National Naval Medical Center Medical Home Program

The NNMC Patient Centered Medical Home Pilot Program is the only existing PCMH pilot program in Military Health System (MHS). An enrolled pilot group of 11,500 patients will be compared to the remaining 11,000 beneficiaries along quality, cost, and satisfaction parameters. A health care team, or “Clinical Micropractice” (CM), forms the fundamental unit of care, consisting of three providers, one registered nurse, three licensed practical nurses/ corpsmen, and two administrative assistants.

The CM is responsible for managing acute, chronic and preventive care as well as coordinating studies and subspecialty care for all assigned patients. Clinical decision support tools, evidence-based practice guidelines and realtime performance monitoring are incorporated into the daily practice. Teams use an Oracle based dashboard to proactively schedule appointments and manage diabetes, CHF, asthma, COPD, as well as arrange preventive services to include cervical cancer screening, mammography, and colon cancer screening. The CM also encourages patients to engage in the management of their own health by providing them with resources, education and skills via improvements in information technology and the implementation of a self management program. Patients can schedule same-day acute appointments with their primary provider and can schedule routine appointments within 2-3 days. Subspecialty appointments are booked upon discharge from the clinical visit by the PCMH team. The model includes integration of behavioral health consultants and nutrition therapists at the point of care.