center, 2007. See Executive Summary, CD-ROM Resource ES-6.Report to Congress on the Comprehensive Policy Improvements to the Care, Management and Transition ofRecovering Service Members. DoD/VA, Sept. 16, 2008. See Executive Summary, CD-ROM Resource ES-3.Serve, Support, Simplify: The President’s Commission on Care for America’s Returning Wounded Warriors,2007. See Executive Summary, CD-ROM Resource ES-8.The President’s Commission on Veterans’ Pensions. Government Printing Office, 2006: http://eisenhower.archives.gov/Research/Finding_Aids/PDFs/US_Pres_Commission_on_Veterans'_Pensions.pdf. See ExecutiveSummary, CD-ROM Resource ES-12.The President’s Task Force to Improve Health Care Delivery for Our Nation's Veterans, 2003. See ExecutiveSummary, CD-ROM Resource ES-10.The Report of the Congressional Commission on Service Members and Veterans Transition Assistance, 1999.See Executive Summary, CD-ROM Resource ES-11.

Page 148Appendix A - ReferencesVersion 3.0Medical Management GuideThe Secretary of Veterans Affairs Task Force on Returning Global War on Terror Heroes, 2007. See ExecutiveSummary, CD-ROM Resource ES-7.Title XVI, Section 1611 of the National Defense Authorization Act (NDAA). U.S. House of Representatives, 2008.See Executive Summary, CD-ROM Resource ES-4.Section I – Medical Management EssentialsCousins, Michael S., Shickle, Lisa M., Bander, John A. An Introduction to Predictive Modeling for DiseaseManagement Risk Stratification. Disease Management, September 2002, 5(3): 157-167.Crossing the Quality Chasm: a new health system for the 21st Century. Committee on Quality Health Care inAmerica, Institute of Medicine. National Academy Press, 2001.Despite Barriers, MCOs Integrate Case, Disease, Utilization Management Functions. Managed Care Week.March 2005.DoD Instruction 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS) and RemoteAreas: http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf.Favor, G., Ricks, R. Preparing to automate the case management process. Nursing Case Management, 1996,1(3), 100-106.First Consulting Group. Access to Care Report for the Air Force Office of the Surgeon General. February 2003.Kelley, M. Model for integrating case management and utilization management. Inside Case Management,2001, 8(8), 8-10.Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed., 378-379. Jones and Bartlett Publishers, 2007.Koulopoulos, T., Champy, J. Building digital value chain. Optimize, 2005, 4(9), 24-34.McKendry, M. J., Sherwin, K. Utilization review and case management integration: An idea whose time hascome…Are you ready? Care Management, 2002, 32-35.Mullahy, C. M. Effective Integration of Utilization and Case Management. The Case Manager, 53-55. 2000.Owen, M. Changes in Case Management. In P. Rossi (Ed.), Case Management in Health Care, 19-32. Saunders,2003.Powell, S.K., Tahan, H.A. CMSA Core Curriculum for Case Management, 2nd ed., 294-300. Lippincott, Williams& Wilkins, 2008.

Medical Management Guide Version 3.0 Appendix A - ReferencesPage 149Qudah, F. J., Brannon, M. Population-Based Case Management. In C. M. Mullahy (Ed.), Essential Readings inCase Management, 2nd ed., 86, 87. Aspen Publishers, 1998.Soumerai, S. B., Avron, J. Principles of education outreach (“academic detailing”) to improve clinical decisionmaking.Journal of American Medical Association, January 1990, 263(4), 549-556.Trends and Practices in Medical Management: 2005 Industry Profile. URAC: http://www.urac.org/docs/resources/MMReport2005.pdf.TRICARE Management Activity (TMA), Population Health Improvement Plan and Guide. TMA/ GovernmentPrinting Office, 2001: http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.TRICARE Fact Sheets, TRICARE Regional Contractors for the United States, Sept. 18, 2006: http://www.tricare.mil/factsheets/viewfactsheet.cfm?id=92.Wilson, W., Carneal, G., Newman, M.B. Documenting Case Management Outcomes, Case in Point, 15. CaseManagement Society of America, February/March 2008: http://www.schoonerhealth.com/files/32736223.pdf.Section II – Utilization ManagementAccreditation Handbook for Ambulatory Health Care. Accreditation Association for Ambulatory Health Care,2008: http://www.aaahc.org/.Carneal, G., Korsch, D. I. (Eds.). The Utilization Management Guide, 3rd ed. URAC, 2005.Code of Federal Regulation (CFR) Title 32, National Defense, Chapter 1: Office of the Secretary of Defense,Section 199, Civilian Health and Medical Program of the Uniformed Services: http://www.gpoaccess.gov/cfr/index.html.• Section 199.2 — Definitions• Section 199.10 — Appeal and hearing procedures• Section 199.15 — Quality and Utilization Review Peer Review Organization (PRO)• Section199.16 — Supplemental Health Care Program for active duty members• Section 199.17 — TRICARE ProgramFreedman, Skip (MD). Understand the nuances of utilization review and utilization management. ManagedHealthcare Executive, Jan. 1, 2006.Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed. Jones and Bartlett Publishers, 2007.McKesson Certified Professional in Healthcare Management (CPHM) Study Guide 2, 2009.TMA Memorandum, Policy Guidance for Referral Management. May 5, 2004; http://www.health.mil/hapolicies.aspx.

Page 150Appendix A - ReferencesVersion 3.0Medical Management GuideTRICARE Operations Manual 6010.51-M, 2002: http://manuals.tricare.osd.mil:• Chapter 8, Section 5 — Referrals/Preauthorizations/Authorizations• Chapter 12, Section 9 — Grievance and Grievance Processing• Chapter 13 — Appeals and Hearings, 2002DoD Instruction 6000.14, Patient Bill of Rights and Responsibilities in the Military Health System (MHS), 2007;http://www.dtic.mil/whs/directivesUnited States Code (U.S.C.) Title 10: http://www.gpoaccess.gov/cfr/index.html:• Section 47 — Uniformed Code of Military Justice• Section 55 — Medical and Dental Care:• 1074: Medical and dental care for members and certain former members• 1077: Medical care for dependents: authorized care in facilities of uniformed services• 1079: Contracts for medical care for spouses and children: plans• 1102: Confidentiality of medical quality assurance records: qualified immunity for participantsSection III – Case ManagementAmerican Health Consultants. Consider a New CM Model to Help Your Staff Work More Efficiently. HospitalCase Management, September 2005.Beauchamp, Tom L., Childress, James F. Principles of Biomedical Ethics. Oxford University Press, 1994, 2008 (6thed.).Cesta, Toni G., Hussein, Tahan, A. Case Manager’s Survival Guide Winning Strategies for Clinical Practice, 2nded., 2003.Cohen, E. L., Cesta, T. G. Nursing Case Management: From Essentials to Advanced Practice Applications. Mosby,2001.Dignified Treatment of Wounded Warriors Act, H.R. 1538. U.S. House of Representatives, July 25, 2007:http://www.govtrack.us/congress/billtext.xpd?bill=h110-1538.Hendricks, A. G. How prepared are you? Ethical and legal challenges facing case managers today. The CaseManager, May/June 2003, 56-62.Joint Publication 4-02.2 — Joint Tactics, Techniques, and Procedures for Patient Movement in Joint Operations,Dec. 30, 1996: http://www.dtic.mil/doctrine/jel/new_pubs/jp4_02_2.pdf.Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed. Aspen, 2007.

Medical Management Guide Version 3.0 Appendix A - ReferencesPage 151Marcum, Cheryl Y., Emmerichs, Robert M.; Sloan, Jennifer S.; Thie, Harry J. Methods and Actions for ImprovingPerformance of the Department of Defense Disability Evaluation System. Rand, 2002.Meek, J. A. Predictive Modeling and Proactive Care Management: Part 1. Lippincott’s Case Management, July/August 2003, 8(4), 170-174.Mullahy, C. M. The Case Manager’s Handbook, 3rd ed. Aspen, 2004.Powell, S.K.; Ignatavicius, D. (Eds.) Case Management Society of America’s Core Curriculum for CaseManagement. Lippincott, Williams & Wilkins, 2001.Powell, S.K., Tahan, H.A. CMSA Core Curriculum for Case Management, 2nd ed., 294-300. Lippincott, Williams& Wilkins, 2008.Public Law 194-262 (H.R. 3118), Veterans’ Health Care Eligibility Reform Act of 1996. U.S. House ofRepresentatives, Oct. 9, 1996: http://www.tavausa.org/PL%20104-262.pdf.Steifel, F.E. Operationalizing integrated care on a clinical level: the INTERMED project, 713-758. The MedicalClinics of North America, 2006.Under Secretary of Defense, Directive-Type Memorandum (DTM) 08-049 – Recovery Coordination Program:Improvements to the Care, Management, and Transition of Recovering Service Members (RSMs), Jan. 19, 2009:http://www.dtic.mil/whs/directives/corres/pdf/DTM-08-049.pdf.Section IV – Disease ManagementAdvancing the Population Health Improvement Model. DMAA: The Care Continuum Alliance, 2009: http://www.dmaa.org/phi_definition.asp.Agency for Healthcare Research and Quality (AHRQ): http://www.ahrq.gov.Almanac of Chronic Disease: Statistics and Commentary on Chronic Disease and Prevention, 2008 ed. 34, 39-44. Partnership to Fight Chronic Disease: http://www.fightchronicdisease.org/pdfs/PFCD_FINAL_PRINT.pdf.U.S. Army Medical Command (MEDCOM) Quality Management Office (QMO): http://www.qmo.amedd.army.mil.DeVol, R., Bedroussian, A. An Unhealthy America: The Economic Burden of Chronic Disease: Charting a NewCourse to Save Lives and Increase Productivity and Economic Growth, 1-2, 39-40, 45-50. Milken Institute,October 2007: http://www.milkeninstitute.org/pdf/chronic_disease_report.pdf.DMAA Definition of Disease Management. DMAA: The Care Continuum Alliance, 2009: http://www.dmaa.org/dm_definition.asp.

Page 152Appendix A - ReferencesVersion 3.0Medical Management GuideEmployer Health Benefits: 2006 Summary of Findings, 6. Kaiser Family Foundation and Health Research andEducational Trust, 2006: http://www.kff.org/insurance/7527/upload/7528.pdf.Healthcare Effectiveness Data and Information Set (HEDIS ® ): http://www.ncqa.org/tabid/59/Default.aspx.Innovations in Chronic Care: A New Generation of Initiatives to Improve America’s Health, ix-x. America’s HealthInsurance Plans, March 2007: http://www.ahipresearch.org/PDFs/Innovations_InCC_07.pdf.Kongstvedt, P. R. Essentials of Managed Health Care, 5th ed. Aspen, 2007.MHS Clinical Quality Management: https://www.mhs-cqm.info/Open/Files/2006_Report_to_Congress.pdf.Most American Adults Have at Least One Chronic Medical Condition. AHRQ News and Numbers, Agency forHealthcare Research and Quality. March 28, 2008: http://www.ahrq.gov/news/nn/nn052808.htm.National Committee for Quality Assurance (NCQA): http://www.ncqa.org.Military Health System Clinical Quality Management (CQM): https://www.mhs-cqm.info/index.aspx.Nichols, W., Farley, D. O., Vaiana, M. E., Cretin, S. Putting Practice Guidelines to Work in the Department ofDefense Medical System: A Guide for Action. Rand, 2001.Overview: National Center for Chronic Disease Prevention and Health Promotion, 2009: http://www.cdc.gov/nccdphp/overview.htm.Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and HealthPromotion, revised August 2008:• Preventing Heart Disease and Stroke. http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/dhdsp.htm.• Preventing Diabetes and Its Complications: http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/diabetes.htm.Sprague, L. Disease management to population-based health: Steps in the right direction. National Health PolicyForum, 2003, 791(3).The Joint Commission (TJC): http://www.jointcommission.org.Welch W. P., Bergsten, C., Cutler, C., Bocchino, C., Smith, Richard I. Disease management practices of healthplans. American Journal of Managed Care, (8) 353-361, 2002.Section V – Medical Management ToolsDefense Health Program (DHP) Performance Contract, TOPS Feature Fourth Quarter FY 2000: http://www.tricare.mil/reptcard/tops/topsrept0012.htm.

Medical Management Guide Version 3.0 Appendix A - ReferencesPage 153GENERAL REFERENCESExecutive SummaryAccreditation Handbook for Ambulatory Health Care. Accreditation Association for Ambulatory Health Care,2008: http://www.aaahc.org/eweb/StartPage.aspx.32 CFR 199.17, TRICARE Program: http://www.access.gpo.gov/nara/cfr/waisidx_05/32cfr199_05.html.42 CFR, Public Health, Centers for Medicare and Medicaid Services (CMS) — Information updated as of July 16,2009: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=/ecfrbrowse/Title42/42tab_02.tpl.Section I – Medical Management EssentialsDoD Population Health Improvement Plan and Guide, 2001. TMA/Government Printing Office:http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.DoDD 1010.10, Health Promotion and Disease/Injury Prevention, Aug. 22, 2003:http://www.dtic.mil/whs/directives.DoDD 6025.18-R, DoD Health Information Privacy Regulation, January 2003:http://www.dtic.mil/whs/directives.Dranove, D. The Economic Evolution of American Healthcare: From Marcus Welby to Managed Care. PrincetonUniversity Press, 2002.Kongstvedt, P. R. Managed Care: What It Is and How It Works, 2nd ed. Jones and Bartlett, 2007.Privacy Act of 1974 (as amended): http://www.usdoj.gov/opcl/privstat.htm (U.S. Department of Justice).Health Insurance Privacy and Accountability Act of 1996 (HIPAA), Aug. 21, 1996:http://aspe.hhs.gov/admnsimp/pL104191.htm. See also:• Centers for Medicare & Medicaid Services (DMS):http://www.cms.hhs.gov/HIPAAGenInfo/Downloads/HIPAALaw.pdf.• Department of Health and Human Services (HHS): http://www.hhs.gov/ocr/privacy/index.html.Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Reorganization Act of 1992 (S. 1306)TRICARE Policy Manual 6010.54-M, TRICARE Overseas Program (TOP), Chap. 12, Sec. 11.1 — Managed CareSupport Contractor (MCSC) Responsibilities for Claims Processing. Aug. 1, 2002: http://www.tricare.mil/tp02/C12S11_1.PDF.

Page 154Appendix A - ReferencesVersion 3.0Medical Management GuideSection II – Utilization ManagementDoD Administrative Instruction No. 81, Privacy Program, 2000. DoD Issuances: http://www.dtic.mil/whs/directives.DoD Directive 5400.11, DoD Privacy Program, 2007. DoD Issuances: http://www.dtic.mil/whs/directives.DoD Instruction 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS) and RemoteAreas, 2006: http://www.dtic.mil/whs/directives/.Public Law 104-191, Health Insurance Portability and Accountability Act of 1996, Sections 261-264. Aug. 21,1996: http://aspe.hhs.gov/admnsimp/pL104191.htm.McKesson ® InterQual ® evidence-based clinical decision support criteria: http://www.mckesson.com.Milliman Ambulatory Care Guidelines ® . Milliman, USA: www.careguidelines.com.Section III – Case ManagementDisease Management, Version 2.0, Program Guide. URAC: www.urac.org.DoDD 1010.10, Health Promotion and Disease/Injury Prevention, Aug. 22, 2003: DoD Issuances: http://www.dtic.mil/whs/directives.DoDD 6025.18-R, DoD Health Information Privacy Regulation, January 2003: DoD Issuances: http://www.dtic.mil/whs/directives.Dorland Healthcare Information, Case Management Resource Guide. Dorland Healthcare Information, 2003:http://www.cmrg.com/Kuhn, A. A necessary discipline: Maximizing case management ROI. Nursing Watch. The Advisory BoardCompany, 2000.Meek, Julie A., DNS. Increasing Return on Investment Potential in Care Management — Predictive Modelingand Proactive Care Management: Part II. Lippincott’s Case Management, September/October 2003, 8 (5):198-202.National Library of Medicine, Medline Plus: http://www.nlm.nih.gov/, http://www.nlm.nih.gov/medlineplus/.Powell, S. K. Advanced Case Management: Outcomes and Beyond. Lippincott, Williams & Wilkins, 2000.Quinn, J., Kellogg, F.R. (Eds.). Case management return on investment: Summary report on the state of the art.Care Management Journal, December 2003.

Medical Management Guide Version 3.0 Appendix A - ReferencesPage 155The Joint Commission (TJC) 2009 National Patient Safety Goals (NPSGs): http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/.TRICARE Benefits: http://www.tricare.osd.mil/.TRICARE Fact Sheets: http://www.tricare.osd.mil/Factsheets/viewfactsheet.cfm?id=127.TRICARE Handbook: http://tricare.osd.mil/tricarehandbook/results.cfm?tn=30&cn=8.TRICARE Policy Manual, 6010.54, Chapter 9, Section 1.1: http://manuals.tricare.osd.mil/.Section IV – Disease ManagementHEALTHeFORCES: Walter Reed Army Medical Center's health outcomes management program.Centers for Medicare and Medicaid Services (CMS): http://www.cms.hhs.gov/.CD-ROM RESOURCESAppendixA-Ref1TMA Medical Management Guide References‘

Page 156Appendix B - AcronymsVersion 3.0Medical Management GuideAppendix B – AcronymsA&DAAAHCACADAMHAADFMADLADMADMEADSMAEAFHSCAFIAFPDAFPHSDAHLTAAHRQAIMALCALOSAMEDDAdmissions and DispositionAccreditation Association forAmbulatory Health CareActive ComponentAlcohol, Drug Abuse, and MentalHealth AdministrationActive Duty Family MemberActivity of Daily LivingAmbulatory Data Module (formerlyAmbulatory Data System [ADS])Active Duty Military ExtensionActive Duty Service MemberAeromedical EvacuationArmed Forces Health SurveillanceCenterAir Force InstructionAir Force Policy DirectiveAir Force Population HealthSupport DivisionArmed Forces Health LongitudinalTechnology Application (formerlyCHCS II)Agency for Healthcare Researchand QualityAccess Improvement Model (AirForce)Assignment Limitation CodeAverage Length of StayArmy Medical DepartmentANGAPHICARARMPARNGASAMASD (HA)BCACBLSBUMEDCBHCOCCECCMCCPCCTPCDCCDISCDMCDRCDWCHCCAir National GuardArmy Population Health InformationConnectionArmy RegulationAnesthesia Report and MonitoringPanelArmy National GuardAmerican Society of AddictionMedicineAssistant Secretary of Defense(Health Affairs)Beneficiary Counseling andAssistance CoordinatorBasic Life SupportBureau of Medicine and Surgery(Navy)Community-Based HealthcareOrganizationCoding Compliance EditorCertified Case ManagerChronic Care ProfessionalCustodial Care Transitional PolicyCenters for Disease Control andPreventionCare Detail Information SystemClinical Data MartClinical Data RepositoryClinical Data WarehouseCooperative Health Care Clinic

Medical Management Guide Version 3.0 Appendix B - AcronymsPage 157CHCSCMCMACCMGCMICMISCMSCMSACOECONUSCORCOTRCPGCPTCQICTPCURESDADCAODCSDEERSDESDHIMSDHSSDIGMASDMComposite Health Care SystemCase ManagementChampus Maximum AllowableChargeClinical Management GroupCase Mix IndexCHAMPUS/TRICARE MedicalInformation SystemCenters for Medicare & MedicaidServicesCase Management Society ofAmericaCenter of ExcellenceContinental United StatesContracting Officer’sRepresentativeContracting Officer’s TechnicalRepresentativeClinical Practice GuidelineCurrent Procedural TerminologyClinical Quality Improvement/Continuous Quality ImprovementComprehensive Transition PlanCHAMPUS/TRICARE UtilizationReporting and Evaluation SystemDepartment of the ArmyDebt Collector Assistance OfficerDirect Care SystemDefense Enrollment EligibilityReporting SystemDisability Evaluation SystemDefense Health InformationManagement SystemDefense Health Services SystemsDrop-in Group MedicalAppointmentsDisease ManagementDMAADMEDMEDDMISDMSSDoDDQDRGEASIVECHOEDEFMPEGLE/MEOCFHIFIRPFRCFTEFYGPMGWOTHAHARTDisease Management Associationof America: The Care ContinuumAllianceDurable Medical EquipmentDefense Medical EpidemiologyDatabaseDefense Military IdentificationSystemDefense Medical SurveillanceSystemDepartment of DefenseData QualityDiagnosis Related GroupExpense Assignment System,Version IVExtended Care Health OptionEmergency DepartmentExceptional Family MemberProgramExecutive Global Look (formerlyPrivilege, Pleasure, Relevant,Reasonable [P2R2])Evaluation and ManagementEpisode of CareFamily Health InitiativeFederal Individual Recovery PlanFederal Recovery CoordinatorFull-time EquivalentFiscal YearGroup Practice ManagerGlobal War on Terrorism (see alsoOverseas Contingency Operations– OCO)Health AffairsHealth Assessment ReportingTool (formerly Health EnrollmentAssessment Review [HEAR])

Page 158Appendix B - AcronymsVersion 3.0Medical Management GuideHAWCHBAHCIHCILHCPCSHCSRHEDIS ®HIPAAHSIHSSHSSCICD-9-CMICDBIOPJPTAJTFLCSWLIMDULODLOSM2MAJCOMMCFASMCSCMDCMDRMEBMEDCENHealth and Wellness CenterHealth Benefits AdvisorHealth Care IntegratorHealthcare Information LineHealthcare Common ProcedureCoding SystemHealthcare Service RecordHealthcare Effectiveness Data andInformation SetHealth Insurance Portability andAccountability Act (of 1996)HealthSciences InstituteHealth Service SupportHealth Service and SupportContractorInternational Classification ofDiseases, Ninth Revision, ClinicalModificationIntegrated Clinical DatabaseImproving OrganizationalPerformanceJoint Patient Tracking ApplicationJoint Task ForceLicensed Clinical Social WorkerLimited DutyLine of DutyLength of StayMHS Management Analysis andReporting ToolMajor Command (Air Force)Managed Care Forecasting andAnalysis SystemManaged Care Support ContractorMajor Diagnostic CategoryMHS Data RepositoryMedical Evaluation BoardMedical CenterMEDCOMMEDDACMEPRSMEQSMEWACSMHOMHSMHS CQMMHSPHPMMMMIGMMSOMRP/MRP2MSAMSIPMSMOMSMPMSWMTFNASNATONCMNCQANDAANEDNMCPHCNGCNAVMISSAMedical Command (Army)Medical Department Activity (Army)Military Expense and PerformanceReporting SystemMEPRS Executive Query SummaryMEPRS Early Warning and ControlSystemMedical HoldoverMilitary Health SystemMilitary Health System ClinicalQuality ManagementMilitary Health System PopulationHealth PortalMedical ManagementMEPRS Management ImprovementGroupMilitary Medical Support OfficeMedical Retention ProcessingMedical Savings AccountModeling and Simulation (M&S)Investment PlanMulti-Service Market OfficeModeling and Simulation (M&S)Master PlanMaster of Social WorkMilitary Treatment FacilityNon-availability StatementNorth Atlantic Treaty OrganizationNurse Case ManagerNational Committee for QualityAssuranceNational Defense Authorization ActNational Enrollment DatabaseNavy and Marine Corps PublicHealth CenterNational Guideline ClearinghouseNavy Medical Informatic SystemsSupport Activity

Medical Management Guide Version 3.0 Appendix B - AcronymsPage 159NMOPNPICNQFNQMCNRDNSQIPOCMOOCOOCONUSODPHPOEFOHIOIFOIGOSHAP4PPASBAPBAMPBBPCEPCMPCOPCPPCSPDCAPDESNational Mail Order PharmacyNational Perinatal InformationCenterNational Quality ForumNational Quality MeasuresClearinghouse/National QualityMonitoring ContractorNational Resource DirectoryNational Surgical QualityImprovement ProgramOffice of the Chief Medical OfficerOverseas Contingency Operations(see also Global War on Terrorism– GWOT)Outside of the Continental UnitedStatesOffice of Disease Prevention andHealth PromotionOperation Enduring FreedomOther Health InsuranceOperation Iraqi FreedomOffice of the Inspector GeneralOccupational Safety Health ActPay for PerformancePatient Administration Systems andBiostatistical ActivityPerformance-based AdjustmentModel (Army)Performance-based BudgetPrimary Care ElementPrimary Care ManagerPrimary Care OptimizationPrimary Care ProviderPurchased Care SystemPlan, Do, Check, ActPhysical Disability EvaluationSystemPDHRAPDTSPEBPEBLOPECPHAPHIPHMMDPHNPIIPKCPPSQAQMRAPRCRCCRCPREFRADREFRADTRITPORMRMCROFRROIRVURWPSADRSECNAVSGSIDRSJAPost Deployment Health RiskAssessmentPharmacy Data Transaction ServicePhysical Evaluation BoardPhysical Evaluation Board LiaisonOfficerPharmacoeconomic CenterPeriodic Health AssessmentProtected Health InformationPopulation Health and MedicalManagement DivisionPopulation Health NavigatorPersonal Identifying InformationProblem Knowledge CouplersProspective Payment SystemQuality AssuranceQuality ManagementRecruitment Assessment ProgramReserve ComponentRecovery Care CoordinatorRecovery Coordination ProgramReleased from Active DutyReleased from Active Duty forTrainingResource Information TechnologyProgram OfficeReferral ManagementReferral Management CenterRight of First RefusalReturn on InvestmentRelative Value UnitRelative Weighted ProductStandard Ambulatory Data RecordSecretary of the NavySurgeon GeneralStandard Inpatient Data RecordStaff Judge Advocate

Page 160Appendix B - AcronymsVersion 3.0Medical Management GuideSMESNIACSSDISSISWIITAMPTDYTJCTLDTMATMA-RTTMIPTOATOCTOLTPCTPLTPRTSCTROUBUUBOUFRUMURURACUSAUSACHPPMUSAFUSAFRUSARSubject Matter ExpertSpecial Needs Identification andAssignment Coordination (formerlyUSAF EFMP)Social Security Disability IndexSupplemental Security IncomeSeverely Wounded, Ill, and InjuredTransitional Assistance MedicalProgramTemporary DutyThe Joint CommissionTemporary Limited DutyTRICARE Management ActivityTMA Reporting ToolsTheater Medical InformationProgramTheater of OperationsTRICARE Operations CenterTRICARE OnlineThird Party CollectionThird Party LiabilityTRICARE Prime RemoteTRICARE Service CenterTRICARE Regional OfficeUnified Biostatistical UtilityUniform Business OfficeUnfunded RequestUtilization ManagementUtilization ReviewUtilization Review AccreditationCommissionUnited States ArmyU. S. Army Center for HealthPromotion and Preventive MedicineUnited States Air ForceUnited States Air Force ReserveUnited States Army ReserveUSCG United States Coast GuardUSMC United States Marine CorpsUSNUnited States NavyUSNR United States Navy ReserveUSPSTF United States Preventive ServicesTask ForceVADepartment of Veterans AffairsVBAVeterans Benefits AdministrationVHAVeterans Health AdministrationWIIWounded, Ill, and InjuredWTWarrior TransitionWTB Warrior Transition BattalionWTU Warrior Transition Unit (Army)WISDOM Working Information Systems toDetermine Optimal ManagementWWR Wounded Warrior RegimentWWWR World Wide Workload ReportsCD-ROM RESOURCESAppendixC-Def2 TRICARE Operations Manual6010.51-M, Appendix A,Acronyms and Definitions‘

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 161Appendix C - DefinitionsAbsent SickAn Active Duty (Army, Navy, Air Force, and Marine Corps) member hospitalized in other than a U.S. MilitaryTreatment Facility and for whom administrative responsibility has been assigned to an MTF. Includes “absentsick moved to an MTF” and “total absent sick.”Resources:DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf.See CD-ROM Resource AppendixC-Def1AccreditationA formal process by which an agency or organization evaluates and recognizes an institution or program ofstudy as meeting certain predetermined criteria or standards.Resources:DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf.See CD-ROM Resource AppendixC-Def1AppealsAn administrative review of program determinations made under the provisions of law and regulation. Anappeal cannot challenge the propriety, equity, or legality of any provision of law or regulation.Resources:Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 10 (199.10): Appeal andhearing procedures: http://www.tricare.mil/FR05/C10.PDF.Benchmark/BenchmarkingBenchmark: A TRICARE clerical and automated systems test using claims and other documents created orapproved by TMA and processed by the contractor. The contractor’s output is compared to predeterminedresults prepared or approved by TMA to determine the accuracy, completeness, and operational characteristics

Page 162Appendix C - DefinitionsVersion 3.0Medical Management Guideof the contractor’s clerical and automated systems components. The purpose of the benchmark is to identifyclerical and automated systems deficiencies which must be corrected before claims can be processed inaccordance with TMA requirements. The comprehensiveness of the benchmark will vary depending on thenumber and type of conditions tested.Benchmarking:• The practice of comparing outcomes against local, Service, or national industry standards. Benchmarkingallows for the identification of areas for improvement and goal-setting as well as recognition of bestpractices.• The comparison of like provider's performance. It is a standard from which to establish what "quality"medical care is and to develop measurements from which to evaluate providers and patient outcomes.Resources:TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002):http://www.tricare.mil/to02/APPA.PDF.See CD-ROM Resource AppendixC-Def2DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf.See CD-ROM Resource AppendixC-Def1General definition as provided in Section IV, Disease ManagementCare CoordinationA comprehensive method of client assessment by Registered Nurses, designed to identify client vulnerability,needs identification, and client goals which results in the development plan of action to produce an outcomethat is desirous for the client. The goal is to provide client advocacy, a system for coordinating client services,and providing a systematic approach for evaluation of the effectiveness of the client’s Life Plan.Resources:TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002):http://www.tricare.mil/to02/APPA.PDF.See CD-ROM Resource AppendixC-Def2Case Management (CM)• A collaborative process of assessment, planning, facilitation, and advocacy for options and services to meetan individual’s health needs through communication and available resources to promote quality, costeffectiveoutcomes.• A collaborative process under the population health continuum which assesses, plans, implements,coordinates, monitors, and evaluates options and services to meet an individual’s health needs throughcommunication and available resources to promote quality, cost-effective outcomes.

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 163• A method of managing the provision of health care to members with catastrophic or high cost medicalconditions. The goal is to coordinate the care so as to both improve continuity and quality of care as well aslower costs. This generally is a dedicated function in the utilization management department.Resources:Case Management Society of America www.cmsa.orgDoDI 6025.20, Medical Management Programs in the Direct Care System (DCS) and Remote Areas: http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf.See CD-ROM Resource MME-1Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199. Part 2 (199.2):http://www.tricare.mil/CFR/C2.PDF. See CD-ROM Resource AppendixC-Def3Case MixCategories of patients, classified by disease, procedure, method of payment, or other characteristics, in aninstitution at any given time, usually measured by counting or aggregating groups of patients sharing one ormore characteristics.Resources:DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdfSee CD-ROM Resource AppendixC-Def1CertificationThe process by which a governmental or non-governmental Agency or association evaluates and recognizesa person who meets predetermined standards; it is sometimes used with reference to materials or services."Certification" is usually applied to individuals and "accreditation" to institutions.Resources:DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf See CD-ROM Resource AppendixC-Def1Clinical Pathways/ ProtocolsTools that delineate the optimal sequencing and timing of interventions by providers for a particular diagnosisor procedure designed to minimize delays and resource utilization and maximize quality of care. They oftenhave a role in the clinical setting, in both the inpatient and outpatient arenas. Although they may be evidencebased,these protocols are distinguished from clinical practice guidelines (CPGs) in that they do not have the fullcomplement of additional resources to support them.Resources:Open Clinical: http://www.openclinical.org/clinicalpathways.html

Page 164Appendix C - DefinitionsVersion 3.0Medical Management GuideClinical Practice Guidelines (CPGs)Systematically developed statements to assist practitioner and patient decisions about appropriate health carefor specific clinical circumstances (Institute of Medicine, 1990). CPGs define the role of specific diagnostic andtreatment modalities in the diagnosis and management of patients. The statements contain recommendationsbased on evidence from a rigorous systematic review and synthesis of the published medical literature.Resources:Department of Health & Human Services (HHS), National Heart Lung and Blood Institute (NHLBI):http://www.nhlbi.nih.gov/guidelines/about.htm.Department of Veterans Affairs (VA): http://www.healthquality.va.gov/index.asp.National Guideline Clearinghouse (NGC): http://www.guideline.gov/index.aspx.U.S. Army Quality Management Office (QMO): https://www.qmo.amedd.army.mil/pguide.htm.Code of Federal Regulations (CFR)The codification of the general and permanent rules published in the Federal Register by the executivedepartments and agencies of the federal government. It is divided into 50 titles that represent broad areassubject to federal regulation. Each volume of the CFR is updated once each calendar year and is issued on aquarterly basis.Resources: Government Printing Office: http://www.gpoaccess.gov/CFR/.Convalescent LeaveAn authorized leave status, not chargeable to the individual, granted to active duty Uniformed Servicemembers while under medical or dental care that is part of the care and treatment prescribed for a member'srecuperation or convalescence. Convalescent leave days are not counted as occupied bed days but are countedas sick days when the convalescent leave occurs before the disposition of the patient. Convalescent leaveoccurring after disposition of the patient while en route to a new command or convalescent leave granted by aline commander after patient discharge from the hospital is not counted as occupied bed days or sick days.Resources: DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999):http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf. See CD-ROM Resource AppendixC-Def 1Cooperative Health Care Clinic (CHCC)In cooperative health care clinics (CHCC), health care is provided to older patients in a group setting. The CHCCconcept, which was developed under a research grant by Kaiser Permanente in Colorado in 1991, showedimprovement in patient and provider satisfaction, as well as improved quality of care and cost effectiveness.Resources:Scott, J., Gade, G., McKenzie, M., Venohr, I. Cooperative health care clinics: a group approach to individualcare. Geriatrics, May 1998, 53(5):68-70, 76-8, 81. National Center for Biotechnology Information (NCBI): http://www.ncbi.nlm.nih.gov/pubmed/9597981?dopt=Abstract.

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 165Cost-Benefit AnalysisThe process of weighing the total expected costs vs. the total expected benefits of one or more actions in orderto choose the most profitable option. This often involves monetary calculations of initial expense vs. expectedreturn. It is usually done to decide whether to make a change or to determine how well, or how poorly, aplanned action (e.g., implementation of a program) will turn out. Also known as “running the numbers.”A cost-benefit analysis finds, quantifies, and adds all the positive factors. These are the benefits. Then itidentifies, quantifies, and subtracts all the negatives, the costs. The difference between the two indicateswhether the planned action is advisable. The real trick to doing a cost benefit analysis well is making sure youinclude all the costs and all the benefits and properly quantify them.Resources:About Business Management: http://management.about.com/cs/money/a/CostBenefit.htm.Covered EntityUnder the Health Insurance Portability and Accountability Act of 1996 (HIPAA), any entity that is:• A healthcare provider that conducts certain transactions in electronic form (called here a "coveredhealthcare provider").• A healthcare clearinghouse.• A health plan.Resources:Centers for Medicare & Medicaid Services (CMS): http://www.cms.hhs.gov/HIPAAGenInfo/06_AreYouaCoveredEntity.asp.Current Procedural Terminology ® (CPT)A coding system that describes the procedures, services, or supplies provided to patients within the outpatientsetting.Current Procedural Terminology ® (CPT), 4th Edition, is a listing of descriptive terms and identifying codes forreporting medical services and procedures. The purpose of CPT is to provide a uniform language that accuratelydescribes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliablenationwide communication among physicians, and other healthcare providers, patients, and third parties.Resources:American Medical Association (AMA):http://www.ama-assn.org/ama/no-index/physician-resources/3882.shtml.Custodial CareThe treatment or services, regardless of who recommends treatment or services or which such treatment orservices are provided, that a) can be rendered safely and reasonably by a person who is not medically skilled orb) is/are designed mainly to help the patient with the activities of daily living.

Page 166Appendix C - DefinitionsVersion 3.0Medical Management GuideResources:DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999): http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdfSee CD-ROM Resource AppendixC-Def 1Custodial Care Transition Policy, TRICARE: http://manuals.tricare.osd.mil/.Demand ManagementA collection of proactive interventions focused on reducing unnecessary healthcare utilization whilesimultaneously encouraging the appropriate use of healthcare resources.Resources:DoD Population Health Improvement Plan and Guide, p. 43 (December 2001): http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.See CD-ROM Resource ES-1Diagnosis-Related Group (DRG)A patient classification system that relates demographic, diagnostic, and therapeutic characteristics of patientsto length of inpatient stay and amount of resources consumed. It provides a framework for specifying hospitalcase mix and identifies classifications of illness and injury for which payment is made under prospective pricingprograms.Resources:DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999): http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf.See CD-ROM Resource AppendixC-Def 1Disability Evaluation System (DES)The purpose of the DES is to maintain a fit and vital force. According to DoD regulations, the DES shouldinclude a Medical Evaluation Board (MEB), a Physical Evaluation Board (PEB), an appellate review process, and afinal disposition. Service members should be assigned a Physical Evaluation Board Liaison Officer (PEBLO) to helpthem navigate the system.Resources:Deployment Health Clinical Center: http://www.pdhealth.mil/hss/des.asp.See Section III, Case ManagementDischarge PlanningThe development of an individualized discharge plan for the patient prior to leaving an institution for home,with the aim of improving patient outcomes, reducing the chance of unplanned readmission to an institution,and containing costs.

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 167Resources:TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002): http://www.tricare.mil/to02/APPA.PDF.See AppendixC-Def2Disease Management (DM)• A system of coordinated healthcare interventions and communications for populations with conditions inwhich patient self-care efforts are significant.• An organized effort to achieve desired health outcomes in populations with prevalent, often chronicdiseases, for which care practices may be subject to considerable variation.An organized effort to achieve desired health outcomes in populations with prevalent, often chronic diseases,for which care practices may be subject to considerable variation. DM programs manage populations and useinterventions that are evidence-based. The term “condition management” is also used to include non-diseasestates, such as pregnancy.Resources:Disease Management Association of America (DMAA): The Care Continuum Alliance: http://www.dmaa.org/dm_definition.asp.DoDI 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS) and Remote Areas:http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed. Jones and Bartlett Publishers, 2007.DoD Population Health Improvement Plan and Guide, p. 43. December 2001: http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.Exceptional Family Member Program (EFMP)See also Military OneSourceThe Military Services use the term Exceptional Family Member Program (EFMP) to refer to two differentfunctions: a personnel function and a family support function. The EFMP family support function is notmandatory. DoD policy allows, but does not require, the Services to offer family support services to EFMswithin their family support systems.In the Army and Marine Corps, EFM support staff are called EFMP Managers (Army) or EFMP Coordinators(Marine Corps).In the Navy, the EFMP staff that support the personnel function may also provide family support services, butthe Navy does not staff their family centers with EFMP Coordinators. In the Air Force, special needs staff arelocated in the Military Treatment Facility (MTF) only.Resources:DoDI 1342.22, Family Centers, Dec. 30, 1992: http://www.dtic.mil/whs/directives/corres/pdf/134222p.pdf.

Page 168Appendix C - DefinitionsVersion 3.0Medical Management GuideExtended Care Health Option (ECHO)See also Program for Persons with Disabilities (PFPWD)A supplemental program to the basic TRICARE program. ECHO provides financial assistance for an integratedset of services and supplies to eligible active duty family members (including family members of activatedNational Guard or Reserve members). There is no enrollment fee for ECHO; however, family members must:• Have an ECHO-qualifying condition.• Enroll in the Exceptional Family Member Program (EFMP) as provided by the sponsor's Service Branch.• Register in ECHO through ECHO case managers in each TRICARE region.Resources:Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 5 (199.5):www.tricare.mil/cfr/C5.PDF.See CD-ROM Resource AppendixC-Def5TRICARE: www.tricare.mil/mybenefit/Download/Forms/ECHO_Flyer_v3_09_L.pdf.Factual Determinations (nonmedical necessity)Determinations issued in cases involving coverage issues, provider authorization (status) requests, hospice care,foreign claims, denials based on sections other than National Defense Civilian Health and Medical Programof the Uniformed Services (CHAMPUS), Title 32, Section 199, Part 4 (199.4), and both medical necessity andfactual determinations.Resources:TRICARE Operations Manual 6010.51-M, Chapter 13, Section 5, Appeal of Factual (Nonmedical Necessity)Determinations: http://www.tricare.mil/TO02/C13S5.pdf.Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 4 (199.4):www.tricare.mil/cfr/C4.PDF.See CD-ROM Resource AppendixC-Def4Federal Recovery Coordinator (FRC)The DoD/VA federal Recovery Coordination Program (RCP) provides senior-level clinical nurses and socialworkers through the VA designated as Federal Recovery Coordinators (FRCs). These staff provide oversight ofthe recovery plan for catastrophically injured Service members. The FRC works with the Service member, his/herfamily, and the recovery team to develop a Federal Individual Recovery Plan (FIRP). The FRC continues to workwith the Service member and his/her family throughout the recovery, rehabilitation, and transition process tomeet their needs. The FRC remains available to the Service member and his/her family for life as long as theyneed.Resources:Department of Veterans Affairs (VA): http://www.oefoif.va.gov/.

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 169Federal Individual Recovery Plan (FIRP)See Federal Recovery Coordinator (FRC)Resources:Department of Veterans Affairs (VA): http://www.oefoif.va.gov/.Global War on Terrorism (GWOT)/Overseas Contingency Operations (OCO)Following the terrorists attacks of Sept. 11, 2001, the U.S. began military operations to combat terrorism bothin the United States and overseas. Military operations to defend the United States against further attacks areknown as Operation Noble Eagle. Ongoing military operations in Afghanistan and Iraq are known as OperationEnduring Freedom (OEF) and Operation Iraqi Freedom (OIF), respectively. Together, these three militaryoperations are identified as the Global War on Terrorism (GWOT).In a memorandum from the Office of Management and Budget (OMB) in March 2009, which was forwardedto Pentagon staff members from the Defense Department's Office of Security Review, the Obamaadministration noted that it “prefers to avoid using the term 'Long War' or 'Global War on Terror' [GWOT].” Itasked that the term “Overseas Contingency Operation” be used instead.Resources:Government Accountability Office (GAO) publication GAO-05-822, Global War on Terrorism — DoD Needs toImprove the Reliability of Cost Data and Provide Additional Guidance to Control Costs, p. 1: http://www.gao.gov/new.items/d05882.pdf.U.S. Department of Defense, Officer of the Inspector General: http://www.dodig.mil/gwot_iraq/index.htm.Wilson, S., Kamen, A. “Global War On Terror” Is Given New Name — Bush's Phrase Is Out, Pentagon Says.The Washington Post, March 25, 2009: http://www.washingtonpost.com/wp-dyn/content/article/2009/03/24/AR2009032402818.html.GrievanceIn the DCS, filing a grievance is the proper method for addressing beneficiary concerns (i.e., complaint) whenthere is a perceived inequity of the benefit, rather than a question of medical necessity.Resources:DoDD 6000.14, Patient Bill of Rights and Responsibilities in the Military Health System (July 30, 1998): http://www.dtic.mil/whs/directives/corres/pdf/600014p.pdf.See also Section II, Utilization ManagementGroup VisitA relatively new model in healthcare delivery where a number of patients meet on a prescribed basis in anexpanded office visit that includes care delivery, education, socialization, and one-to-one physician-patienttime, as needed. Group visits offer staff a new and more satisfying way to interact with patients that makesefficient use of resources, improves access, and uses group process to help motivate behavior change and

Page 170Appendix C - DefinitionsVersion 3.0Medical Management Guideimprove outcomes. The Group Visit Starter Kit describes the Cooperative Health Care Clinic (CHCC) modeldeveloped by the Kaiser Colorado staff. Group visits were pioneered with frail elderly patients who were highutilizers of primary care.In this model, the healthcare team facilitates an interactive process of care delivery in a periodic group visitprogram. The team empowers the patient, who is supported by information and encouraged to make informedhealthcare decisions. The group visit can be conceptualized as an extended doctor's office visit where notonly physical and medical needs are met, but education, social, and psychological concerns can be dealt witheffectively.Resources:Institute for Healthcare Improvement: http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/Tools/GroupVisitStartKit.htm.Improving Chronic Care:• http://www.improvingchroniccare.org/downloads/groupvisitmodelcomparison.pdf• http://www.improvingchroniccare.org/downloads/group_visit_starter_kit_copy1.docHealth PromotionAny combination of health information, education, diagnostic screening, and healthcare interventions designedto facilitate behavioral alterations that will improve or protect health. It includes those activities intended toinfluence and support individual lifestyle modification and self-care.MHS population health initiatives often follow guidance from Healthy People (e.g., Healthy People 2010).Resources:DoD Manual 6015.1-M, Glossary of Healthcare Terminology (January 1999): http://www.dtic.mil/whs/directives/corres/pdf/601501m.pdf.See CD-ROM Resource AppendixC-Def 1DoDD 1010.10, Health Promotion and Disease Injury Prevention (Aug. 22, 2003): http://www.dtic.mil/whs/directives/corres/pdf/101010p.pdf.Healthy People 2010: http://www.healthypeople.gov/.Health Insurance Portability and Accountability Act (of 1996) (HIPAA)A law that includes provisions for health insurance portability, fraud and abuse control, tax-related provisions,group health plan requirements, revenue offset provisions, and administrative simplification requirements.It addresses the use, disclosure, and security of private health information. It affects health care in terms ofpatient privacy and confidentiality. The HIPAA Privacy Rule establishes national standards to protect individuals’medical records and other personal health information and applies to health plans, healthcare clearinghouses,and those healthcare providers that conduct certain healthcare transactions electronically. The Rule requiresappropriate safeguards to protect the privacy of personal health information (PHI) and sets limits and conditionson the uses and disclosures that may be made of such information without patient authorization. The Rule also

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 171gives patients rights over their PHI, including the right to examine and obtain a copy of their health records andrequest corrections.Resources:TRICARE:• http://www.tricare.osd.mil/hipaa/faq_ans.htm• http://www.tricare.osd.mil/tmaprivacy/hipaa/hipaacompliance/images/pdf/Documentation_Jan03.pdfDepartment of Health and Human Services (HHS):• http://www.hhs.gov/ocr/hipaa/• http://www.hhs.gov/ocr/privacy/hipaa/administrative/privacyrule/index.htmlInternational Classification of Diseases – 9th Revision – Clinical Modification (ICD-9-CM)The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on theWorld Health Organization's Ninth Revision, International Classification of Diseases (ICD-9). ICD-9-CM is theofficial system of assigning codes to diagnoses and procedures associated with hospital utilization in the UnitedStates. The ICD-9 is used to code and classify mortality data from death certificates. The ICD-9-CM consists of:• A tabular list containing a numerical list of the disease code numbers in tabular form.• An alphabetical index to the disease entries.• A classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabularlist).Resources:Centers for Disease Control and Prevention (CDC) — Classifications of Diseases and Functioning andDisabilities: http://www.cdc.gov/nchs/about/otheract/icd9/abticd9.htm.Inter/Intraregional CareCare received in a region other than the region in which the beneficiary is enrolled, which includes bothcontinental U.S. and overseas locations.Intraregional care is care received within a region where a beneficiary is enrolled but outside their MTF’scatchment area. Care may be received from any branch of Service.Resources: N/ALight DutyTime spent performing “light duty” work does not count against an employee’s FMLA leave entitlement. Theemployee’s right to restoration is held in abeyance during the period of time the employee performs light duty(or until the end of the applicable 12-month FMLA leave year). An employee who is voluntarily performing alight duty assignment is not on FMLA leave.Presumes frequent provider/patient interaction to determine whether return to full duty status or moreintensive therapeutic intervention is appropriate in any given case; therefore, light duty will be ordered in

Page 172Appendix C - DefinitionsVersion 3.0Medical Management Guideperiods not to exceed 30 days to ensure appropriate patient clinical oversight. Consecutive light duty forany “new condition” up to 90 days may be ordered by the provider (in maximum 30-day periods), but inno case will light duty exceed 90 consecutive days, inclusive of any convalescent leave periods. The FederalEmployees' Compensation Program (FECA) for the Army requires that light duty assignments be provided toemployees faced with job-related injuries or occupational illnesses or diseases. When medical care is authorizedunder the Federal Employees' Compensation Act (FECA), the supervisor, in coordination with the CivilianPersonnel Assistance Center (CPAC), offers the employee light duty work in his/her assigned position, or inanother position, compatible with medically imposed restrictions/limitations. Any position offers made mustbe evaluated by the employee's attending physician to ensure the modified work assignment can safely beperformed by the employee based upon the limitations of his/her medical condition.Resources:Department of Labor, Wage and Hour Division, Final Rule under the Family and Medical Leave Act (FMLA)(effective Jan. 16, 2009):• http://www.dol.gov/esa/whd/fmla/• http://www.dol.gov/esa/whd/fmla/finalrule.htmArmy Civilian Personnel Onlinehttp://www.cpol.army.mil/library/permiss/2904e.htmlhttp://www.cpol.army.mil/library/permiss/2904.htmlLimited Duty (LIMDU)See also Temporary Limited Duty (TLD)/Permanent Limited Duty (IPLD)Limited Duty status allows a Marine to remain on Active Duty when they are not currently fit for full duty, butthere is high likelihood that, with appropriate treatment, they can be restored to ongoing full and productiveduty in a reasonable amount of time (defined as 6-14 months). This status will usually prevent them from beingdeployable and has some other administrative ramifications.Resources:U.S. Marine Corps (USMC): http://www.usmc-mccs.org/LEADERSGUIDE/keyterm_display.cfm?anchor=LimitedDuty.Line of Duty (LOD)An inquiry into the circumstances surrounding the injury or disease of an Active Duty Service member (ADSM).LOD is used to determine the status of an ADSM for indemnity and compensation purposes. LOD investigationsanswer three primary questions:1. Did the member’s injury or disease occur while performing military duty in a duty status?2. If not, was it aggravated by military duty?3. Was the occurrence or aggravation due to the ADSM’s intentional injury or willful negligence?

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 173Resources:Army: AR 635-40, Physical Evaluation for Retention, Retirement, and Separation:http://www.army.mil/usapa/epubs/pdf/r635_40.pdf.Air Force: AFI 36-2910, Line of Duty (Misconduct) Determinations: http://www.e-publishing.af.mil/.Air Force: AFI 48-123, Medical Examinations and Standards: http://www.e-publishing.af.mil/.Managed Care Support Contractor (MCSC)The 50 United States are divided into three TRICARE regions. Each of the regions has a regional contractorthat helps administer the TRICARE benefit plan. These roles are defined as Managed Care Support Contractors(MCSCs). The regional contractors provide a variety of functions, including:• Establishing TRICARE provider networks.• Operating TRICARE service centers.• Providing customer service call centers.• Providing administrative support, such as enrollment, care authorization, and claims processing.• Communicating and distributing educational information to beneficiaries and providers.MCSCs work with their TRICARE Regional Offices to manage the benefit at the local level, and receive overallguidance from TMA headquarters.Resources:TRICARE:• http://www.tricare.mil/factsheets/viewfactsheet.cfm?id=92• http://www.tricare.mil/tp02/C12S11_1.PDFSee Section I, Medical Management Essentials.McKesson ® InterQual ® Evidence-based Clinical Decision Support CriteriaCriteria that assist in determining the appropriate level of clinical care for adult and pediatric patients inthe acute, long-term, rehabilitation, subacute, home care, and skilled nursing facility settings. They provideevidence-based clinically appropriate decision-making support to promote care management and facilitation,quality improvement, and beneficiary satisfaction.The criteria are designed to screen for cases that warrant medical review. Used as a UM tool for managing care,it is not intended to deny care, but can function as a decision support tool. TMA purchases an enterprise-widelicense annually for a variety of McKesson InterQual criteria sets for use within MTFs.Resources:McKesson: http://www.mckesson.com/.

Page 174Appendix C - DefinitionsVersion 3.0Medical Management GuideMedicaidA healthcare coverage program for certain low-income individuals and families who meet state and federaleligibility requirements. Medicaid does not pay money to patients directly; instead, it sends payments directlyto healthcare providers. Depending on a state's rules, patients may also be asked to pay a small part of the cost(co-payment) for some medical services. Medicaid is a state administered program, with each state setting itsown guidelines regarding eligibility and services. Many groups of people are covered by Medicaid, but certainrequirements must be met related to age; whether an individual is pregnant, disabled, blind, or aged; incomeand resources; and a U.S. citizenship or an immigration status. The rules for counting income and resources varyfrom state to state and from group to group. There are special rules for those who live in nursing homes and fordisabled children living at home.Resources:Centers for Medicare & Medicaid Services (CMS): http://www.cms.hhs.gov/home/medicaid.asp.Medical Department Activity (MEDDAC)The Army’s medical department.Resources:Go Army – Army Health Care: http://www.goarmy.com/amedd/.Medical Evaluation Board (MEB)The MEB is a board to identify members whose physical or mental qualification for full duty is in doubt orwhose physical or mental limitation precludes return to full duty within a reasonable period of time; speaks tothe degree to which a member can perform his or her duties.Resources:Army: AR 40-400, Patient Administration: http://www.army.mil/usapa/epubs/pdf/r40_400.pdf.Army: AR 40-501, Standards of Medical Fitness: http://www.army.mil/usapa/epubs/pdf/r40_501.pdf.AFI 36-3209, Separation and Retirement Procedures for Air Force National Guard and Air Force ReserveMembers: www.af.mil/shared/media/epubs/AFI36-3209.pdf.Navy: SECNAVINST 1850.4E — Disability and Evaluation Manual:• http://doni.daps.dla.mil/default.aspx Search for: 1850.4E• http://www-nmcphc.med.navy.mil/LGuide/Medical/Medical_Boards.htmMedical Hold• Mobilized RC soldiers who were unable to deploy with their units due to a medical condition, and werenot REFRAD within 30 days of mobilization. These soldiers remain on Active Duty awaiting medical/administrative disposition.• Redeployed/Demobilizing RC soldiers who sustained injury, disease, or aggravated pre-existing conditionsthat require medical/administrative resolution before REFRAD/ demobilization.

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 175Medical Retention Processing (MRP) - Medical holdover soldiers mobilized under Title 10 USC 12302 ISOGWOT. All RC soldiers with medical conditions that require more than 60 days for resolution will be asked tovolunteer to transition to a Medical Retention Processing Unit (MRPU). Soldiers who do not volunteer will bereleased from active duty and briefed on follow-on medical entitlements such as VA hospitals.Resources:Fort Carson the Mountain Post: http://www.carson.army.mil/Moblas/Medical%20Hold.htm.Medical Management (MM)An integrated managed care model that promotes Utilization Management (UM), Case Management (CM),and Disease Management (DM) programs as a hybrid approach to managing patient care. It includes a shift toevidence-based, outcome-oriented UM, and a greater emphasis on integrating clinical practice guidelines intothe MM process, thereby holding the system accountable for patient outcomes.Resources: DoD Instruction 6025.20, Medical Management (MM) Programs in the Direct Care System (DCS)and Remote Areas (Jan. 5, 2006): http://www.dtic.mil/whs/directives/corres/pdf/602520p.pdf.Medical NecessityAccepted healthcare services and supplies provided by healthcare entities, appropriate to the evaluation andtreatment of a disease, condition, illness, or injury and consistent with the applicable standard of care. Whetherservices or supplies are deemed “medically or psychologically necessary,” depends on the frequency, extent,and types of medical services or supplies which represent appropriate medical care and that are generallyaccepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness,injury, pregnancy, and mental disorders or that are reasonable and adequate for well-baby care.Resources:American College of Medical Quality (ACMQ), Policy 8: Definition and Application of Medical Necessity: http://www.acmq.org/policies/policy8.pdf.Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 2 (199.2):http://www.tricare.mil/CFR/C2.PDF. See CD-ROM Resource AppendixC-Def3MedicareA health insurance program for people age 65 or older, people under age 65 with certain disabilities, andpeople of all ages with End Stage Renal Disease (permanent kidney failure requiring dialysis or transplant).Medicare has Part A (Hospital Insurance), Part B (Medical Insurance), and Prescription Drug Coverage.Resources:Centers for Medicare & Medicaid Services (CMS):• http://www.cms.hhs.gov/MedicareGenInfo/• http://www.cms.hhs.gov/home/medicare.aspMedicare: http://questions.medicare.gov/cgi-bin/medicare.cfg/php/enduser/std_alp.php.

Page 176Appendix C - DefinitionsVersion 3.0Medical Management GuideMilitary MedicineEvery Service’s delivery of health care within their departments, under the leadership of the Surgeon General,varies in its administration (i.e., different programs and services). Refer to each command/headquarters’references for more specific information. Military medicine within the DoD collaborates closely with the VA.Resources:Army Medicine—Army Medical Command (AMEDD): http://www.armymedicine.army.mil/index.html.Air Force Medicine—Air Force Medical Service (AFMS): http://www.airforcemedicine.afms.mil/.Navy Medicine—Bureau of Medicine and Surgery (BUMED): https://navymedicine.med.navy.mil/.Department of Veteran’s Affairs (VA): http://www.va.gov/.Milliman Care Guidelines ®Published by Milliman USA, these guidelines are a set of standardized criteria used in Medical Managementprograms, such as UM. The Guidelines are valuable management tools for treatment that span the continuumof patient care, describing best practices for treating common conditions in a variety of care settings. Used inconjunction with the healthcare professional’s clinical judgment, they define the assessment and treatmentmodalities that should occur at the primary care level prior to referral for specialty care.TMA maintains an enterprise-wide license annually for use by MTF personnel within the DCS and is user/password protected.Milliman Care Guidelines produces annually updated, evidence-based clinical guidelines that span thecontinuum of care, including chronic care management. The Milliman Care Guidelines ® provide much more thanjust authorization criteria, driving high-quality care through such tools as care pathway tables, flagged qualitymeasures, and integrated medical evidence.The current best evidence is optimal only when it allows healthcare professionals to make decisions about thecare of individual patients in an efficient and timely manner. To that end, the Care Guidelines are incorporatedinto easy-to-use software. From Web-based applications, to interactive software producing real-timemanagement reports, to handheld versions, Care Guidelines software makes the current best evidence readilyavailable for use where it matters: at the point of care.Resources:Milliman USA: http://www.milliman.com/.Milliman Care Guidelines: http://www.careguidelines.com/.CareWeb (Client Access): http://www.careguidelines.com/login-careweb.htm.National Defense Authorization Act (NDAA) 2008/NDAA 2007The National Defense Authorization Act (NDAA) 2008, Title XVI — Wounded Warrior Matters, acknowledgeschallenges associated with caring for wounded, ill, and injured (WII) ADSMs and their families. Under Title XVI,the law outlines specific screening, referral, and management requirements for PTSD, TBI, and behavioral healthconditions.

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 177In September 2008, the DoD and VA released their response to requirements in the Report to Congress on theComprehensive Policy Improvements to the Care, Management, and Transition of Recovering Service Members(NDAA Section 1611 and 1615). The DoD/VA report outlines provisions implemented by the two Departmentsthat affect medical case managers in the MTF.Resources:Government Printing Office (GPO): http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=110_cong_public_laws&docid=f:publ181.110.See Executive Summary, CD-ROM Resource ES-3.Overseas Contingency Operations (OCO)See Global War on Terrorism (GWOT)Permanent Disability Retirement List (PDRL)See also Temporary Disability Retirement List (TDRL)If a Service member has been found to be unfit by reason of disability that is found to be of a permanentnature and has been rated at 30 percent or greater, or if rated at less than 30 percent but the Service memberhas 20 or more years of service, that Service member will be placed on the PDRL under authority of Title 10of the U.S. Code, Section 1201 or 1204. This is a permanent status. A member of the Temporary DisabilityRetirement List (TDRL) whose disability is now considered to be of a permanent nature will be transferred tothe PDRL.Resources:Defense Finance and Accounting Service (DFAS): http://www.dfas.mil/retiredpay/disabilityretirements.html.Permanent Limited Duty (PLD)See Limited Duty (LIMDU)(DoD) Pharmacoeconomic Center (PEC)A DoD customer-oriented center of expertise (COE) implementing recognized state of the artpharmacoeconomic analysis for the purpose of improving readiness by increasing value, quality, and access tomedical care and pharmacotherapy within the MHS’ available resources.Resources:http://www.pec.ha.osd.mil/Physical Evaluation Board (PEB)A fact-finding body (informal and formal board) that investigates the nature, origin, degree of impairment,and probable permanence of the physical or mental defect or condition of an ADSM; speaks to the member’sfitness for continued service based on limitations identified in the MEB.

Page 178Appendix C - DefinitionsVersion 3.0Medical Management GuideResources:Army: AR 635-40, Physical Evaluation for Retention, Retirement, and Separation (Feb. 8, 2006):http://www.army.mil/usapa/epubs/pdf/r635_40.pdf.Army: AR 600-60, Physical Performance Evaluation System (Feb. 28, 2008):http://www.army.mil/usapa/epubs/pdf/r600_60.pdf.Air Force: AFI 36-3212, Physical Evaluation for Retention, Retirement, and Separation (Feb. 2, 2006): http://www.af.mil/shared/media/epubs/AFI36-3212.pdf.DoDD 1332.18, Separation or Retirement for Physical Disability (Jan. 5, 2006): http://www.dtic.mil/whs/directives/corres/pdf/133218p.pdf.Population HealthPopulation-based health care improves the health status of all our beneficiaries by delivering proactive, efficient,and effective evidence-based interventions in partnership with our patients.Resources:2001 DoD Population Health Improvement Plan and Guide: http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.See CD-ROM Resource ES-1Predictive ModelingA set of tools used to stratify a population according to its risk of nearly any outcome. Ideally, patients are riskstratifiedto identify opportunities for intervention before the occurrence of adverse outcomes that result inincreased medical costs.A technological tool that functions as an electronic claims canvasser searching for predefined variables ofinterest. This tool is used to identify high-cost diagnoses that, in turn, provide a risk score indicative of thelikelihood to utilize more healthcare resources and dollars than persons of the same age and gender.Resources:Cousins, Michael S., Shickle, Lisa M., Bander, John A. An Introduction to Predictive Modeling for DiseaseManagement Risk Stratification. Disease Management, September 2002 — 5(3): 157-167.Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed., 378-379. Jones and Bartlett Publishers, 2007.See CD-ROM Resources MME-1 and MME-2Carlson, B. Predictive Modeling, Sharp Lens on Near Future. Managed Care, July 2003. MediMedia USA:http://www.managedcaremag.com/archives/0307/0307.predictive.html.Hodgman, S.B., BS, MSc, RN, CPUM. Predictive Modeling & Outcomes. Professional Case Management, 13:1,19–23, January/February 2008: http://www.nursingcenter.com/prodev/ce_article.asp?tid=765747.

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 179Primary Prevention(see also Secondary Prevention, Tertiary Prevention)A stage of Medical Management that occurs when the goal is to avert or slow the onset or incidence ofdisease.Resources:2001 DoD Population Health Improvement Plan and Guide: http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.See Executive Summary, CD-ROM Resource ES-1Wilson, W., Carneal, G., Newman, M.B. Documenting Case Management Outcomes, Case in Point, 15. CaseManagement Society of America, February/March 2008: http://www.schoonerhealth.com/files/32736223.pdf.ProfilingThe collection and analysis of clinical utilization data to produce specific information on resource consumptionand outcomes of care.Resources:Kongstvedt, P.R. Essentials of Managed Health Care, 5th ed. Jones and Bartlett Publishers, 2007.Kongstvedt, P. R. The Managed Health Care Handbook. Aspen, 2007.Program for Persons with Disabilities (PFPWD)See Extended Care Health Option (ECHO)Recovery Care Coordinator (RCC)See also Federal Recovery Coordinator, Recovery Care Plan, Recovery Coordination ProgramThe ultimate resource for wounded, ill, and injured Service members and veterans, and their families. This roleoversees the development and delivery of services/resources through the comprehensive recovery care plan inconjunction with multi-disciplinary teams (MDTs), to ensure quality care and accountability.Resources:National Resource Directory: http://www.nationalresourcedirectory.gov/.Department of Veterans Affairs (VA): http://www.va.gov/JOBS/Fed_Recover_Coord.asp.See CD-ROM Resources CM-25, CM-26, CM-27, CM-28, CM-29, CM-30, CM-31, CM-32Recovery Care PlanSee also Recovery Care Coordinator, Recovery Coordination ProgramAn individualized, integrated, longitudinal, medical/nonmedical service plan across the continuum of care tomeet personal and professional goals of wounded, ill, and injured Service members and veterans, and theirfamilies.Resources: See Recovery Coordination Program

Page 180Appendix C - DefinitionsVersion 3.0Medical Management GuideRecovery Coordination Program (RCP)See also Recovery Care Coordinator, Recovery Care PlanNDAA 2008 requires the Services (Army, Navy, AF, Marines) to establish a federal Recovery Care Program (RCP)for wounded, ill, and injured Service members who may be medically retired or separated from the military.Referral for the program is through a screening process performed by the Service that considers acuity in bothmedical and nonmedical (e.g., financial, housing, family support) areas.Resources:National Resource Directory: http://www.nationalresourcedirectory.gov/.Department of Veterans Affairs: http://www.va.gov/JOBS/Fed_Recover_Coord.asp.See CD-ROM Resources CM-25 through CM-32.Referral Management (RM)The process by which primary care managers (PCMs) determine if they need to refer a member either to aspecialist or for services to be performed outside of the PCM’s office (e.g., diagnostic tests, outpatient surgery,home health care). If a referral is necessary, the PCM also needs to decide to whom the referral is made, forhow long, and for which services.Resources:Milliman Care Guidelines ® : http://www.careguidelines.com/login-careweb.htm.TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002):http://www.tricare.mil/to02/APPA.PDF.See CD-ROM Resource AppendixC-Def2Respite CareShort-term care for a patient in order to provide rest and change for those who have been caring for the patientat home, usually the patient’s family. Respite care is an essential part of the overall support that families mayneed to keep their child with a disability or chronic illness at home.Resources:TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and Definitions (Aug. 1, 2002):http://www.tricare.mil/to02/APPA.PDF.See CD-ROM Resource AppendixC-Def2Autism and PPD Support Network: http://www.autism-pdd.net/respite.html.Secondary Prevention(see also Primary Prevention, Tertiary Prevention)A stage of Medical Management that occurs when the goal is to detect disease.

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 181Resources:2001 DoD Population Health Improvement Plan and Guide: http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.See Executive Summary, CD-ROM Resource ES-1Wilson, W., Carneal, G., Newman, M.B. Documenting Case Management Outcomes, Case in Point, 15. CaseManagement Society of America, February/March 2008: http://www.schoonerhealth.com/files/32736223.pdf.Self-Management/Self-Care ProgramsThe provision of information and services to members of a healthcare plan to assist them to maintain personalhealth and make appropriate decisions concerning medical care.Resources:HealthWise Handbook: http://www.healthwise.org/p_selfcare.aspx.Vickery, D.; Fries, J. Take Care of Yourself, 8th ed. Da-Capo Press, 2004.Self-Management EducationWhen patients are involved in their own care, have increased knowledge of their condition, and confidence intheir ability to adapt to change; and their ability to reach treatment goals is realized. Self-care may include:• Health promotion activities.• Clinical preventive services.• Behavior modification.• Compliance monitoring.Resources:Institute for Healthcare Improvement (IHI): http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/Changes/Self-Management.htm.Healthnet Federal Services: https://www.hnfs.net/bene/healthyliving/self-care.htm.California HealthCare Foundation: http://www.chcf.org/topics/chronicdisease/index.cfm?subtopic=CL613.Social Security Disability Income (SSDI)SSDI is paid to individuals who have worked in the recent years, usually 5 out of the last 10 years. Forindividuals under 31 years old, the requirements are a little different since they may have not been in the workforce as long.Resources:Social Security Administration (SSA): http://www.ssa.gov/disability/.Social Security Disability Claims: http://www.social-security-disability-claims.org/.

Page 182Appendix C - DefinitionsVersion 3.0Medical Management GuideSupplemental Security Income (SSI)SSI is a federal income supplement program funded by general tax revenues (not Social Security taxes). It isdesigned to help aged, blind, and disabled people who have little or no income. It provides cash to meet basicneeds for food, clothing, and shelter.Resources:Social Security Administration (SSA): http://www.socialsecurity.gov/ssi/.Temporary Disability Retirement List (TDRL)See also Permanent Disability Retirement List (PDRL)If, as the result of a Physical Evaluation Board finding, a Service member is found unfit to perform his/her dutiesby reason of a disability which may not be of a permanent nature, that Service member may be placed on theTemporary Disability Retired List under the authority of Title 10 of the U.S. Code, Section 1202 or 1205.Resources:Defense Finance and Accounting Service (DFAS): http://www.dfas.mil/retiredpay/disabilityretirements.html.Temporary Limited Duty (TLD)See Limited Duty (LIMDU)Tertiary Prevention(see also Primary Prevention, Secondary Prevention)A stage of Medical Management that occurs when the goal is to prevent further suffering at end the stage ofthe disease.Resources:2001 DoD Population Health Improvement Plan and Guide: http://www.tricare.mil/ocmo/download/mhs_phi_guide.pdf.See Executive Summary, CD-ROM Resource ES-1.Wilson, W., Carneal, G., Newman, M.B. Documenting Case Management Outcomes, Case in Point, 15. CaseManagement Society of America, February/March 2008: http://www.schoonerhealth.com/files/32736223.pdf.Transitional Assistance Management Program (TAMP)TAMP offers transitional TRICARE coverage to certain separating ADSMs and their eligible family members.Care is available for a limited time. Under the National Defense Authorization Act for Fiscal Year 2005, effectiveOct. 28, 2004, TRICARE eligibility under the TAMP has been permanently extended from 60 or 120 days to 180days.The four categories for TAMP are:• Members involuntarily separated from active duty and their eligible family members.• National Guard and Reserve members, collectively known as the Reserve Component (RC), separated from

Medical Management Guide Version 3.0 Appendix C - DefinitionsPage 183Active Duty after being called up or ordered in support of a contingency operation for an Active Dutyperiod of more than 30 days, and their family members.• Members separated from Active Duty after being involuntarily retained in support of a contingencyoperation, and their family members.• Members separated from Active Duty following a voluntary agreement to stay on Active Duty for less thanone year in support of a contingency mission, and their family members.Resources:TRICARE: http://www.tricare.mil/factsheets/viewfactsheet.cfm?id=317.Traumatic Injury Protection under Service members' Group Life Insurance (TSGLI)A traumatic injury protection rider under Service members’ Group Life Insurance (SGLI) that provides forpayment to any member of the Uniformed Services covered by SGLI who sustains a traumatic injury resulting incertain severe losses. Effective Dec. 1, 2005, every member who has SGLI also has TSGLI. This coverage appliesto ADSMs, Reservists, National Guard members, funeral honors duty, and one-day muster duty. This benefit isalso provided retroactively for members who incur severe losses as a result of traumatic injury between Oct. 7,2001 and Dec. 1, 2005 if the loss was the direct result of injuries incurred in Operation Enduring Freedom (OEF)or Operation Iraqi Freedom (OIF).Resources:Department of Veterans Affairs (VA): http://www.insurance.va.gov/SGLISITE/legislation/TSGLIFacts.htm.Utilization Management (UM)A methodology that addresses the issue of managing use of resources in the delivery of health care, while alsomeasuring the quality associated with the delivery of that care.Resources:McKesson Certified Professional in Healthcare Management (CPHM) Study Guide 2, 148. September 2009.Utilization Review (UR)The process of determining whether all aspects of a patient’s care, at every level, are medically necessary andappropriate.Resources:McKesson Certified Professional in Healthcare Management (CPHM) Study Guide 2, 148. September 2009.

Page 184Appendix C - DefinitionsVersion 3.0Medical Management GuideVariance AnalysisVariance analysis is the variation or differences in quality and cost (underuse or overuse of services) in care thatidentifies opportunities for cost reduction and quality improvement. Variations can be negative or positive andmay occur in six sources:1. Patient/family2. Clinical status3. Practitioner4. Community5. Service delays6. System delaysThere are two types of variance data: patient care activity is not performed as ordered and expected outcomesare not achieved. Variance analyses may include both cost and statistical variances.Resources:Rossi, P. A. Case Management in Healthcare: A Practical Guide. (2nd ed.). W.B. Saunders, 2003:http://www.ramex.com/title.asp?id=9606.StatGraphics: http://www.statgraphics.com/analysis_of_variance.htm.CD-ROM RESOURCESAppendixC-Def1 DoD Manual 6015.1-M, Glossary of Healthcare TerminologyAppendixC-Def2 TRICARE Operations Manual 6010.51-M, Appendix A, Acronyms and DefinitionsAppendixC-Def3 Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 2(199.2)AppendixC-Def4 Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 4(199.4)AppendixC-Def5 Code of Federal Regulations (CFR), Title 32 — National Defense, Section 199, Part 5(199.5)‘

Medical Management Guide Version 3.0 Appendix D - ResourcesPage 185Appendix D – ResourcesAgency for Health Care Research and Quality (AHRQ)A federal agency whose mission is to improve the quality, safety, efficiency, and effectiveness of health care forall Americans. Information from AHRQ research helps people make more informed decisions and improve thequality of healthcare services. The website supports evidence-based practice, clinical practice guidelines (CPGs),the National Guideline Clearinghouse, healthcare outcomes and efficacy, quality, and patient safety.Resources: http://www.ahrq.gov/Air Force Wounded Warrior (AFW2)The Air Force facilitates enhanced assistance for airmen/women and their families through AFW2. An AFwounded warrior is any airman/woman with a combat or hostile-related injury or illness requiring long-termcare that will require a Medical Evaluation Board (MEB) or Physical Evaluation Board (PEB) to determine fitnessfor duty. A combat or hostile-related injury results from hazardous service or performance of duty underconditions simulating war or through an instrumentality of war.Resources: http://www.woundedwarrior.af.mil/ VA: http://www.veteransforamerica.org/woundedwarrior/DoD/MHS: http://mhs.osd.mil/WoundedWarrior.aspxArmed Forces Health Surveillance Center (AFHSC)A center designated by Health Affairs and the Secretary of Defense as the central epidemiological resource formedical surveillance of military and military-associated populations. Via the DMSS and DMED databases, theAFHSC provides regularly scheduled and customer-requested analyses and reports to policymakers, medicalplanners, and researchers.Resources: http://afhsc.army.mil/Army Wounded Warrior Program (AW2) — U.S. Army Human Resources CommandSee also Warrior in Transition (WT) ProgramThe Army facilitates enhanced assistance for soldiers and their families through AW2. An Army woundedwarrior is any soldier with a combat or hostile-related injury or illness requiring long-term care that will requirea Medical Evaluation Board (MEB) or Physical Evaluation Board (PEB) to determine fitness for duty. A combat orhostile-related injury results from hazardous service or performance of duty under conditions simulating war orthrough an instrumentality of war.

Page 186Appendix D - ResourcesVersion 3.0Medical Management GuideResources: https://www.aw2.army.mil/index.htmlVA: http://www.veteransforamerica.org/woundedwarrior/DoD/MHS: http://mhs.osd.mil/WoundedWarrior.aspxBNET Business LibraryResources: http://jobfunctions.bnet.com/Industries/Healthcare+and+Medical/Case Management Society of America (CMSA)An international, non-profit organization dedicated to the support and development of the profession of CaseManagement through educational forums, networking opportunities, and legislative involvement. CMSA offersmembership discounts for military personnel, as well as a military forum during its annual national conference.Resources: http://cmsa.org/Center for Case ManagementResources: http://www.cfcm.com/Centers for Medicare & Medicaid Services (CMS)A federal agency within the Department of Health and Human Services (HHS). CMS programs/initiativesinclude Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP), and Clinical LaboratoryImprovement Amendments (CLIA).Resources: http://www.cms.hhs.gov/Community Based Warrior Transition Unit (CBWTU) ProgramA program initiated in 2004 that allows Reserve Component (RC) soldiers placed in Medical RetentionProcessing (MRP) status to return home and complete their medical care in their local communities, rather thanbeing required to remain on an installation that may be thousands of miles from their homes and families. Itis the policy of the U.S. Army Medical Command (MEDCOM) that all RC WT soldiers be assessed for referralto the CBWTU. When referred by the WTU nurse case manager (NCM) and accepted by the CBWTU, the WTsoldier is transferred and attached to the CBWTU that covers the region where that soldier lives. There arenine CBWTU regional headquarters, located in the states of Alabama, Arkansas, California, Florida, Illinois,Massachusetts, Utah, and Virginia; and in Puerto Rico. WT soldiers at the CBWTU normally receive theirmedical care from civilian network providers and are managed by their assigned CBWTU NCM. WT soldierswho live within the TRICARE catchment area of an MTF are enrolled Prime to that location but continue to bemanaged by the CBWTU NCM.Resources:U.S. Army Medical Department (AMEDD), North Atlantic Regional Medical Command: http://www.narmc.amedd.army.mil/Pages/default.aspx

Medical Management Guide Version 3.0 Appendix D - ResourcesPage 187Defense Health Services Systems (DHSS)The office that provides decision support information and tools used by managers, clinicians, and analysts tomanage the business of health care within the MHS. DHSS is comprised of a data warehouse and operationaldata marts to support clinical practice, medical logistics, and the business of military medicine. Among thedeployed applications supported by DHSS are the MCFAS, M2, Clinical Data Mart (CDM), EAS-IV, TRICAREOnline (TOL), and the TMA reporting tools (CDIS, CMIS, and CURES) — see Section V, Medical ManagementTools.Resources: http://www.health.mil/DHSS/Department of Veterans Affairs (VA)Established March 15, 1989 as the federal agency succeeding the Veterans Administration. It is responsible forproviding federal benefits to veterans and their families. Headed by the Secretary of Veterans Affairs, the VA isthe second-largest of the 15 Cabinet departments and operates nationwide programs for health care, financialassistance, and burial benefits.Resources: http://www.va.gov/JournalsA list of current journals and other general website publication resources.Resources:Medical ManagementAmerican Journal of Managed Care (AJMC): http://www.ajmc.com/Frontiers of Health Services Management — American College of Healthcare Executives (ACHP), HealthAdministration Press: http://www.ache.org/Group Practice Journal — American Medical Group Association: http://www.amga.org/Health Care Management Review — Wolters Kluwer Health/Lippincott, Williams & Wilkins: http://journals.lww.com/Health Care Management Science — Springer: http://www.springer.com/Health Care Risk Report: http://www.healthcareriskreport.com/Health Economics: http://www.healtheconomics.com/journals.cfmHealthcare Executive — American College of Healthcare Executives (ACHP), Health Administration Press: http://www.ache.org/HealthLeaders Media: http://www.healthleadersmedia.com/International Journal of Healthcare Quality Assurance:http://info.emeraldinsight.com/products/journals/Journal for Healthcare Quality — National Association for Healthcare Quality: http://www.nahq.org/journal/Journal of Health Care Finance — Wolters Kluwer/Aspen Publishers: http://www.aspenpublishers.com/Journal of Healthcare Information Management — Healthcare Information and Management Systems Society(HIMSS): http://www.himss.org/

Page 188Appendix D - ResourcesVersion 3.0Medical Management GuideJournal of Healthcare Management — American College of Healthcare Executives (ACHP), HealthAdministration Press: http://www.ache.org/Managed Care Magazine: http://www.managedcaremag.com/Managed Care Interface — Medicom International/Managed Care Online: http://www.mcol.com/Managed Healthcare Executive: http://managedhealthcareexecutive.modernmedicine.com/Case ManagementAmerican Journal of Medical Quality — SAGE JOURNALS Online: http://ajm.sagepub.com/Care Management Journals (Journal of Case Management/Journal of Long Term Home Health Care) — SpringerPublishing Company: http://www.springerpub.com/International Journal for Human Caring (IJHC): http://www.humancaring.org/journal/Case Management Advisor — AHC Media, LLC: http://www.ahcpub.com/Collaborative Case Management — American Case Management Association: http://www.acmaweb.org/The Health Care Manager — Wolters Kluwer/Lippincott, Williams & Wilkins: http://journals.lww.com/Home Healthcare Nurse — Home Healthcare Nurses Association: http://www.homehealthcarenurseonline.com/Medical Disability AdvisorProfessional Case Management — Wolters Kluwer/Lippincott, Williams & Wilkins: http://journals.lww.com/.Official journal of:• Case Management Society of America: http://www.cmsa.org/• National Case Management Network of Canada: http://www.ncmn.ca/Social Work in Healthcare — Routledge, Taylor and Francis Group: http://www.routledge.com/The Case Manager: http://www.thecsmgr.com/Disease ManagementDisease Management — Mary Ann Liebert, Inc. Publishers: http://www.liebertpub.com/ — Official journal ofthe Disease Management Association of America: The Care Continuum Alliance (DMAA): http://www.dmaa.org/Disease Management and Clinical Outcomes — Elsevier Science: http://www.elsevier.com/Disease Management and Health Outcomes — ADIS Data Information/Wolters Kluwer: http://pharma.wkhealth.com/International Journal of Evidence-Based Healthcare — Joanna Briggs Institute: http://www.joannabriggs.edu.au/about/home.php — Wiley: http://www.wiley.com/Evidence-Based Medicine: http://ebm.bmj.com/MHS Clinical Quality Management (CQM)The MHS portal offering information and educational resources for MHS staff in the areas of clinical quality,patient safety, and quality assurance.Resources: https://www.mhs-cqm.info/

Medical Management Guide Version 3.0 Appendix D - ResourcesPage 189Military OneSourceMilitary OneSource is a Tri-Service, 24/7 information and referral program for participating Service families. Itoffers resources to help families address a wide range of everyday issues, including parenting and child care,older adults, education, and financial and legal matters. Assistance may be obtained via phone or online. EachService has its own home page and log-on tool.Resources: http://www.militaryonesource.comArmy: http://www.armyonesource.com/Air Force: http://www.airforceonesource.com/Navy: http://www.navyonesource.com/Military Medical Support Office (MMSO)A TRICARE office that provides a variety of functions, as follows:• Acts as a liaison between MCSCs, Services, Commanders, and MTFs for ADSMs not enrolled to MTFs onmilitary-unique issues.• Provides customer service for Commanders, HBA, MTF and TPR ADSMs.• Identifies ADSMs with serious medical conditions for the Services.• Assists MCSC/MTF on care management coordination, as needed.• Authorizes care for National Guard/Reserve members not eligible in DEERS (i.e., line-of-duty injuries/illnesses).• Provides claims payment determinations for MCSCs unable to pay.• Coordinates appeals for denied claims and debt collection cases.Resources: http://www.tricare.mil/tma/MMSO/index.aspxMulti-Service Market Office (MSMO)A TRICARE office that serves areas with more than one Service with an MTF and in which the markets overlap.A Senior Market Manager — a designated MTF Commander — is appointed to each MSMO. This role isresponsible for developing a single, consolidated, integrated business plan for the DCS and PCS for otherServices located in the MSMO. There are 12 MSMOs, located in the following geographic areas: NationalCapital Area (NCA), Tidewater, Ft. Bragg/Pope, Charleston, Ft. Jackson/Shaw, Gulf Coast, San Antonio,Colorado Springs, San Diego, Puget Sound, Hawaii, and Alaska. All other MTFs are considered single marketmanagers.Resources: http://www.tricare.osd.mil/National Committee on Quality Assurance (NCQA)A private, non-profit organization that is dedicated to improving healthcare quality. NCQA also providesaccreditation for organizational health plans that report performance on quality of care, access, service, andmember satisfaction.Resources: http://www.ncqa.org/

Page 190Appendix D - ResourcesVersion 3.0Medical Management GuideNational Guideline Clearinghouse (NGC)A public resource for evidence-based clinical practice guidelines. NGC is sponsored by the AHRQ andprovides an easily accessible mechanism for obtaining objective, detailed information on CPGs and furtheringtheir dissemination, implementation, and use.Resources: http://www.guideline.gov/National Quality Forum (NQF)Promotes change through development and implementation of a national strategy for healthcare qualitymeasurement and reporting.Resources: http://www.qualityforum.org/National Quality Measures Clearinghouse (NQMC)A public archive for evidence-based quality measures and measure sets sponsored by the AHRQ. It wasdeveloped to promote widespread access to quality measures by the healthcare community.Resources: http://www.qualitymeasures.ahrq.gov/National Transition of Care Coalition (NTOCC)A coalition formed in 2006 that brings together thought leaders, patient advocates, and healthcare providersfrom various care settings who are dedicated to improving the quality of care coordination and communicationwhen patients are transferred from one level of care to another.Resources: http://www.ntocc.orgNavy Safe HarborThe Navy facilitates enhanced assistance for seamen/women and their families through Navy Safe Harbor. ANavy wounded warrior is any seaman/woman with a combat or hostile-related injury or illness requiring longtermcare that will require a Medical Evaluation Board (MEB) or Physical Evaluation Board (PEB) to determinefitness for duty. A combat or hostile-related injury results from hazardous service or performance of duty underconditions simulating war or through an instrumentality of war.Resources: http://www.npc.navy.mil/CommandSupport/SafeHarbor/VA: http://www.veteransforamerica.org/woundedwarrior/ DoD/MHS: http://mhs.osd.mil/WoundedWarrior.aspxPopulation Health and Medical Management Division (PHMMD)(formerly MHS Optimization and Population Health Support Center [OPHSC])The PHMMD is the division within the TRICARE Office of the Chief Medical Officer (OCMO) that provides asingle point of access for reference materials, tools, Service links, MHS innovations, discussion forums, andaccredited Web-based learning modules that support and promote essential transformation, cultural change,and knowledge transfer.Resources: http://www.tricare.mil/ocmo/OCMO_PHMM.cfm

Medical Management Guide Version 3.0 Appendix D - ResourcesPage 191Social Security Administration (SSA)/Social Security OnlineA federal program to assist with the economic security of U.S. citizens. Social Security assists with retirementbenefits for the primary worker, as well as survivor benefits and benefits for the retiree’s spouse and children.Social security also provides for disability benefits through Medicare (see Centers for Medicare & MedicaidServices).Resources: http://www.ssa.gov/The Joint Commission (TJC)An independent, non-profit organization that is the predominant standard-setting and accrediting body inU.S. health care. TJC develops state-of-the-art, professionally based standards and evaluates the compliance ofhealthcare organizations against these criteria. TJC’s mission is to continuously improve the safety and quality ofcare provided to the public through the provision of healthcare accreditation and related services that supportperformance improvement in healthcare organizations.Resources: http://www.jointcommission.org/TRICAREThe DoD’s worldwide healthcare program for Active Duty and retired Uniformed Services members and theirfamilies. Consists of:• TRICARE Prime (managed care option)• TRICARE Extra (preferred provider option)• TRICARE Standard (fee-for-service option)• TRICARE For Life (for Medicare-eligible beneficiaries age 65 and over effective 1 Oct 01)Eligible MHS beneficiaries receive certain benefits based on their chosen health plan.Resources: http://www.tricare.osd.mil/ e-mail: questions@tma.osd.milTRICARE Area Office (TAO) — see TRICARE Regional Office (TRO)In overseas locations, TRICARE Regional Offices (TROs, see below) are called “area offices.” The TAOs consist ofEurope, Pacific, Alaska, and Latin America/Canada.Resources: See TRICARE Regional Office (TRO)TRICARE Online (TOL)An enterprise-wide, secure Internet portal for use by DoD beneficiaries, providers, and managers worldwide.TOL provides access to health and contact information for hospitals, clinics, and providers. It provides links toinformation on TRICARE services and benefits, as well as helpful resources, such as DM tools, a drug interactionchecker, and a Personal Health Journal. TOL enables TRICARE Prime and Plus members to make appointmentswith a PCM online. TOL is maintained by the Clinical Information Technology Program Office (CITPO) at theDefense Health Services Systems (DHSS).Resources: http://www.tricareonline.com/

Page 192Appendix D - ResourcesVersion 3.0Medical Management GuideTRICARE Regional Office (TRO)TRICARE has three regional offices: North, South, and West.Resources: http://www.tricare.osd.mil/Uniformed Biostatistical Utility (UBU) Working GroupThe group responsible for the detailed analysis required to standardize biostatistical data elements, definitions,data collection processes, procedure codes, diagnoses, and algorithms across the MHS. The UBU WorkingGroup consists of multi-disciplinary functional experts from each Service. The UBU also consists of a subworkgroupof Service coders who develop and publish DoD Coding Guidelines when coding patient care in theMHS.Resources: http://www.tricare.mil/ocfo/bea/ubu/index.cfmUniformed Business Office (UBO)An office within the TRICARE Office of the Chief Financial Officer (OCFO) Management Control & FinancialStudies (MCFS) Division. It supports TRICARE managed care programs by providing tools and policies toenhance and improve the effectiveness of the financial and collection operations. This includes providingsupport for managing and expediting collections from patients and third-party insurers; consistent and uniformreporting of expense, manpower, and workload data; and enhancing third-party reimbursements. These effortsare coordinated by the charted UBO Advisory Working Group, which includes members from each Service.Resources: http://www.tricare.mil/ocfo/mcfs/ubo/index.cfmU.S. Army Medical Command (MEDCOM) Quality Management Office (QMO)Resources: https://www.qmo.amedd.army.mil/U.S. Preventive Services Task Force (USPSTF)An independent panel of experts in primary care and prevention that systematically reviews the evidence ofeffectiveness and develops recommendations for clinical preventive services.Resources: http://www.ahrq.gov/clinic/uspstfix.htmUtilization Review Accreditation Commission (URAC) (formerly American Accreditation HealthcareCommission [AAHC])A not-for-profit organization founded to promote the accountability of healthcare organizations withthe establishment of utilization review accreditation standards. Individual states often require utilizationmanagement organizations to be URAC-accredited before they can operate.Resources: www.urac.org

Medical Management Guide Version 3.0 Appendix D - ResourcesPage 193Warrior in Transition Program (WT) — see also Army Wounded Warrior Program (AW2)As a result of Global War on Terrorism (GWOT) missions, including Operation Iraqi Freedom (OIF) and OperationEnduring Freedom (OEF), the highest rate of transition resource need has occurred in the Army. A uniqueresponsibility for case managers working in the MHS involves caring for Army Service members in WarriorTransition (WT) status.A WT member is defined as a Service member from any component (Active Compo [1], Army National Guard[2], or USAR [3]) who has been assigned to a WT unit.• Active Compo soldiers who require at least six months of significant care and rehabilitation and intensiveCM are assigned to a WTU.• Reserve Component (RC) WT soldiers are assigned to a WTU when they:o Have experienced injury or illness during training prior to mobilization (e.g., during training).o Have sustained injuries during deployment and were Medevaced.o Upon redeployment, were identified with an injury or illness that was caused by mobilization oraggravated during mobilization.RC soldiers are placed on Medical Retention Processing (MRP), MRP2, or Active Duty Medical Extension (ADME)orders when they are assigned to the WTU.WTU Nurse Case Manager (NCM)The WTU nurse case manager (NCM) in the WTU is involved not only with the medical care and executionof the treatment plan, but also with the WT soldier’s transition back to duty; or to civilian life, if separatedfrom the Service. As part of the Triad of care (the primary case manager [PCM], NCM, and squad leader), theNCM plays a key role in the development of the Comprehensive Transition Plan (CTP). He/she is responsiblefor documenting the clinical aspects of the CTP, coordinating with the VA for post-WTU care and follow-onservices, and ensuring the family is aware and engaged to the extent possible in the WT soldier’s care andtransition. The NCM also works closely with other members of the recovery team, including AW2 advocates,FRCs, and RCCs.While in WT status, a soldier is on a Temporary or Permanent profile and receives the appropriate medical careuntil he/she is determined to fall under one of the following statuses:• Found fit for duty and returned to his/her unit.• Released from Active Duty (REFRAD) Reserve Component (RC) soldier.• Has achieved optimal medical benefit according to the PCM (and therefore does not meet retentionstandards), has been referred to and completed a Medical Evaluation Board (MEB), and has completed thePhysical Disability Evaluation System (PDES) process.The Army has instituted the following enhanced access standards to improve the medical treatment process:• Seventy-two hours for initial specialty referrals.• One week for magnetic resonance imaging and other diagnostic studies.• Two weeks for surgery (from decision time to day of surgery).In addition, the ratio of WT soldiers to NCMs is 1:20, to facilitate close monitoring and assistance for the WT

Page 194Appendix D - ResourcesVersion 3.0Medical Management Guideand his/her family. These standards exceed TRICARE standards and are only applicable to care within MTFs.The MEDCOM standard for completing the MEB is 90 days. It is critical that the NCM work closely with theassigned Physical Evaluation Board Liaison Officer (PEBLO) to make the process as expeditious as possible.Resources: https://www.aw2.army.mil/index.htmlWounded Warrior Regiment (WWR) – MarinesEstablished in April 2007 as a result of Planning Guidance created in 2006 by the 34th Commandant of theMarine Corps, the WWR grew out of a combination of the 2005 Marine for Life Ill/ Injured Support Sectionand the 2004 wounded warrior barracks in Camp Lejeune, North Carolina. Its mission is to provide andfacilitate assistance to wounded, ill, and injured Marines and sailors attached to or in support of Marine unitsthroughout the phases of recovery; as well as assisting their family members. The WWR is headquartered inQuantico, Virginia, with Wounded Warrior Battalions on both the East and West Coasts.Resources: http://www.woundedwarriorregiment.org/WWR.aspxCD-ROM RESOURCESAppendixD_Res1Army G-1 WTU Consolidated Guidance‘Hyperlinks to outside websites: Links to outside websites found printed here are provided only as a convenience to assist you inlocating information that may be helpful. You should note that changes may occur since the printing of this Guide which may affectthe accuracy or availability of the referenced hyperlink. Please see the CD-ROM for perma-saved resource information.All contents © 2009 DoD/Office of the Chief Medical Officer (OCMO)/TRICARE Management Activity (TMA) and the various otherorganizations whose work is reproduced here.