2014 Green Book: Army Medicine: Strengthening 'Health of Our Nation' by improving health of our Army

By Lt. Gen. Patricia D. Horoho, Commanding General, U.S. Army Medical CommandSeptember 15, 2015

"The preservation of a Soldier's health should be the commander's first and greatest care."

- Regulation for Order and Discipline of the troops, 1779

For the first time in our Nation's history, we are decreasing the size of our Army before we have ended our longest war. Nonetheless, Army Medicine must work aggressively to sustain its combat casualty care skills, nurture an environment of dignity and respect, and maintain trust with the American people.

Army Medicine's Four Priorities

Today Army Medicine provides responsive and reliable healthcare while improving the readiness, resilience, and performance of our Force. We focus efforts across our four top priorities: Combat Casualty Care; Readiness and Health of the Force; a Ready and Deployable Medical Force; and the Health of Families and Retirees. These four priorities are strategically nested with those of the U.S. Army and the Military Health System, and span the entire spectrum of health from medics providing combat casualty care on the battlefield to primary care teams back in garrison caring for Soldiers, Families and Retirees.

To continue addressing these priorities, Army Medicine has a nearly $2 billion research and development command, and health science diplomacy in more than 40 countries. We have 128 graduate medical education programs and 20 health professional education programs, with the highest graduation success rate across the nation.

Combat Casualty Care

Combat Casualty Care extends from lifesaving treatment by the medic at the point of injury, to the combat support hospital, through theater evacuation, to definitive care, healing and rehabilitation at our US-based Medical Centers, and includes the transition of our Wounded Warriors back to service, or to the civilian workforce, or as Veterans through the Integrated Disability Evaluation System.

Combat Casualty Care is not limited to the battlefield of today; it extends to research and development, training leaders, and crafting doctrine that will save lives and maintain health in all future operational environments. The Soldiers serving in combat zones now and in the future not only deserve the same quality care as those who we served during the peak years of two simultaneous theaters of conflict -- they deserve even better care since we must learn and evolve.

Our medical teams have achieved the highest combat survival rates in history. Multiple improvements in battlefield medical care, including the effective use of Tactical Combat Casualty Care protocols at the point of injury, tourniquet use, rapid evacuation, and early pain management strategies have contributed to the all-time high-survivability rate of more than 90 percent during Operation Enduring Freedom and Operation Iraqi Freedom. These same clinical teams are now providing safe, quality patient care in hospitals at home and abroad.

Our emphasis on fitness, surveillance and disease prevention in the combat theater has also led to the lowest Disease Non-Battle Injury hospitalization rates (33 per 1000 Soldiers) in history. Protecting Soldiers from conditions that threaten their health is operationally sound and cost effective. Though medical care of our sick and injured will always be necessary, the demands for health care can be reduced through prevention.

Army Medicine--through the efforts of the Army Public Health Command--continues to shape this proactive, preventive vision by identifying infectious and chronic disease threats, assessing occupational and environmental health hazards from chemical exposures in deployed settings, evaluating injury risks during military training, identifying risk factors associated with military suicides and inspecting food and drinking water supplies on Army installations and operational base camps.

We have also considered the long-term impacts of war, and recognize that not all combat injuries are visible. The rapid coordination of traumatic brain injury screening and clinical practice guidelines allowed for our in-theater concussive care centers to achieve a 98 percent Return-to-Duty rate. In addition, by embedding capabilities such as behavioral health and physical therapy with deployed units, we are able to provide early evaluation and treatment, keep the Soldier with the unit, and decrease evacuation requirements.

Readiness and Health of the Force

Army Medicine directly influences combat power by ensuring the medical readiness and the health of the Force, both active and reserve components. To maintain a ready and deployable Force, our Nation's Army requires a comprehensive System for Health designed to maximize the fighting strength, prevent disease and injury, build resiliency and promote healthy behaviors. Our personnel and services must improve, restore and maintain the resilience, agility, and performance of our Service Members.

Our Health and Readiness Platforms include aid stations, Soldier Centered Medical Homes, dental clinics, and garrison Medical Treatment Facilities. Programs and initiatives designed to improve healthy behaviors, such as the Performance Triad of healthy sleep, activity, and nutrition, increase the health and resilience of our Soldiers to better prepare them for challenges unseen.

A Ready and Deployable Medical Force

Our Nation has never had a more combat skilled medical force, able to rapidly introduce lessons learned from the battlefield into mainstream clinical practice. The skills, knowledge, and abilities that have provided our Nation's military the highest quality care must be preserved, and continue to evolve to meet the needs of future conflicts. It is the healthcare of our Soldiers, Retirees and Families in the garrison environment that provides the Health and Readiness Platform for our clinical teams to maintain the critical wartime clinical skills needed to save lives along the continuum of Combat Casualty Care. As Army Medicine enhances the clinical proficiency of deployed healthcare team members, or provides the training and leader development to command an MTF, we ensure the Army has a ready medical force to support them.

The Health of Retirees and Families

Our Families have demonstrated unprecedented strength and resilience, quietly shouldering the burdens of our Nation's wars. Our System for Health provides care that recognizes the unique circumstances and stressors placed on our military Families. By decreasing variance across our enterprise, we are employing standardized processes that improve safety, quality, efficiency, and the overall patient care experience throughout the Army.

A comprehensive and coordinated team working to move the dial further towards health has demonstrated that this model can and does work. Our Patient Centered Medical Homes (PCMH) and Army Wellness Centers (AWC) show how our model of care can improve the health of our population: PCMH/AWC data reveal improved health outcomes, improved medical readiness, and decreased emergency room (ER) utilizations.

A System for Health

Health is a critical enabler of readiness, and Army Medicine is a valuable partner in making our Force "Army Strong." Our strategy -- the Army Medicine 2020 Campaign Plan - supports the Army's vision for 2020 and beyond, the Army's Ready and Resilient Campaign Plan (R2C), and the MHS Quadruple Aim. The Army Medicine 2020 Campaign Plan ensures we remain a vibrant and relevant organization contributing to our Nation's security.

We are aggressively moving from a healthcare system -- a system that primarily focused on injuries and illness -- to a System for Health that now incorporates and balances health, prevention and wellness as a part of the primary focus for readiness. We continue to aggressively move forward in pursuit of becoming the safest hospitals and clinics available anywhere.

We are investing in research focused on prevention. As an example, US Army Research Institute of Environmental Medicine (USARIEM) investigators, along with extramural collaborators, have an ongoing research program to better understand the physiological mechanisms underlying musculoskeletal injury risk potential and ways to mitigate that risk. They are identifying the mediators of muscle and bone repair, tissue adaptation, and biomechanical factors of injury and fatigue. USARIEM researchers are exploring the rehabilitation science applications for Wounded Warriors, the pathways involved in muscle recovery, as well as possible nutritional interventions.

The Performance Triad

The impacts of restful sleep, regular physical activity, and good nutrition are visible in both the short- and long-term. The Performance Triad, an initiative under R2C, is central to the Army Medicine 2020 Campaign Plan that focuses on sleep, activity, and nutrition to improve readiness and health.

The Performance Triad is also a key element within the System for Health and one of the fundamental mechanisms to optimize performance, resilience, and health. A Pilot Program at three diverse Army units: Joint Base Lewis-McChord, WA; Fort Bliss, TX; and Fort Bragg, NC concluded in May 2014. A brigade element based at Fort Bragg deployed to Afghanistan and continued to test the program there, with positive results. The Pilot Program assessed the reach, effectiveness, implementation, adoption, and programmatic achievements to inform and improve a broader implementation.

A Globally Ready and Deployable Force

Our Nation's Army is regionally engaged and globally responsive, providing a full range of capabilities to combatant commanders in a joint, multi-national environment. Army Medicine is both a valuable part and key enabler of the ready and deployable Force. As our military strategy rebalances towards the Asia-Pacific, the readiness of our military requires preparation to meet global challenges. The strategic focus on the Asia-Pacific includes an individual Soldier's readiness to face infectious disease threats, the preparation of our medical assets to conduct disease surveillance, and the innovation of medical research to advance care in a corner of the globe covered by large bodies of water and increased travel distances.

As an Army, as a military, and as a Nation, we have a global influence on medicine and health. The Department of Defense (DoD) supports global health engagement efforts that align with the DoD mission to help ensure geopolitical stability and security. The Army's Global Health Engagements and global presence support those DoD efforts. Military medicine has shown that we are a force multiplier and an enabler of readiness and global diplomacy. Currently we provide medical capabilities on five continents and 11 time zones, in 40 different countries.

Strategies to Enhance Efficiency of Direct Care

As the size of our Army draws down, Army Medicine will adapt without diminishing our ability to provide the highest quality care and readiness. Increasing healthcare costs, the increasing burden of preventable diseases, and mounting fiscal pressures are driving the Nation to examine how we are delivering care, and how we incentivize and enable health. This is both a time of challenge and a time of great opportunity.

Army Medicine continually assesses the efficiency and effectiveness of the delivery of health services support regarding military readiness, and manpower requirements. It also assesses need currency of the whole team, and healthcare demands to continue to provide the most efficient delivery of safe, quality care in both the forward deployed and garrison environments, in a fiscally sustainable manner.

Through our service lines and standardization of processes across the MEDCOM, we have synchronized our policies, programs and resources, with the following results:

• Our medical and dental readiness is at the highest level since 2001;

• Utilization of behavioral healthcare has increased from 900,000 encounters in 2007 to almost 2 million in 2013;

• Since embedding behavioral health personnel in the brigade footprint, Soldiers used outpatient behavioral healthcare more frequently, had fewer acute crises, and required approximately 25,000 fewer inpatient psychiatric bed days in 2013 compared to 2012.

• While such noted civilian medical facilities as Johns Hopkins, Massachusetts General and the University of Michigan receive satisfaction rates of more than 80 percent, ten percent higher than the national average, Army Medicine has consistently rated more than 90 percent.

Although these are significant improvements, this is just the beginning as we continue our transition from a healthcare system to a System for Health. We remain committed to helping all patients prevent disease by making healthier lifestyle choices. It is only through health that we can achieve our strategic priorities of Combat Casualty Care, Readiness and Health of the Force, a Ready and Deployable Medical Force, and the Health of Families and Retirees. Even though some changes will be made within our healthcare system, we will continue to provide cutting-edge care wherever and whenever needed.