Army Medical Home
(AMH)
Roles and
Responsibilities
Manual
April 2017 version 1.0
UNCLASSIFIED
Acknowledgement
A special thank you is provided to the many clinical and administrative healthcare professionals
who contributed their time, expertise, and invested interest in the development of this manual for
the OTSG/MEDCOM Army Medical Home. This manual reflects a collaborative team effort to
support the Army Medical Home mission to provide comprehensive, high quality and safe patient
health care for the eligible beneficiary.
Primary Care Service Line (PCSL) Leads:
Carol A. Newman, DNP, RN, CPNP-PC, Sr. Nurse Executive, PCSL
Angelika W. Chiri, MAJ, AN, Nurse Staff Officer, PCSL
Subject Matter Experts (SME):
Cynthia M. Campbell, MHA, BSN, RN
Dawn Lewis, LVN
Elizabeth H. Duque, LTC, MC
Jeremy B. Barber, SFC, 68P
Kenneth E. Russell, MPA, MSA, BSP, FACHE
Army Medical Home (AMH) Work Group
Aditya A. Bhagwat, CDR, USPHS
Anita L. Sachs, MS, BSN, RN
Ashley R. Carlson, CPT, SP
Beverly K. Luce, MHSA, BSN, RN, FACHE, CCM
Bradley S. Tragord, MAJ, SP
Christina M. Ferguson, MSN, RN,
Crystal G. Lastinger, ADN, RN, CCM
David L. Allegretti, SGM, 68C
Giovanna R. Buford, RN
Ian E. Lee, LTC, SP
Jill D. Lynch, Ph.D.
John R. Ekstrand, COL, MC
John Spain, COL, SP
Joshua L. June, MSG, 68W
ii
Kevin J. Ridderhoff, LTC, SP
Leonore B. Gregory, RN
Marsha H. Graham, MSN, RN, CCM
Raelene M. Showery, PharmD, BCPS
Robert L. Nace, LTC, SP
Scott R. Gregg, LTC, SP
Stefanie L. Whitaker, CPT, AN
Stephanie M. Gasper, CPT(P), MS
Stephanie A. Meyer, LTC, MS
Suzanne T. Phillips, PharmD, PhD, MPH,
BCPS
Tad
Gow, BSN, RN, CCM
Vinzuella L. Boddie, MSN, RN
Executive Summary
The Army Medical Home (AMH) implementation in 2011 enhanced the military's delivery of
health care for our beneficiaries. OPORD 11-20, Army Patient-Centered Medical Home
(PCMH), dated 25 January 2011 defined the core Patient-Centered Medical Home staffing
model. As the AMH health care delivery model matured and transitioned into the
sustainment phase, OPORD 16-02, AMH was published 29 October 2015. The core staffing
model remained the same in the sustainment phase, consisting of one full time equivalent
(FTE) Primary Care Manager (PCM) supported by 3.1 support staff and a team of integrated
specialists (e.g., Clinical Pharmacist, Physical Therapist, Dietitian, and Behavioral Health
staff). The Professional Services Model (PSM) determines manpower requirements for the
ambulatory care environment based on provider aggregate relative value units (RVU)
earned.
The continued effort to enhance readiness and the AMH platform is supported by the
AMH Roles and Responsibility Manual. The manual serves as a guide to govern the
roles and responsibilities of the staff assigned to the AMEDD AMH. The recommended
staff tasks, though not inclusive, serve as a guide to enhance efficiencies of the AMH
workflow. The recommended workflows promote unity of effort and contribute to the
standardization of expectations and efficiencies of the AMH interdisciplinary clinical and
administrative teams.
Essential to an efficient and productive workflow, staff must demonstrate competency to
perform at their full scope of practice. The Competency Based Orientation (CBO) tools,
for non-credentialed AMH staff, complement individualized functional roles, provide
standardization of knowledge, skills, and abilities (KSA), and establishes a solid
foundation to develop individual role performance standards.
The AMH Roles and Responsibility Manual establishes standards and incorporates the
basic tenants of a High Reliability Organization (HRO) to promote the delivery of safe,
quality health care in the AMH and enhance the consistent patient experience.
One Team...One Purpose Conserving the Fighting Strength
iii
Table of Contents
Army Medical Home Staffing Fact Sheets…. ......................................................................... 1
Medical Director ................................................................................................................. 1
Officer-in-Charge (OIC)...................................................................................................... 6
Group Practice Manager (GPM)/Practice Manager (PM) ................................................. 11
Clinical Nurse Officer-in-Charge (CNOIC)........................................................................ 15
Non-commissioned Officer-in-Charge (NCOIC) ............................................................... 18
Primary Care Manager (PCM) ......................................................................................... 23
Nurse Case Manager (NCM) ........................................................................................... 26
Registered Nurse (RN) .................................................................................................... 29
Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN)/Practical Nursing
Specialist (68C) .......................................................................................................... 32
Health Care Specialist (68W)........................................................................................... 35
Medical Support Assistant (MSA)..................................................................................... 38
Population Health Registered Nurse (PH-RN) ................................................................. 41
Clinical Pharmacist .......................................................................................................... 44
Clinical Pharmacy Technician/Pharmacy Specialist (68Q) (CBMH) ................................. 48
Medical Technician (Laboratory)/Medical Laboratory Specialist (68K) (CBMH) ............... 50
Registered Dietitian Nutritionist (RDN) ............................................................................. 52
Physical Therapist (PT) ................................................................................................... 54
Physical Therapy Assistant (PTA)/ Physical Therapy Specialist (68F) ............................. 56
Internal Behavioral Health Consultant (IBHC) .................................................................. 58
Behavioral Health Care Facilitator (BHCF) ...................................................................... 60
Glossary Acronym Definition ................................................................................................ 65
Army Medical Home Patient Care Workflow ........................................................................ 69
AMH Workflow – Patient Access ……………………………………………………………...69
AMH Workflow – Patient Appointment Process……………………………………………...71
AMH Workflow – Patient Transition of Care ..................................................................... 73
AMH Workflow – Patient Network/Transition of Care ....................................................... 75
AMH Competency Based Orientation (CBO)........................................................................ 76
AMH Core Competency Factors ...................................................................................... 76
AMH CNOIC/NCOIC ........................................................................................................ 76
AMH Nursing Personnel (RN/LVN/LPN/68C) .................................................................. 76
iv
AMH Health Care Specialist (68W) .................................................................................. 76
AMH Medical Support Assistant (MSA)............................................................................ 76
AMH Nurse Case Manager (NCM) .................................................................................. 76
AMH Population Health Registered Nurse (PH-RN) ........................................................ 77
AMH Pharmacy Technician/(68Q) (CBMH) ...................................................................... 77
AMH Physical Therapy Assistant (PTA)/Physical Therapy Specialist (68F) ..................... 77
AMH Behavioral Health Care Facilitator (BHCF).............................................................. 77
AMH Medical Technician (Laboratory)/Medical Laboratory Specialist (68K) (CBMH) ...... 77
v
Army Medical Home Staffing Fact Sheets
Medical Director
Medical Director
Background:
 Standardized position description (PD) and position series/grade:
– Supervisory Physician (Family Practice)
Position series/grade: GP-0602-14, PD: MC341260
– Military Rank: CPT/MAJ/LTC (Captain/Major/Lieutenant Colonel)
 Leadership training:
– Basic Healthcare Administration Phase 1&2 - Army Training Requirements
and Resources System (ATRRS) 6I-F13/340-F8
– Department of the Army Supervisory Development Course - ATRRS
1-250-C53 Distance Learning (DL)
 Medical Director will complete all mandatory training per Appendix 3 to Annex
R in Operations Order (OPORD) 16-02 Army Medical Home (AMH), 29
October 2015.

Clinical Care: Provides clinical care to patients. Responsible for the quality
of care provided by the Primary Care Managers (PCM) by implementing
standard work using evidence based practices and applying process
improvement tools to proactively identify opportunities to improve care.
Manages the peer review process and supporting systems to include the
maintenance of certifications and training for all staff.

Administrative: Responsible for daily clinic operations, primarily focus is on
provider staff. Responsibilities may include Access to Care (ATC) and PCM
schedules, ensuring quality care is provided, supports customer service,
command climate, and culture of the AMH. Utilizes High Reliability
Organization (HRO) principles (proactive to preventing errors/preoccupation
with failure, sensitivity to operations, deference to expertise, reluctance to
simplify, and commitment to resilience) to lead the organization in creating a
culture focused on patient safety, continuous learning, innovation and
improvement. May supervise PCMs if Officer-in-Charge/Practice Manager
(OIC/PM) is non-clinical personnel, or senior rate Primary Care Behavioral
Health (PCBH) personnel (Internal Behavioral Health Consultant [IBHC] and
Behavioral Health Care Facilitator [BHCF]) if appointed PCBH-Clinical
Supervisor. Reviews credentials packets and privilege requests for providers,
ensures adherence to supervision plans, manages Focused Provider
Performance Evaluations (FPPE) and Ongoing Provider Performance
Evaluations (OPPE) for clinic and reports to local Credentials Committee about
status of providers. Maintains two-way open communication and accountability
(both up and down the chain of command) to promote transparency of
communication.
1
Medical Director
Daily Tasks:
Clinical:
 Reviews patient and staff schedule with the medical home team to
ensure availability of appropriate staffing coverage to support the daily
mission.
 Attends medical home daily huddle and communicates important
administrative information to the team utilizing Team Strategies and Tools to
Enhance Performance and Patient Safety (TeamSTEPPS®) principles.
 Provides current, evidence-based care for enrolled patients.
 Verifies patient with the Joint Commission (TJC) patient safety goals using
the two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Reviews and addresses test results/incomplete telephone consult (Tcon)/Secure Messaging (SM).
 Collaborates with core team by reviewing team schedule 72 hours out
and adjusts as needed to support care.
 Monitors and ensures completion of provider Electronic Health Record (EHR)
progress notes/Tri-Service Workflow (TSWF) Alternate Input Method (AIM)
forms within guidelines of 72 hours.
 Assumes duties of health care providers that are unexpectedly absent.
 Assumes duties of Medical Officer on Duty (MOD)/walk-in duties/call
and inpatient coverage as required.
 Supports second opinion and inquiries from other PCM.
 Leads by treating staff and patients courteously and professionally.
 Provides daily onsite/walk-around leadership (available to answer questions,
address concerns, etc.), demonstrating sensitivity to operations and
encouraging vigilance for opportunities to improve safety and quality care.
Administrative:
 Conducts leadership rounds to learn how to help front line staff improve care
and eliminate harm.
 Provides guidance and direction on clinical issues and provider staffing
concerns.
 Meets routinely with AMH leadership team.
 Responds to Interactive Customer Evaluation (ICE) Comments that
involve standard of care or provider concerns.
2
Medical Director
Weekly Tasks:
Clinical:
 Reviews consult queues in EHR.
 Responds to inquiries: Command, Inspector General (IG), and congressional
as required.
 Initiates service recovery (e.g., addresses dissatisfied patients)
demonstrating respect for people and creating a just culture in which staff
and patients are trusted and valued.
Administrative:
 Practices TeamSTEPPS® communication and leadership delivery by
publically praising positive comments, identification of improvement
opportunities, etc.
 Counsels staff privately when improvements are identified or individual
performance plans are indicated.
 Leads weekly clinical leadership meeting, reviewing clinical highlights (e.g.,
Clinical Practice Guidelines [CPG] updates) program updates, recognition
status, the Healthcare Effectiveness Data and Information Set (HEDIS®)
metrics, patient satisfaction, and any additional information for clinic leadership
to discuss/review.
 Demonstrates deference to expertise, granting individuals with the
greatest expertise relevant to managing a new situation decision–making
authority to resolve the situation positively.
 Ensures all actions and decisions demonstrate a just culture in which staff
are trusted, valued, and relied on to initiate improvements and innovations
at the front line.
 Reviews privileging/credential packets.
 Attends Military Treatment Facility (MTF) credential meetings as appointed
by the command.
 Ensures Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
 Manages staff requests for leaves and training to maintain ATC standards.
 Ensures effective, clear communication of command and leadership priorities
by disseminating and supporting the commander’s mission/vision and
ensuring the team possesses an appropriate understanding.
 Fosters a culture of safety focused on safe care, continuous learning,
innovation, and improvement.
3
Medical Director
Monthly/Yearly Tasks:
Clinical:
 Identifies staff training requirements and provides opportunities to expand
their competencies. Ensures all staff are oriented and trained in HRO
principles, specifically including preoccupation with failure and reluctance to
simplify to foster an organizational safety culture.
 Reviews and monitors HEDIS® results and develops action plans with
leadership team to foster improvements.
 Reviews potential and actual risk management concerns and mitigates
as needed.
 Ensures compliance with currency of PCM licensure, Basic Life Support
(BLS), required Continued Medical Education (CME), and mandatory
training requirements.
 Participates with Morbidity and Mortality (M&M) conferences/case studies.
Using Lean Six Sigma, change management, and other process improvement
tools, identifies opportunities to improve care in the work environment,
encouraging staff to be constantly vigilant for any deviations from best
practices and speaking up when identifying opportunities to improve safety for
care provided.
 Schedules and conducts timely performance counseling through
mentoring supervised staff (e.g., informal and/or formal).
Administrative:
 Provides verbal and nonverbal feedback to team on performance and
outcomes metrics (e.g., bulletin board, verbal announcements, etc.),
encouraging development of a just culture focused on patient safety.
 Ensures work schedules are posted in advance in accordance with
current Medical Command (MEDCOM) guidance and policies.
 Reviews and discusses results from the patient satisfaction application (e.g.,
current provider/support staff satisfaction survey, ICE, and/or local survey)
with the health care team regarding both positive and opportunities to
enhance current practice through a collaborative team approach.
 Completes FPPE for new or challenged health care providers.
 Completes OPPE semi-annually and forwards to the Credentials Office
(e.g., spot check).
 Conducts staff quarterly counseling, annual evaluation, and submission
of awards as indicated.
 Collaborates with MTF Human Resource (HR), Human Resource
Command (HRC), and Non-commissioned Officer-in-Charge (NCOIC)
and/or Chain-of-Command to fill staff vacancies and submit requisitions
as required.
 May be involved in the hiring of new providers to include request for
personnel actions (RPA) determinations and interviewing of providers,
dependent on location.
4
Medical Director
 Completes Soldier requirements in timely manner (medical readiness,
Army Physical Fitness Test (APFT), Commanding General (CG) top 10,
etc.).
5
Officer-in-Charge (OIC)
OIC
Background:



Standardized position description (PD) and position series/grade:
– Supervisory Physician (Family Practice)
Position series/grade: GP-0602-14, PD: MC341260
– Supervisory Nurse (Advanced Practice Registered Nurse [APRN]
PRACT/Family Practice) Nurse Practitioner (NP)
Position series/grade: GP-0610-13, PD: MC342589
– Supervisory Physician Assistant (PA)
Position series/grade: GP-0603-12, PD: MC34592
– Military Rank: CPT/MAJ/LTC (Captain/Major/Lieutenant Colonel)
(Physician, NP, PA)
Leadership training:
– Basic Healthcare Administration Phase 1&2 - Army Training Requirements
and Resources System (ATRRS) 6I-F13/340-F8
– Department of the Army Supervisory Development Course - ATRRS
1-250-C53 Distance Learning (DL)
OIC will complete all mandatory training per Appendix 3 to Annex R in
Operations Order (OPORD) 16-02 Army Medical Home (AMH), 29 October
2015.

Clinical Care: Provides clinical care to patients. Responsible for providing
quality of care provided by the Primary Care Managers (PCM) by
implementing standard work using acknowledged leading practices and by
using process improvement tools to proactively identify opportunities to
improve care. The OIC, if a physician may be dual-hatted as the medical
director dependent on local command requirements and, if so, will assume
roles and responsibilities of the medical director in addition to the OIC duties.

Administrative: Responsible for daily clinic operations to include access to
care (ATC), customer service, climate, and culture of the section. Utilizes High
Reliability Organization (HRO) principles (proactive to preventing
errors/preoccupation with failure, sensitivity to operations, deference to
expertise, reluctance to simplify, and commitment to resilience) to lead the
organization in creating a culture focused on patient safety, continuous
learning, innovation and improvement. Ensures staff maintains timekeeping
requirements, currency of required training, compliance with the Joint
Commission (TJC) and AMH designation standards, and safety measures.
Typically supervises the PCM, Clinical Nurse Officer-in-Charge (CNOIC),
Group Practice Manager (GPM)/Practice Manager (PM), Non-commissioned
Officer-in-Charge (NCOIC), and at times, specialized personnel. Serves as
rater for Primary Care Behavior Health (PCBH)
6
Officer-in-Charge (OIC)
personnel (Internal Behavioral Health Consultant [IBHC] and Behavioral
Health Care Facilitator [BHCF]). Maintains two-way communication and
accountability, both up and down the chain of command. Transparency of
communication is of paramount importance.
Daily Tasks:
Clinical:
 Reviews patient and staff schedule with the medical home team to
ensure appropriate staffing coverage in support of daily mission.
 Attends medical home daily huddle with core team using Team Strategies
and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®)
principles to communicate information with the entire team.
 Verifies patient with the Joint Commission (TJC) patient safety goals using the
two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Provides current, evidence-based care to enrolled patients.
 Reviews and addresses test results/incomplete telephone consult
(T-con)/Secure Messaging (SM).
 Collaborates with core team reviewing team schedule 72 hours out and
adjusts as needed to support care.
 Monitors and ensures completion of provider Electronic Health Record (EHR)
progress notes/Tri-Service Workflow (TSWF) Alternate Input Method (AIM)
forms within guidelines of 72 hours.
 Responds to inquiries: command inquires Inspector General (IG) inquiries,
and congressional inquiries as required.
 Initiates service recovery (e.g., addresses patient and/or staff concerns)
demonstrating respect for people and creating a just culture in which staff
and patients are trusted and valued.
 Assumes duties of health care providers that are unexpectedly absent.
 Assumes duties of Medical Officer on Duty (MOD)/walk-in duties/call
and inpatient coverage as required.
 Leads by treating staff and patients courteously and professionally.
 Completes patient progress notes/Tri-Service Workflow (TSWF) Alternate
Input Method (AIM) forms in the EHR within 72 hours.
 Provides daily onsite/walk-around leadership (available to answer questions,
address concerns, etc.), demonstrating sensitivity to operations and
encouraging vigilance for opportunities to improve safety and quality care.
Administrative:
 Attends medical home daily huddle and communicates important
administrative information to the team utilizing TeamSTEPPS® principles.
7
Officer-in-Charge (OIC)
 Conducts leadership rounds to learn how to help front line staff improve care
and eliminate harm.
 Provides guidance and direction on current issue(s) of the day.
 Meets routinely with AMH leadership team.
 Validates staffing support each day to ensure adequate support for
scheduled appointments.
 Spot checks & counsels staff as appropriate, mentors.
 Responds to Interactive Customer Evaluation (ICE) comments.
 Teaches, coaches, and mentors providers on Clinical Practice Guidelines
(CPG) and provision of evidence-based care.
Weekly Tasks:
Clinical:
 Reviews consult queues in EHR.
 Responds to inquiries: Command, Inspector General (IG), and congressional
as required.
 Initiates service recovery (e.g., addresses patient and/or staff concerns)
demonstrating respect for people and creating a just culture in which staff
and patients are trusted and valued.
Administrative:
 Practices TeamSTEPPS® communication and leadership delivery by
publically praising positive comments, identification of improvement
opportunities, etc.
 Counsels’ staff, privately, when improvements are identified or individual
performance plans are indicated.
 Leads weekly clinical leadership meeting, reviewing clinical highlights (e.g.,
program updates, recognition status, personnel [appraisals, awards,
Permanent Change of Station (PCS), hiring actions, etc.), the Healthcare
Effectiveness Data and Information Set (HEDIS®) metrics, patient satisfaction,
and any additional information for clinic leadership to discuss/review.
 Demonstrates deference to expertise, granting individuals with the
greatest expertise relevant to managing a new situation decision–
making authority to resolve the situation positively.
 Ensures all actions and decisions demonstrate a just culture in which staff
are trusted, valued, and relied on to initiate improvements and innovations
at the front line.
 Validates clinic schedule prior to opening schedule for booking (e.g.,
demand management: PCM and appropriate support staff ratio).
 Ensures Automated Time Attendance and Production System
8
Officer-in-Charge (OIC)
 (ATAAPS)/Defense Medical Human Resource System-internet
(DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report time.
 Manages staff requests for leaves and training to maintain Access to Care
(ATC) standards.
 Ensures effective, clear communication of command and leadership priorities
by disseminating and supporting the commander’s mission/vision and
ensuring the team possesses an appropriate understanding.
 Fosters a culture of safety focused on safe care, continuous learning,
innovation, and improvement.
Monthly/Yearly Tasks:
Clinical:
 Identifies staff training requirements and provides opportunities to expand
their competencies. Ensures all staff are oriented and trained in High
Reliability Organization principles, specifically including preoccupation with
preventing adverse events and reluctance to simplify to foster an
organizational culture of safety.
 Reviews and monitors HEDIS® results and develops action plans to
foster improvements.
 Ensures compliance with currency of staff licensure, Basic Life Support
(BLS), required Continued Medical Education (CME), and mandatory
training requirements.
 Schedules and conducts timely performance counseling through
mentoring supervised staff (e.g., informal and/or formal).
Administrative:
 Provides verbal and nonverbal feedback to team on performance and
outcomes metrics (e.g., bulletin board, verbal announcements, etc.),
encouraging development of a just culture focused on patient safety.
 Ensures work schedules are posted in advance in accordance with
current Medical Command (MEDCOM) policy and OPORD.
 Meets with business/clinical operations staff regarding ATC
performance measures/metrics to optimize appointment availability
based on demand management to clinical services.
 Reviews and discusses patient satisfaction application results (e.g., current
provider/support staff satisfaction survey, ICE, and/or local survey) with the
health care team regarding both positive and opportunities to enhance
current practice through a collaborative team approach.
 Conducts staff quarterly counseling, annual evaluation, and submission
of awards as indicated.
9
Officer-in-Charge (OIC)
 Processes retention incentives as earned.
 Briefs review and analysis (R&A) to command staff. Identifies needs and
submits action plan requests through designated program.
 Actively participates in Program Budget Advisory Committee (PBAC) meetings.
 Collaborates with MTF Human Resource (HR), Human Resource
Command (HRC), and Non-commissioned Officer-in-Charge (NCOIC)
and/or Chain-of-Command (CoC) to fill staff vacancies and submit
requisitions as required.
 Submits Request for Personnel Actions (RPA) in a timely manner in
compliance with local standard operating procedures (SOPs).
 Completes Soldier requirements in timely manner (medical readiness,
Army Physical Fitness Test (APFT), Commanding General (CG) top 10,
etc.).
10
Group Practice Manager (GPM)/Practice Manager (PM)
GPM/PM
Background:





Standardized position description (PD) Supervisory Health System
Administrator, Community Based Medical Home (CBMH) only
– Position series/grade: GS-0670-14, PD: MC347496
Standardized position description (PD) Supervisory Health Systems
Specialist, (CBMH only)
– Position series/grade: GS-0671-11, PD: MC347515
Military Rank: CPT/MAJ/LTC (Captain/Major/Lieutenant Colonel) or
E7/E8 (Sergeant First Class/Master Sergeant)
Mandatory Training:
– Basic Healthcare Administration Phase 1&2 - Army Training Requirements
and Resources System (ATRRS) 6I-F13/340-F8
– Practice Manager - ATRRS 26A-F57/300-F57
– Department of the Army Supervisor Development - ATRRS 1-250-C53
(DL)
GPM/PM will complete all mandatory training per Appendix 3 to Annex R in
Operations Order (OPORD) 16-02 Army Medical Home (AMH), 29 October
2015.
GPM/PM Roles and Functions:
 Supervises daily operations of stand-alone clinic. Collaborates to ensure
appointment access to care (ATC) standards is met and clinics are optimized.
 Monitors productivity targets and adjusts templates as appropriate.
 Facilitates decision-making, conflict resolution, strategic planning and dialogue
within the clinic.
 Provides oversight for department operating budgets and business plans.
 Reviews directives from higher authorities and advises of any potential impact
to the clinic.
 Directs analysis and evaluation of healthcare delivery and the effectiveness
and efficiency within the clinic; collaborates with Department Chief, Officer-inCharge (OIC).
 Establishes evaluation criteria and develops analytical methods based on
broad management principles.
 Coordinates closely with clinical and administrative activities on matters
that affect costs, program effectiveness, and standards of healthcare
delivery.
– Coordinates budget planning and execution with Resource
Management (RM) and provides recommendations on the allocation
of funds and resources based on adjustments in program objectives
and needs.
– Establishes, prepares, and maintains the overall clinic budget.
11
Group Practice Manager (GPM)/Practice Manager (PM)




– Prepares various reports and briefings with regard to budget
execution plans.
– Coordinates on all financial requests and exercises full authority for
establishing financial priorities for required personnel, services,
supplies, equipment (both medical and non-medical), and allocates
available funds accordingly.
Recommends and executes plans to improve quality of care, cost
reduction, access to care, healthcare delivery operations, and
administrative support.
Integrates all operational components and ensures coordination with input
from appropriate activities.
Facilitates public relations – works with patient advocate and/or Public
Affairs Officer (PAO) relating to patient issues/concerns and facilitates
review of the provider satisfaction survey report for the clinic.
Functions as clinics’ on-site Patient Advocate.
Personnel Management:
 Assumes a leadership role in developing internal personnel management
policies for all employees (e.g., military, civilian, and contract employees) of
the clinic.
Collaborates with Department Chief/OIC/Clinical Nurse Officer-in-Charge
(CNOIC), and Non-commissioned Officer-in-Charge (NCOIC).
 Provides supervision to team, which includes Physicians and other
healthcare professionals such as Nurse Practitioner (NP), Physician
Assistants (PA), and Pharmacist.
 Collaborates with clinic leadership in the management of and recommending
of various career-development/professional enrichment programs, for both
professional and non-professional employees.
 Serves as the on-site Contracting Officer’s Representative (COR) if required.
 Collaborates with clinic leadership on workflow, staffing concerns, interviewing
of potential new hires, makes or approves selections for subordinate
nonsupervisory positions, and recommends selections for subordinate
supervisory positions.
 Coordinates with Human Resource (HR) and Resource Management
(RM) Manpower to manage clinic Table of Distribution (TDA) and
Position Control Roster (PCR).
 Collaborates with the NCOIC and/or CNOIC focusing on the daily clinical and
administrative operations of the medical home by monitoring defined clinical
performance metrics, Defense Medical Human Resources System-internet
(DMHRSi) accuracy, staffing requirements, and daily operational functions of
the AMH to ensure compliance with the Joint Commission (TJC) and AMH
designation standards.
 Advises clinic leadership team on civilian personnel matters:
promotions, evaluations, awards, disciplinary actions, and employee
grievances.
12
Group Practice Manager (GPM)/Practice Manager (PM)
Daily Tasks:
 Attends medical home daily huddle and communicates important
administrative information to the team.
 Assesses impacts of unanticipated absences (call outs) and cross-levels
staffing in coordination with nursing supervisors. Notifies call center/Clinical
Support Division (CSD)/Department of Primary Care for any needs to make
resulting modifications to the schedule.
 Manages the day-to-day operations of the clinic; ensures clinical staff focuses
on patient care and are unencumbered by administrative tasks.
 Reviews telephone consult (T-con) backlog to identify providers/teams that
are out of compliance with T-con timeliness standards; assess demand
beyond clinic’s capability.
 Ensures compliance with daily End of Day (EOD) administrative processing.
 Coordinates responses to patient complaints with nursing leadership.
 Addresses staff issues; Equal Opportunity (EO), American Federation of
Government Employees (AFGE), and Human Resources (HR) as
needed.
 Manages clinical access to care (daily access and barriers to access).
 Ensures confidentiality and compliance with the Health Insurance
Portability Accountability Act (HIPAA).
 Monitors/manages/enforces processes and/or changes for reception/front
desk personnel.
Weekly Tasks:
 Manages staffing shortages with nursing supervisor/CNOIC and/or NCOIC.
 Manages Primary Care Manager (PCM) annual/sick leave requests to
maintain visibility of decrements that result in reduced access for
empanelled patients; develops mitigation strategy.
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
 Maintains close coordination between clinic and department leadership,
Managed Care/Clinical Support Division/Clinical Operations and
Centralized Patient Appointing Supervisor.
 Reviews, updates, and creates required clinic Standard Operating
Procedures (SOP), policies, etc. in collaboration with leadership.
Monthly Tasks:
 Plans/organizes/schedules clinic meetings: mandatory training requirements;
13
Group Practice Manager (GPM)/Practice Manager (PM)
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Process Improvement (PI), Nurse Practice Council (NPC), and leadership
meetings.
Downloads/analyzes all TRICARE Operations Center (TOC) reports.
Builds and publishes PCM/team performance: PCM satisfaction
survey, Continuity, Workload, Emergency Department (ED)/Urgent
Care Clinic (UCC)/Acute Care Clinic (ACC)/Network Leakage, and
the Healthcare Effectiveness Data and Information Set (HEDIS®)
measures.
Reviews/approves PCM scheduled absences to ensure future access is not
impacted and de-conflicts absences, if minimum access standard cannot be
met.
Reviews templates/builds and publishes PCM schedules within
MEDCOM standards.
Monitors encounter timeliness to facilitate clinic flow and access to care.
Manages secure messaging (SM) operations (administrative and clinical
boxes), add/delete staff, purge patients no longer empanelled, serves as the
clinic SM Super User, and conducts staff training as required.
Provides Relative Value Unit (RVU)/Encounter data to Medical Director to
support credentialing requirements (Ongoing Professional Practice
Evaluation [OPPE]/Focused Professional Practice Evaluation [FPPE]).
Attends Department of Primary Care and other recurring meetings as
required (e.g., Leadership, Process Improvement, Patient Advisory Council,
etc.).
Monitors/manages/enforces processes and/or changes for the Medical
Support Assistants (MSAs).
Facilitates budget management, focused on cost reduction and maximization
of clinic revenue.
Demonstrates knowledge of MEDCOM and Military Health System (MHS)
data systems; monitors, trends, and analyzes all objective performance
measures/metrics.
14
Clinical Nurse Officer-in-Charge (CNOIC)
CNOIC
Background:




Standardized position description (PD) Supervisory Nurse (Admin/Ambulatory).
– Position series/grade: GS-0610-12, PD: MC396394
Military Rank: CPT/MAJ/LTC (Captain/Major/Lieutenant Colonel)
Leadership training:
– Department of the Army Supervisor Development Course – Army Training
Requirements and Resources System (ATRRS) 1-250-C53 Distance
Learning (DL)
– US Army Medical Department (AMEDD) CNOIC/Non-commissioned
Officer-in-Charge (NCOIC) Leader Development Course - ATRRS 6EF5/300-F42
– Basic Healthcare Administration Phase 1&2 - Army Training Requirements
and Resources System (ATRRS) 6I-F13/340-F8
CNOIC will complete all mandatory training per Appendix 3 to Annex R in
Operations Order (OPORD) 16-02 Army Medical Home (AMH), 29 October
2015.
Daily Tasks:
 Attends medical home daily huddle and communicates important
administrative information to the team.
 Reviews patient and staff schedule with the medical home team to
ensure coverage in support of daily mission.
 Verifies patient with the Joint Commission (TJC) patient safety goals using the
two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Supervises all assigned nursing staff (military and civilian) to include the
Nurse Case Manager (NCM) and Population Health-Registered Nurse (PHRN); does not supervise assigned nurse practitioners (NP).
 Collaborates with the Non-commissioned Officer-in-Charge (NCOIC) and/or
Group Practice Manager (GPM)/Practice Manager (PM) focusing on the daily
clinical and administrative operations of the medical home by monitoring
defined clinical performance metrics, Defense Medical Human Resources
System-internet (DMHRSi) accuracy, staffing requirements, and daily
operational functions of the AMH to ensure compliance with TJC and AMH
designation standards.
 Conducts in-person rounds of the medical home throughout the day to
assess workflow efficiencies, proactively identifies issues, and seeks
resolution in a collaborative manner with assigned staff.
15
Clinical Nurse Officer-in-Charge (CNOIC)
Weekly/bi-weekly Tasks:
 Reviews staffing schedule with NCOIC and GPM/PM to ensure coverage
is supportive of mission requirements. Proactively identifies staffing gaps
and plans appropriate coverage to meet daily mission requirements.
 Collaborates with GPM/PM and NCOIC regarding leaves, appointments,
training, etc. to support scheduled and unscheduled staff absences.
 Reviews/Maintains/Signs Automated Time Attendance and Production System
(ATAAPS)/DMHRSi compliance, bi-weekly, for nursing staff time
cards/workload. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report time.
Monthly Tasks:
 Engages and collaborates with the Unit Practice Council to review the
council’s progress, recommendations, etc. in support of the Patient Caring
Touch System (PCTS).
 Conducts monthly staff meetings in collaboration with the NCOIC and
GPM/PM; meets to review team progress, addresses concerns/issues
(clinical and administrative), process improvement projects, TJC and AMH
designation compliance, etc.
 Reviews Nurse Case Manager (NCM) acuity trackers and provides guidance
to enhance case management and care coordination.
 Assigns and monitors the delegation of additional duties assigned to the
nursing staff (e.g., Competency Assessment File (CAF), Basic Life Support
(BLS) currency, Registered Nurse (RN), Licensed Practical Nurse
(LPN)/Licensed Vocational Nurse (LVN)/Practical Nursing Specialist (68C)
and Health Care Specialist (68W) licensure/certification status, etc.).
 Reviews Healthcare Effectiveness Data and Information Set (HEDIS®) data
with Population Health–Registered Nurse (PH-RN) or assigned Team RN to
identify compliance and areas to improve.
 Reviews the Interactive Customer Evaluation (ICE) and Provider Satisfaction
Survey to address concerns/issues in a timely manner through collaboration
with medical home staff and/or Patient Representative/Guest Relations staff
for resolution.
 Reviews monthly Secure Messaging (SM) utilization report/status of
enrollment; directs workflow improvements as necessary; ensures all SM in
clinical box is acknowledged within 24 hours of receipt.
 Reviews and endorses Point-of-Care Testing logbooks indicating
compliance if applicable (e.g., glucometer, urine human chorionic
gonadotropin [hCG], etc.).
 Reviews procedure logbook and documentation with procedure staff to
ensure safety standards are met according to local policy.
16
Clinical Nurse Officer-in-Charge (CNOIC)
Additional Tasks:
 Conducts timely staff counseling (e.g., initial and quarterly); ensures all staff
receives supportive counseling during the year and documents appropriately
per the Civilian Appraisal System (e.g., Total Army Performance Evaluation
System [TAPES]/DoD Personnel Management and Appraisal Program
[DPMAP]) guidelines, Office of Personnel Management (OPM), and
MEDCOM guidance.
 Completes timely evaluations in accordance with TAPES/DPMAP, OPM, and
MEDCOM G1-Personnel policies/guidelines.
 Ensures supervised civilian nursing support staff completes an Individual
Development Plan (IDP) and supervised military staff completes a support
form per established OPM/MEDCOM G1-Personnel policies/guidelines.
 Ensures supervised nursing support staff (e.g., Medical Support Assistants
[MSA], [LPN/ LVN/68C, 68W, and/or Nursing Assistant [NA]) have completed a
Competency Based Orientation (CBO) according to AR 40-68, Quality
Management, and local policy. Reviews all areas that require a performance
plan and activates plan to support the full scope of their competencies with the
preceptor. Has full oversight of completion, to include re-evaluation of
established performance plan, if required.
 Reviews and revises standard operating procedures (SOP) annually and
as needed.
 Reviews and collaborates with NCOIC and GPM/PM regarding the scheduling
of mandatory training requirements for all staff (e.g., military, civilian, and
contract) to ensure compliance and competencies.
 Reviews clinic concerns with NCOIC and GPM/PM (e.g., equipment
status, supplies, etc.).
 Collaborates with assigned medical coder to ensure staff is trained on
current coding procedures.
 Reviews nursing peer reviews and identifies opportunities to enhance
efficiencies and professional development.
 Attends assigned meetings and performs additional duties as designated
by senior leadership.
17
Non-commissioned Officer-in-Charge (NCOIC)
NCOIC
Background:
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Military Rank: SSG/SFC (Staff Sergeant/Sergeant First Class)
Training:
– Basic Healthcare Administration Phase 1&2 - Army Training Requirements
and Resources System (ATRRS) 6I-F13/340-F8
– Practice Manager - ATRRS 26A-F57/300-F57
– Department of the Army Supervisor Development Course - ATRRS 1-250C53 (DL)
– US Army Medical Department (AMEDD) Clinical Nurse Officer-in-Charge
(CNOIC)/NCOIC Leader Development - ATRRS 6E-F5/300-F42
NCOIC will complete all mandatory training per Appendix 3 AMH Training to
Annex R to Operations Order (OPORD) 16-02 Army Medical Home (AMH),
29 October 2015, if assigned to an AMH.
NCOIC Roles and Functions:
 Supervises daily operations of stand-alone clinic. Collaborates to ensure
appointment access to care (ATC) standards is met and clinics are optimized.
 Accountable for tracking productivity targets.
 Facilitates decision-making, conflict resolution, strategic planning, and dialogue
within the clinic staff.
 Assists with oversight for department operating budgets and business plans.
 Reviews directives from higher authorities and advises of any potential impact
to the clinic.
 Assists with the analysis and evaluation of healthcare delivery and the
effectiveness and efficiency within the clinic – collaborates with
Department Chief, Officer-in-Charge (OIC).
 Follows evaluation criteria and analytical methods based on broad
management principles as specified by Army and MEDCOM policy and
guidelines.
 Coordinates closely with clinical and administrative activities on matters
that affect costs, program effectiveness, and standards of healthcare
delivery.
– Coordinates budget planning and execution with Resource
Management (RM) and assists with the allocation of funds and
resources based on adjustments in program objectives and needs.
– Assists with the maintenance of overall clinic budget.
– Assists in preparing various reports and briefings in regards to
budget execution plans.
– Coordinates all financial requests and assists with establishing
financial priorities for needed personnel, services, and supplies.
18
Non-commissioned Officer-in-Charge (NCOIC)
 Integrates all operational components and ensures coordination with input
from appropriate activities.
 Facilitates public relations – works with patient advocate and/or Public
Affairs Officer (PAO) relating to patient issues/concerns and facilitates
review of the provider satisfaction survey report for the clinic.
 Functions as the clinics on-site Patient Advocate.
 Serves as the on-site Contracting Officer’s Representative (COR).
 Collaborates with clinic leadership on workflow, staffing concerns, interviewing
of potential new hires, assists with the selection for subordinate
nonsupervisory positions, and recommends selections for subordinate
supervisory positions.
 Coordinates with Human Resource (HR) and Resource Management
(RM) Manpower to manage clinic Table of Distribution (TDA).
 Advises clinic leadership team on civilian personnel matters:
promotions, evaluations, awards, disciplinary actions, and employee
grievances.
Daily Tasks:
 Attends medical home daily huddle and communicates important
administrative information to the team.
 Reviews patient and staff schedule with the medical home team to
ensure coverage in support of daily mission.
 Verifies patient with the Joint Commission (TJC) patient safety goals using
the two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Faceto-face or non-face-to-face).
 Manages the day-to-day operations of the clinic; ensures clinical staff focuses
on patient care and are unencumbered by administrative tasks.
 Tracks access and provider availability, tracks appointment templates.
 Oversees clerical staff, monitors telephone calls, and consults.
 Makes recommendations to improve clinic efficiency and effectiveness in
meeting patient needs using resources to promote quality and costeffective patient centered care.
 Collaborates with Clinical Nurse Officer-in-Charge (CNOIC) to
ensure compliance with TJC and AMH designation standards.
 Ensures emergency preparedness according to Military Treatment Facility
(MTF) policies.
 Provides technical advice, support, and assistance to all staff.
 Reviews front desk Medical Support Assistant (MSA) work to ensure End of
Day (EOD) close out within Electronic Health Record (EHR).
 Ensures compliance with daily EOD administrative processing.
 Coordinates responses to patient inquiries/concerns with the AMH
leadership team.
19
Non-commissioned Officer-in-Charge (NCOIC)
 Addresses staff issues in accordance with Equal Opportunity (EO),
American Federation of government Employees (AFGE), and Human
Resources (HR) governing policies as needed.
 Identifies and manages the challenges and barriers of daily access by
providing solutions to improve appointment availability.
 Ensures confidentiality and compliance with the Health Insurance
Portability Accountability Act (HIPAA) is maintained among clinic staff.
 Monitors/manages/enforces process and/or changes for MSA staff.
Weekly/bi-weekly Tasks:
 Reviews/Maintains/Signs Automated Time Attendance and Production
System (ATAAPS)/Defense Medical Human Resource System-internet
(DMHRSi) compliance, bi-weekly, for nursing staff time cards/workload.
Utilizes appropriate Medical Expense and Performance Reporting System
(MEPRS) code/functional cost codes (FCC) to report time.
 Monitors and engages staff to complete mandatory Department of the
Army/MEDCOM training. Upon completion, uploads information into the
Digital Training Management System (DTMS).
 Reviews and confirms Defense Travel System (DTS) travel pertaining to
clinic staff before submission to DTS Travel Action Officer (AO)/Agent.
 Reviews and comments on Interactive Customer Evaluation (ICE) submissions
to ensure a timely response according to local policy.
 Maintains close coordination between clinic and department leadership,
Managed Care/Clinical Support Division/Clinical Operations and
Centralized Patient Appointing Supervisor.
 Reviews, updates, composes required clinic Standard Operating
Procedures (SOP’s), policies, etc. as designated.
Monthly Tasks:
 Plans/organizes/schedules clinic meetings: mandatory training requirements,
Process Improvement (PI), Nurse Practice Council (NPC), leadership
meetings, etc.
 Monitors patient encounter timeliness.
 Attends Department of Primary Care and other recurring meetings as
required: leadership, process improvement, patient advisory council, etc.
 Monitors/manages/enforces process and/or changes for MSA
workflow/daily tasks.
 Reviews the clinic budget, manages equipment hand receipts, and
current inventory of supplies on hand.
 Acts as the billing official for credit card purchases within the department/clinic.
20
Non-commissioned Officer-in-Charge (NCOIC)
 Ensures Competency Assessment Files (CAF) are reflective of clinical
proficiency and are updated with the required information (e.g., certifications,
licenses, competencies, training certificates, etc.) according to Army
Regulation AR 40-68, Quality Management, and local policy.
 Collaborates with CNOIC and Group Practice Manager (GPM)/Practice
Manager (PM) regarding the scheduling and maintenance of clinic
educational in-services and training.
 Conducts timely staff counseling for supervised staff (e.g., initial and
quarterly); ensures all clinical staff receive annual supportive counseling and
appropriately documents counseling per Civilian Appraisal System (e.g., Total
Army Performance Evaluation System [TAPES]/DoD Personnel Management
and Appraisal Program [DPMAP]) guidelines, Office of Personnel
Management (OPM), and MEDCOM G1-Personnel policies/guidelines.
 Oversees and/or establishes a functional Class VIII – Medical
materials (equipment and consumables) re-supply program using
Defense Medical Logistics Standard Support (DMLSS).
 Ensures patient and clinic safety compliance in accordance with TJC
standards and local policies.
Annual Tasks:
 Prioritizes and oversees the clinic’s Capital Expense Equipment Program
(CEEP) order requests.
 Collaborates with GPM/PM to review of AMH designation standards.
 Completes timely civilian evaluations according to TAPES/DPMAP and Army
regulations.
 Reviews with service line Chief and Military Treatment Facility (MTF)
Senior Enlisted Advisor to define enlisted rating chain.
 Reviews with service line Chief and MTF Senior Enlisted Advisor to
manage current and future Tables of Distribution and Allowances (TDA) in
accordance with MEDCOM OPORD 16-02, appendix 1, Primary Care
Service Line Organization.
Additional Tasks:
 Ensures supervised civilian nursing support staff completes an Individual
Development Plan (IDP) and supervised military staff completes a support
form per established OPM/MEDCOM G1-Personnel policies/guidelines.
 Ensures supervised nursing support staff (e.g., Medical Support Assistants
[MSA], Licensed Practical Nurse [LPN]/Licensed Vocational Nurse
[LVN]/Practical Nursing Specialist [68C], Health Care Specialist [68W], and/or
Nursing Assistant [NA]) have completed a Competency Based Orientation
(CBO) according to AR 40-68, Quality Management, and local policy.
 Reviews all areas that require a performance plan and activates plan to
support the full scope of their competencies with the preceptor.
Has full oversight of completion, to include re-evaluation of established
21
Non-commissioned Officer-in-Charge (NCOIC)
performance plan, if required.
 Reviews Standard Operating Procedures (SOP) annually and as needed.
Assists with the revision of outdated policies as indicated.
AMH Specific Duties:
The following monthly or weekly reports are utilized by GPM/PM/NCOIC team in
order to facilitate daily business operations.
 Provider Productivity Application (PPA): monthly report that affords visibility of
health care provider productivity compared to average Relative Value Unit
(RVU) per PCM. Assists in the correction of RVU coding (under or over).
 Practice Management Revenue Model (PMRM) Report: monthly report
that depicts the dollar earnings and views of productivity, including
ambulatory, inpatient, & administrative components of the clinic.
 Access to Care (ATC) Report: monthly report that shows the total number
of appointments booked, the number of appointments that must meet the
ATC standards, per OPORD 16-2 Army Medical Home, Appendix 8 to
Annex R, Creating Access, 29 October 2015, and OPORD 16-36,
Optimizing Access to Primary Care, 19 February 2016.
22
Primary Care Manager (PCM)
Physician, Nurse Practitioner (NP), and Physician Assistant (PA)
Background:
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
Standardized position description (PD) and position series/grade:
– Supervisory Physician (Family Practice) GP-0602-14, PD: MC341260
– Physician (Family Practice) GP-0602-14, PD: MC342498
– Physician (Internal Medicine) GP-0602-14, PD: MC444051
– Physician (Pediatrics) GP-0602-14, PD: MC444060
– Supervisory Nurse (Advanced Practice Registered Nurse [APRN]/Family
Practice) GS-0610-13, PD: MC342589
– Nurse (APRN/Family Practice) GS-0610-13, PD: MC341641
– Nurse (APRN/Pediatrics) GS-0610-1, PD: MC438062
– Supervisory Physician Assistant GS-0603-12, PD: MC345492
– Physician Assistant GS-0603-12, PD: MC345451
Government Service (GS) PCM will complete Basic Foundations course:
Civilian Education System (CES) Basic Course, course number: 1-250-C60
(DL); Civilian Human Resources Training Application System (CHRTS) or
Army Training Requirements and Resources System (ATRRS)
PCM will complete training requirements per Appendix 3 AMH Training to
Annex R to Operations Order (OPORD) 16-02 Army Medical Home (AMH),
29 October 2015.
Daily Tasks:
 Attends medical home daily huddle. Attends or leads team huddle and
reviews schedule with core team members comprised of Licensed Practical
Nurse (LPN)/Licensed Vocational Nurse (LVN)/Practical Nursing Specialist
(68C)/ and Health Care Specialist (68W) to ensure coverage, plan for
procedures, and support of patient care (PCM should ensure they are
reviewing the Healthcare Effectiveness Data and Information Set (HEDIS®)
metrics, immunizations, medical readiness, and transitions of care
indicators).
 Collaborates with team members to optimize the team’s performance
metrics (e.g., safety/quality, access to care, medical readiness, population
health, and efficiency).
 Verifies patient with the Joint Commission (TJC) patient safety goals using the
two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Provides evidence-based care for eligible patient population.
 Documents and codes the encounter, to include the Comprehensive Care
Plan (CCP), in the Electronic Health Record (EHR). Utilizes Tri-Service
Workflow (TSWF) Alternate Input Method (AIM) forms to support
documentation.
23
Primary Care Manager (PCM)
 Reviews and completes daily telephone consults and Secure Messaging
(SM) in clinical box with team. Disseminates appropriate SM for action to
care team per local policy.
 Utilizes clinical information management/information technology enablers
(e.g., Medical Applications Process Solutions (MAPS) 2.0, SM, voice
recognition, and macro tools) to efficiently optimize the available time for
patient interaction.
 Coordinates and collaborates with team, specialists, community resources,
and Family members to develop and maintain a goal-oriented,
comprehensive, comprehensible, and integrated plan of care.
 Reviews diagnostic studies (complete and incomplete) and provides
guidance to team for follow-up care.
 Teaches medical, PA, and NP students and residents on evidence-based
care.
Weekly Tasks:
 Reviews schedule for current week and the following week in order to
screen for patients that do not require a face-to-face or require an earlier
appointment.
 Reviews diagnostic studies (complete and incomplete) and provides
guidance to team for follow-up care.
 Participates in grand rounds educational opportunities.
 Participates in call/night shifts, covering inpatient, urgent care and
Obstetrics services as required by Military Treatment Facility (MTF) and
local policy.
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
Monthly Tasks:
 Reviews monthly report for outstanding diagnostic studies (incomplete)
and provides guidance to team for follow-up care.
 Reviews Chronic Pain, High Utilizer, and Polypharmacy (CHUP), Military
Health System Population Health Portal (CarePoint 4G® MHSPHP
application), Primary Care Empanelment (PCE) tool data with the team to
ensure appropriate patients are scheduled for care management and care
coordination.
 Participates in departmental peer-review per local policy.
 Participates in departmental morbidity and mortality reviews per local policy.
 Attends clinic meetings to ensure knowledge of updates/changes and
advocates for team and patients.
24
Primary Care Manager (PCM)
 Completes monthly, quarterly, and yearly mandatory training requirements.
 Ensures currency of all licensure standards to include Basic Life Support
(BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life
Support (PALS), Continuing Medical Education (CME), and Continuing
Education Units (CEU).
 Provides feedback to team members on their progress and goals.
 Completes timely performance evaluations supervised staff to include
medical, PA, and NP students and rotating residents.
25
Nurse Case Manager (NCM)
NCM
Background:

Standardized position description (PD) Nurse (Clinical/Case/Mgt) (Nurse
Case Manager).
– Position series/grade: GS-0610-12, PD: MC342514
 Military Rank: 1LT/CPT/MAJ (First Lieutenant/Captain/Major)
 NCM mandatory training:
– US Army Medical Command (AMEDD) Nurse Case Management Course
Army Training Requirements and Resources System (ATRRS) 6F-F3
– Nurse Case Manager Military Health System (MHS) Learn and Milliman
Care Guidelines, online care management courses
 NCM will complete all mandatory training per Appendix 3, AMH Training to
Annex R, to Operations Order (OPORD) 16-02 Army Medical Home (AMH),
29 October 2015.
 References: OPORD 13-25, Nursing Case Management Guidance, 2
January 2013 and OPORD 16-20, Army Medical Home (AMH), 29 October
2015
Daily Tasks:
 Attends medical home daily huddle. Interfaces with the AMH team members
to synchronize healthcare management for identified patients along the
healthcare continuum.
 Reviews team schedule for Chronic Pain, High Utilizer, and Polypharmacy
(CHUP) patients, patients who may require NCM care, or patients already
under NCM care who are being seen by their Primary Care Manager (PCM) or
the team for the day.
 Verifies patient with the Joint Commission (TJC) patient safety goals using
the two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Coordinates with pharmacist regarding patients on schedule that may require
or are already under NCM care for the day. Reviews CHUP list with
pharmacist.
 Reviews discharged Emergency Department (ED) and in-patients that are
assigned to the team for transition of care, working with Team Registered
Nurses (RN) to ensure patients assigned to the team receive appropriate
follow-up care per MEDCOM policy memo 16-063, Transitions of Care
Process for Preventing Readmission, 11 August 2016.
 Creates Comprehensive Care Plans (CCP) for acuity 3-4 patients and
discusses plan with PCM for acceptance or revisions. Reviews the CCPs with
the PCM and inter-disciplinary team members in a collaborative fashion to
ensure effective case management/care coordination is met within specified
timeframes.
26
Nurse Case Manager (NCM)
 Describes NCM roles/responsibilities to the patient and Family members to
establish an individualized care plan. Obtains letter of agreement for
services and authorization for release of information before requesting
information from external providers (e.g., Managed Care Support Contractor
(MCSC) care in the civilian network). Promotes transition of care, care
coordination, case management, and continuity of care within the direct
care system (e.g., Military Treatment Facility [MTF] and civilian network.
 Performs detailed assessment of assigned cases (varied patient
population: infant, child, and adult) during interactions with patient and
family.
 Facilitates utilization management for level of care status and collaboration
with health care team.
 Identifies patient and Family needs to include: education/learning needs,
financial needs, potential resources and support systems, advance
directives, and any specialty referrals as appropriate.
 Coordinates with external health care (e.g., network health system, social
work, Tri-care/Healthnet, Department of Veterans Affairs/Department of
Defense (VA/DoD) and other MTFs.
 May serve as a Lead Coordinator for Active Duty (AD) transfers between
regions and VA/DoD; to include Warrior Transition Unit [WTU]).
 Communicates actively with patients in Secure Messaging (SM) clinical
box. Ensures account is registered as a Provider account for secure
messaging to support patients in NCM care.
 Reviews daily to address patient communication needs and
communicates updates to the PCM utilizing colleague to colleague
secure messaging.
 Documents all workload and codes all services in the Electronic Health Record
(EHR) using the Tri-Service Workflow (TSWF) Case Management (CM)
Alternate Input Method (AIM) forms and Department of Defense (DoD)
established provider specialty codes, Health Insurance Portability and
Accountability Act (HIPAA) taxonomy codes, Medical Expense and
Performance Reporting System (MEPRS) codes, diagnosis codes, and
Healthcare Common Procedure Coding System codes.
 Documents in acuity tracker daily workload of case managed patients.
 Documents the NCM care in the EHR utilizing predominantly the TSWF CM
AIM forms, and/or telephone consult (T-con) per local policy.
Weekly Tasks:




Reviews CHUP list and collaborates with clinical team.
Reviews and updates acuity tracker for workload accountability.
Seeks out opportunities to engage clinical teams to inquire about NCM patients.
Facilitates follow-up with NCM patients, patient discharges (ED or hospital),
and in-patient admissions.
27
Nurse Case Manager (NCM)
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
Monthly Tasks:
 Participates/attends monthly Extension for Community Healthcare
Outcomes (ECHO) training at local MTF.
 Sends completed acuity tracker to Clinical Nurse Officer-in-Charge (CNOIC)
and Regional Lead NCM.
28
Team Registered Nurse (RN)
RN
Background:
 Standardized position description (PD) Nurse (Clinical/Ambulatory)
(Team Nurse).
– Position series/grade: GS-0610-11, PD: MC344943
 Military Rank: 1LT/CPT (First Lieutenant/Captain)
 RN will complete all mandatory training per Appendix 3, Army Medical Home
(AMH) Training to Annex R, to Operations Order (OPORD) 16-02 Army
Medical Home (AMH), 29 October 2015.
Daily Tasks:
 Pre-Visit Planning/Prescreening:
– Reviews Electronic Health Record (EHR) and Military Health
System Population Health Portal (CarePoint 4G® MHSPHP
application), 24-72 hours prior to scheduled appointment.
– Reviews Patient Centered Medical Home (PCMH) Team Huddle Tool
for clinic patient appointments 24-72 hours to identify Primary Care
Manager (PCM) continuity and review appointments to adjust care, if
appropriate, to be supported by other venues (e.g., phone visit, nurse
visit, pharmacy visit, Secure Messaging [SM], or virtual health visit).
– Retrieves documentation for visit (e.g., Emergency Department [ED]
discharge summary, sleep study results, labs, radiology results,
inpatient discharge summary, etc.).
– Reviews and re-aligns patients with assigned PCM if possible or at a
minimum maintain team continuity (RN and Licensed Practical Nurse
[LPN]/Licensed Vocational Nurse [LVN]/Practical Nursing Specialist
[68C] Health Care Specialist [68W] collaborative effort).
– Reviews with Population Health Registered Nurse (PH-RN), LPN/LVN
and Medic: cross-reference Healthcare Effectiveness Data and
Information Set (HEDIS®)/Wellness list CarePoint 4G® MHSPHP for
patients that require testing or appointments for the delinquent HEDIS®
measures (promotes preventative health measures). Prepares with the
PH-RN the HEDIS® letter to give patient at the appointment and input all
orders to support care.
– Reviews with LPN/LVN/68C/68W labs/radiology, and consults for
patient follow-up, either face-to-face appointments or communication via
secure messaging (SM).
– Reviews medical readiness databases (Medical Readiness
Assessment Tool [MRAT], Medical Protection System [MEDPROS],
etc.) and identifies outstanding requirements.
29
Team Registered Nurse (RN)
 Collaborates with team to post daily assignment board:
– Assigns team members with their dedicated teams at least 80% of
the time.
– Notes any appointments that the staff members may need to attend,
call outs, and leaves.
– Identifies all procedures or patient appointments that may require
additional consideration (e.g., female chaperone, interpreter,
additional staff support, etc.).
– Reviews PCM continuity and delinquent encounters to report in huddle.
– Assigns staff to complete daily checks e.g., crash cart, Immunization
room coverage, CODE Team/Rapid Response roles/responsibilities,
etc.
 Prepares and conducts the team huddle each morning using an
assignment board.
 Verifies patient with the Joint Commission (TJC) patient safety goals using the
two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Triages acute walk-in and telephone consult patients to assess need for
same day appointment or future appointment. Discusses needs with PCM
or team provider to have patient seen, if necessary, in clinic or transfer to
Urgent Care Clinic (UCC)/ED.
 Addresses all high priority/red telephone consults (T-cons) within 1 hour.
 Conducts telephonic follow-up with patients triaged by the Defense Health
Agency (DHA) contracted Nurse Advice Line (NAL) service in the past 72
hours.
 Provides complex patient education (when LPN/LVN/68W refers patient to
RN), for team provider’s patients (e.g., asthma training, diabetes training,
medication use [inhaler, Lovenox®, etc.]).
 Coordinates future patient care: initiates a priority review of the team
template with the intent to bridge “access to care” goals linking
LPN/LVN/68W tasks to patient needs (e.g., medication refills, specialty care
consult/referral assistance, and new provider information).
 Monitors each individual core team PCM (every clinic block) to ensure the
Team RN supports any patient care needs during the scheduled day.
 Monitors clinic: hourly walk around/checks to maintain proficient patient flow
and thru-put.
 Directs Patient Care as needed to include, but not limited to medication
delivery, procedures, Intravenous (IV) initiation, nebulizer treatments, etc.
 Collaborates with team to ensure compliance with TJC and AMH
designation standards.
 Documents patient care in the Electronic Health Record (EHR) utilizing
predominantly the Tri-Service Workflow (TSWF) form Alternate Input
Method (AIM) forms, and/or telephone consult (T-con) per local policy.
30
Team Registered Nurse (RN)
Weekly Tasks:
 Ensures self and team Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report time
bi-weekly.
 Reviews “Patient Pick-Up Folder” (or local term), ensures patients have
received notification by either phone or secure messaging to pick-up
requested documentation.
Monthly Tasks:
 Monitors compliance of the clinic Point-of-Care Testing (POCT) log
book(s) according to local Standard Operating Procedures (SOPs).
 Reviews assigned teams peer review monthly records. Discusses review
with nursing staff on team for opportunities to improve in professional
performance and nursing documentation.
 Engages and collaborates with team on Patient Caring Touch System (PCTS).
Additional Tasks:
 Participates and/or coordinates clinic Skill Builder activities/in-services as a
part of PCTS. Each Fiscal Year (FY) clinical staff is surveyed to establish
training requests and requirements for the training calendar (e.g., annual
training needs assessment).
 Monitors or functions as the POCT representative for clinic, if applicable.
Monitoring includes log book(s) and annual training completed by all
applicable staff. (May delegate training record, team logbook management
and representative to LPN/LVN/68C/68W/Medical Support Assistant [MSA]
on a team).
 Participates and/or coordinates as clinic Mock Code Coordinator with Noncommissioned Officer-in-Charge (NCOIC). Participates and/or coordinates
annual mock codes (Adult/Adolescent/Pediatric) per Military Treatment
Facility (MTF) and clinic SOP. Ensures all staff is trained and aware of
their roles/responsibilities regarding activation of the rapid response team
and/or contacting 911 in emergent situations.
 Participates and/or assigned as Performance Improvement (PI) representative.
31
Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN)/Practical
Nursing Specialist (68C)
LPN/LVN/68C
Background:



Standardized position description (PD) Practical Nurse.
– Position series/grade: GS-0620-05, PD: MC345872.
Military Rank: E3-E5 (Private First Class [PFC]/Sergeant [SGT])
LPN/LVN/68C will complete all mandatory training per Appendix 3, Army
Medical Home (AMH) Training to Annex R to Operations Order (OPORD)
16-02 Army Medical Home (AMH), 29 October 2015.
Daily Tasks:
 Prepares assigned rooms for clinic schedule (e.g., computer ready, room
stocked for the day’s clinic, etc.).
 Attends clinic huddle for overview of day and individual team huddle to
review scheduled patients with Primary Care Manager (PCM) to coordinate
delivery of care.
 Checks:
– Crash cart if applicable (Community Based Medical Home (CBMH)
and Soldier Centered Medical Home (SCMH) may have Automated
External Defibrillator [AED] and contact 911). Validates knowledge of
Rapid response team (RRT) identification and supporting process.
– Immunization refrigerator/freezer temperature checks per the clinic
standard operating procedure (SOP) and Military Treatment Facility
(MTF) SOPs.
 Prepares procedure rooms by ensuring required equipment, consent forms
etc. are available for the days schedule. Cleans used equipment,
instruments, and transports to Clinical Management System (CMS) per the
clinic SOP and MTF guidance (Infection Control).
 Performs Point-of-Care testing (POCT) checks if applicable (e.g., glucometer,
human chorionic gonadotropin [hCG] urine). Ensures logged entry per the
local SOP, POCT, and MTF guidance.
 Verifies patient with the Joint Commission (TJC) patient safety goals using
the two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Reviews medical readiness databases (Medical Readiness Assessment
Tool [MRAT], Medical Protection System [MEDPROS], etc.).
32
Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN)/Practical
Nursing Specialist (68C)
 Screens patients using the Tri-Service Workflow (TSWF) Alternate Input
Method (AIM) forms and places patient in the PCM designated exam room for
evaluation.
 Assesses patients’ vital signs and conducts initial pre-screening according to
the Electronic Health Record (EHR).
 Documents patient care in the EHR utilizing predominantly the TSWF AIM
forms, and/or telephone consult (T-con) per local policy.
 Completes physical assessment of chief complaint(s) for the PCM during
the triage process.
 Provides nursing support and patient care as needed to include, medication
administration, patient monitoring, and clinical assistance with procedures
(e.g., assists with general procedures, administers
medication/immunizations, treatments, toenail removal, suture removal,
intravenous [IVs], nebulized treatments, etc.) under the direction of the
PCM.
 Collects and prepares laboratory specimens according to local
Standard Operating Procedures (SOPs).
 Assists with the scheduling of follow-up appointment(s) if applicable,
provides direction sheet for additional medical care/diagnostic testing: lab,
x-ray, referral management, pharmacy, Nurse Case Manager (NCM), etc.
 Provides health coaching and educational material as directed by
PCM/Team RN.
 Educates patient on use of TRICARE Online (TOL), Secure Messaging
(SM), and Nurse Advice Line (NAL) as access to care (ATC) tools.
 Reviews SM throughout the day and address appropriately with PCM or
Team Registered Nurse (RN).
 Utilizes EHR to book, reschedule, check-in or cancel patient appointments.
 Reviews patient demographics to update and ensure eligibility for care.
 Restocks and cleans/disinfects assigned rooms according to clinic SOP’s
and infection control guidelines.
 Completes end-of-day tasks:
– Restocks and cleans assigned rooms to prepare for the next
day schedule.
– Ensures all lab orders have been completed, dispensed to the
proper ancillary service, and annotated within the patients EHR.
– Reviews, at a minimum, next day schedule to include copy forward,
the Healthcare Effectiveness Data and Information Set (HEDIS®)
metrics, procedure preparation, wellness screening paperwork, etc.
– Reviews patient appointments, 24-78 hours prior to scheduled
appointment and identifies opportunities to provide patient and
PCM continuity or access to care via other options (e.g., nurse
visit, SM, pharmacist, NCM, etc.).
33
Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN)/Practical
Nursing Specialist (68C)
Weekly Tasks:
 Collaborates with PCM to review the following:
– New patients empaneled to team:
 Reviews medical records.
 Contacts, arranges for follow-up as needed.
– Reviews outstanding laboratory, radiology, and consult/referral
request(s) for empanelled patients.
 Reviews medication dispensing equipment (assigned staff):
– Reviews for expired medications/immunizations.
– Reviews all immunization vaccines located in refrigerator and freezer
and validates appropriate storage temperature.
– Reviews for count verification/supply needs.
– Restocks/reorders team rooms supplies.
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
Monthly Tasks:
 Manages and reports clinic data/metrics (assigned staff).
– Papanicolaou Test (PAP) logbook – reports.
– Procedure book – number of procedures, record review for consent etc.
– Peer review – reviews minimum of three records and provides report
to Team RN and Clinical Nurse Officer-in Charge (CNOIC).
Additional Tasks:
 Participates and/or functions as the clinic Patient Caring Touch System
(PCTS) representative and/or attends meetings.
 Participates and/or functions as the Infection Control (IC) clinic representative
to include high-level disinfection (HLD) (if HLD applicable to clinic) per local
SOPs.
 Participates in Unit Practice Council (UPC) for the clinic –
membership determined by peers through the election process.
 Participates in presentations for the Skill Builder lectures as a lecturer
according to local SOPs.
 Participates and/or coordinates new staff orientation program with
CNOIC/Non-commissioned Officer-in-Charge (NCOIC) direction as Lead
LPN/LVN/68C.
34
Health Care Specialist (68W)
68W
Background:



Military Rank: E3-E5 (Private First Class [PFC]/Sergeant [SGT])
68W will complete all mandatory training per Appendix 3, Army Medical
Home (AMH) Training to Annex R, to Operations Order (OPORD) 16-02
Army Medical Home (AMH), 29 October 2015.
Medical Operations Data Systems (MODS) access and proficiency.
Daily Tasks:
 Essential tasks and duties are interchangeable with the Licensed Practical
Nurse (LPN)/Licensed Vocational Nurse (LVN)/Practical Nursing Specialist
(68C) role within 68W scope of practice and competency training/validation.
 Prepares assigned rooms for clinic schedule (e.g., computer ready, room
stocked for the days clinic, etc.).
 Checks: Crash cart if applicable (Community Based Medical Home (CBMH)
and Soldier Centered Medical Home (SCMH) may have Automated External
Defibrillator [AED] and contact 911). Validates knowledge of Rapid response
team (RRT) identification and supporting process.
 Attends clinic huddle for overview of day and individual team to review
scheduled patients with Primary Care Manager (PCM) and coordinates
delivery of care.
 Reviews medical readiness databases (Medical Readiness Assessment
Tool [MRAT], Medical Protection System [MEDPROS], etc.).
 Verifies patient with the Joint Commission (TJC) patient safety goals using the
two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Screens patients using the Tri-Service Workflow (TSWF) Alternate Input
Method (AIM) forms and places in PCM exam room for evaluation. Assesses
patient’s vitals and conducts initial pre-screening assessment according to
core TSWF AIM form.
 Completes physical assessment of chief complaint(s) for the PCM during
the triage process.
 Provides nursing support (e.g., patient examination, treatment, and
assistance with procedures).
 Provides health coaching and educational material as directed by
PCM/Team RN.
 Coordinates patient care across multiple settings (e.g., specialty, behavioral
health, surgical services, etc.); schedules follow-up appointment if applicable,
provides direction sheet for additional medical care/diagnostic testing: lab, xray, referral management, pharmacy, Nurse Case Manager (NCM), etc.
35
Health Care Specialist (68W)
 Educates patient on use of TRICARE Online (TOL), Secure Messaging
(SM), and Nurse Advice Line (NAL) as access to care (ATC) tools.
 Reviews SM throughout the day and addresses appropriately with PCM or
Team Registered Nurse (RN).
 Performs general office duties such as answering telephones, taking
dictation, and completing clinical and administrative forms.
 Utilizes protocols and Standing Orders as directed.
 Documents patient care in the Electronic Health Record (EHR) utilizing
predominantly the TSWF AIM forms, and/or telephone consult (T-con) per
local policy.
 Performs patient care as needed to include, patient monitoring and clinical
assistance with procedures (e.g., Intravenous (IVs), nebulized treatments,
toenail removal, suture removal, etc.) under the direction of the PCM.
 Performs basic blood draws, validated by competency assessment and
local SOP.
 Collects and prepares laboratory specimens according to local SOP.
 Performs Point-of-Care testing (POCT) checks if applicable (e.g.,
glucometer, human chorionic gonadotropin [hCG] urine). Ensures logged
entry per the local standard operating procedures (SOP), POCT, and MTF
guidance.
 Utilizes the EHR to book, reschedule, check-in or cancel patient
appointments. Reviews patient demographics to update and ensure patient
is eligible for care.
 Restocks and cleans assigned rooms according to clinic SOP and
infection control guidelines.
 Prepares procedure room(s) by ensuring required equipment, consent forms
etc. are available for the day’s schedule.
 Cleans and disinfects used procedure equipment/instruments and transports
to Central Material Supply (CMS)/Sterile Processing and Distribution (SPD)
per the clinic SOP and MTF guidance (Infection Control).
 Completes end-of-day tasks:
– Restocks and cleans assigned rooms to prepare for next day schedule.
– Reviews, at a minimum, next day schedule to include copy forward,
HEDIS® metrics, procedure preparation, wellness screening
paperwork, etc.
– Reviews patient appointments, 24-78 hours prior to scheduled
appointment and identifies opportunities to provide patient and
PCM continuity or access to care via other options (e.g., nurse
visit, SM, pharmacist, nurse case manager [NCM]).
– Assists in the completion of the end-of-day summary within EHR.
– Ensures that all lab orders have been completed, dispensed to the
proper ancillary service, and annotated in the patients Electronic Health
Record (EHR).
36
Health Care Specialist (68W)
Weekly Tasks:
 Collaborates with PCM to review the following:
− New patients empaneled to team
 Reviews medical records.
 Contacts, arranges for follow up care as necessary.
 Reviews outstanding laboratory, radiology, and referral/consult(s) for
empanelled patients. Restocks/reorders team rooms supplies.
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
Additional Tasks:
 Participates and/or functions as the clinic Patient Caring Touch System
(PCTS) representative and/or attends meetings.
 Participates and/or functions as the Infection Control clinic representative to
include high-level disinfection (HLD) (if HLD applicable to clinic) per local
SOPs.
 Participates in Unit Practice Council (UPC) for clinic – membership
determined by peers through election process.
 Participates in presentations for Skill Builder/continuing education lectures as
a lecturer according to local SOPs.
Annual Tasks:
 Assesses and completes Clinic Competency checklist defined by MTF,
according to skillset.
 Maintains Military Occupational Specialty (MOS)-Qualifications (Q’s):
qualifications for maintaining a current National Registry of Emergency
Medical Technicians (NREMT®) license and current Basic Life Support
(BLS) certification.
 Maintains Medical Simulation Training Centers (MSTC) Table Level (LVLs) 18 competencies. Skills may be instructed and validated in the AMH based
on the defined scope of practice for the 68W per MEDCOM Regulation 4050, Career Management Field (CMF) 68 Clinical Baseline Competencies for
Enlisted Medical Personnel Performing Direct Patient Care at the Military
Treatment Facility, dated 10 November 2016, defines the skill sets.
37
Medical Support Assistant (MSA)
MSA
Background:


Standardized position description (PD) Medical Support Assistant
− Position series/grade: GS-0679-05, PD: MC424044
MSA will complete all mandatory training per Appendix 3 Army Medical
Home (AMH) Training to Annex R to Operations Order (OPORD) 16-02
Army Medical Home (AMH), 29 October 2015.
Daily Tasks:
 Customer service:
– Promotes and adheres to the service and communication standards.
– Employs customer service skills defined in B.A.S.I.C.S.
communications (Break barriers, Anticipate and Accommodate,
Seek Solutions, Initiate and Interact, Communicate, Service) and
service recovery standards.
– Informs patients of delays and wait times.
– Displays name and position at front desk by wearing badge
and/or placing nameplate on reception desk.
– Ensures that patients are not asked to call back if their
concern cannot be resolved immediately.
– Ensures that telephone callers are not placed on hold without
first determining their wait preference.
 Visit preparation:
– Facilitates the completion of all required pre-visit forms
and questionnaires, both hard copy and digital.
 Reception processing:
– Verifies patient with a valid military identification card (ID) for age
10 and above, and by the Joint Commission (TJC) patient safety
goals using the two approved patient identifiers: Full name and
date of birth (DOB), as per Patient Administration Department
(PAD) and the Military Treatment Facility (MTF). Appropriately
addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
– Validates appointment time and Primary Care Manager (PCM),
complete “reception” process by checking the patient in, and
verifies all patient demographic data to ensure up-to-date contact
information.
– Completes all Electronic Health Record (EHR) based reception
steps in compliance with current business rules.
– Provides patient with medication verification form and any other
clinic required forms, instruct patient to either return completed
paperwork to the front desk staff or provide forms to support staff.
38
Medical Support Assistant (MSA)






– Reviews medical readiness databases (Medical Readiness
Assessment Tool [MRAT], Medical Protection System [MEDPROS],
etc.).
Transition management:
– Facilitates a set of actions designed to ensure the coordination and
continuity of health care as patients transfer between different
locations or different levels of care within the same location.
– Assists with the transfer of information to and from specialty
providers and network healthcare organizations.
Information services:
– Assists patients with questions on clinic operations, access
options, scope of services, and sources of care by answering
questions and providing written material and guidance on webbased resources.
– Welcomes and orients new patients.
– Reinforces the importance of the PCM and patient continuity.
– Reviews Secure Messaging (SM) from the administrative in-box as
assigned; forwards messages and creates telephone consult (T-con)
messages in the EHR to appropriate team staff (e.g., PCM,
Registered Nurse (RN), Nurse Case Manager (NCM), Pharmacist,
Internal Behavioral Health Consultant (IBHC) or Behavior Health
Care Facilitator (BHCF).
– Assists with appointments scheduling for walk-in patients and followup appointments for patients seen in the clinic that day. Supports
clinic Standard Operating Procedures (SOPs).
– Schedules patients for procedure clinic, Osteopathic Manipulative
Treatment (OMT)/Sports Medicine or other specialty care within the
clinic, if applicable.
Completes end-of-day report.
Care coordination:
– Facilitates transfer of information to and from outside sources of care.
– Reviews schedules to identify opportunities to improve
PCM continuity in preparation for the daily team huddle.
– Assists with the transition to self-management process in
coordination with clinical staff through health coaching.
Access support services:
– Books clinician-directed follow-up appointments and
provides appointment reminder cards prior to a patient
leaving the clinic.
– Assists with SM and TRICARE Online (TOL) registration.
Communications management:
– Screens incoming telephone calls and responds/dispositions
to appropriate staff through telephone consult (T-con).
– Notifies patients of schedule changes and other administrative matters.
– Facilitates communication between the patient and the clinical team.
39
Medical Support Assistant (MSA)
 Administrative and other duties:
– Executes other duties as assigned.
Weekly Tasks:
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
40
Population Health-Registered Nurse (PH-RN)
PH-RN
Background:


Standardized position description (PD) Population Health Nurse
− Position series/grade: GS-0610-11, PD: MC399232
PH-RN nurse will complete all mandatory training per Appendix 3 Army
Medical Home (AMH) Training to Annex R to Operations Order (OPORD) 1602 Army Medical Home (AMH), 29 October 2015.
PH-RN roles and functions:
 Supports AMH operations.
 Demonstrates competency in Military Health System Population Health
Portal (CarePoint 4G® MHSPHP application), Microsoft Excel, Microsoft
PowerPoint, and PCMH dashboard.
 Demonstrates understanding of the Health Effectiveness Data and
Information Set (HEDIS®) methodologies, benchmarks, and Department of
Veterans’ Affairs/Department of Defense (VA/DoD) Clinical Practice
Guidelines (CPG) in support of metrics.
 Serves as clinic CPG and HEDIS® metric champion.
 Identifies Performance Improvement (PI) recommendations and
monitors outcomes.
 Serves as health promotion and disease prevention/management champion.
 Coordinates programs such as diabetes education, cancer screening
awareness, and participates in health promotion events throughout the facility.
 Educates staff and providers on CPG updates and HEDIS® metric changes.
Daily Tasks:
 Attends clinic huddle for overview of day and individual team huddle to
review scheduled patients with Primary Care Manager (PCM) and
coordinates delivery of care.
 Reviews pending appointments for next business day and relays information
to care team regarding any required preventative health screenings.
 Identifies acute 24 hr. appointments from the CarePoint 4G® MHSPHP or
Patient Centered Medical Home (PCMH) Team Huddle Tool to review for
required preventive health screenings.
 Orders diagnostic tests (e.g., labs, mammograms, etc.) and
initiates consults/referrals as indicated per local policies.
 Verifies patient with the Joint Commission (TJC) patient safety
goals using the two approved patient identifiers: Full name and
date of birth (DOB). Appropriately addresses patient by title/rank
(for direct patient care: Face-to-face or non-face-to-face).
41
Population Health-Registered Nurse (PH-RN)
 Calls patients from individual action lists to book appointments, order labs,
and update patient demographics.
 Facilitates transitions of care: If patient’s exams/assessments are
completed in network, sends a DD Form 2870, Authorization for
Disclosure for Medical or Dental Information, to the network provider for
the medical release of information form to capture the external results.
 Scans received results into Health Artifact and Image Management Solution
(HAIMS) and completes the Tri-Service Workflow (TSWF) Alternate Input
Method (AIM) forms to capture data in the CarePoint 4G® MHSPHP.
Weekly Tasks:
 Retrieves clinic appointment lists from the CarePoint 4G® MHSPHP or
PCMH Team Huddle Tool for the upcoming week to scrub for needed
labs/mammograms/procedures.
 Coordinates with clinic to organize specific day’s appointment slots for cervical
screenings and/or mammograms for identified patients requiring these
diagnostic studies.
 Communicates with patients via secure messaging (SM) or postal mail
regarding due/overdue preventative screenings.
 Reviews screenings not completed/ordered at appointments and
contacts patients as appropriate.
 Provides Core Care Team with listing of empaneled patients to contact
that require preventative screenings.
 Maintains close coordination between clinic and department leadership.
 Organizes, collaborates with integrated specialist (e.g., Pharmacist, Nurse
Case Manager [NCM]), and assists/conducts educational classes for the
clinic (e.g., Asthma, Diabetes, etc.).
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
Monthly Tasks:
 Analyzes monthly HEDIS® data to evaluate the status of metrics measured
for trending patterns (up/down) and opportunities to implement
individualized interventions to facilitate a positive effect on outcomes
measures.
 Identifies empanelled patient populations that require additional
care management using CarePoint 4G® MHSPHP.
42
Population Health-Registered Nurse (PH-RN)
 Identifies educational material for patient education (e.g., preventive health
measures [colonoscopy, breast health, women’s health, etc.] and chronic
disease management [hypertension, high cholesterol, etc.]) to support the
enrolled population. Obtains/orders appropriate educational material from
approved resources for the AMH.
 Collaborates with the multidisciplinary team to improve quality of care provided.
 Reviews specific action lists to identify patients that need appointments.
 Attends CarePoint 4G® MHSPHP webinars to maintain current
knowledge regarding patient care information.
 Reviews CarePoint 4G® MHSPHP registry exclusions to determine if
still applicable or if expiring.
 Creates population management report cards for clinic level, team level,
and provider level based upon CarePoint 4G® MHSPHP registry data.
 Creates and/or briefs HEDIS® monthly performance reports to Medical
Treatment Facility (MTF) Commander and Medical Staff Executive Committee.
 Reviews compliance with implemented Clinical Practice Guidelines (CPG).
 Attends facility and department level meetings regarding Population Health.
As Needed:
 Coordinates the implementation and adherence to CPGs.
 Educates team members regarding financial implications of patient
care decisions.
 Mentors/coaches staff regarding importance of population health and CPGs.
43
Clinical Pharmacist
Clinical Pharmacist
Background:
 Standardized position description (PD) Clinical Pharmacist
– Position series/grade: GS-0660-12, PD: MC391418
 Military Rank: CPT/MAJ/LTC (Captain/Major/Lieutenant Colonel)
 Mandatory Training:
– PCMH-core training (ATRRS 081SDL14-MEDCOM-0001)
– Extension for Community Health Outcomes (ECHO) monthly training
 Clinical Pharmacists will complete all mandatory training per Appendix 3 Army
Medical Home (AMH) Training to Annex R to Operations Order (OPORD) 1602 Army Medical Home (AMH), 29 October 2015.
Clinical Pharmacist Roles and Functions:
 Direct Patient Care
– Provides ambulatory care services
o Participates in services specializing in disease state and
therapeutic management (e.g., tobacco cessation,
anticoagulation, hypertension, hyperlipidemia, diabetes, asthma,
pain management, polypharmacy, infectious disease, and overthe-counter medication selection).
o Collaborates with medical home staff.
– Provides individualized Comprehensive Medication Therapy
Management (CMTM)
o Evaluates medication therapy for appropriateness, effectiveness,
safety, and adherence through assessment of health and
medication history.
o Perform limited physical assessments to evaluate medication effects.
o Orders and interprets laboratory tests.
o Prescribes in accordance with evidence-based clinical
practice guidelines.
o Educates patients, families, and/or caregivers on proper
use of medications and/or devices.
o Documents and communicates information to the healthcare team.
o Assesses/facilitates medication and treatment plan adherence,
goal setting, and self-management.
o Performs medication reconciliation.
 Reviews patient’s complete medication regimen prior to a
scheduled appointment or at any point during the care of the
patient with the intent to identify safety or clinical issues, such
as those related to poly-pharmacy, drug-drug interactions, or
barriers to adherence.
44
Clinical Pharmacist





– Provides health and wellness services.
o Participates in immunization screening, ordering, and administration.
o Provides educational classes (e.g., asthma, diabetes,
hyperlipidemia, smoking cessation, and weight loss).
Indirect Patient Care
– Monitors patients enrolled in enhanced supervision or safety
programs such as Sole Provider or Prescription Restriction (e.g.,
Military Treatment Facility [MTF] Restriction).
– Proactively identifies new and established patients with medication
related risks by applying population health tools and data.
Improve quality of care delivered within the organization.
– Assists in the development of population health initiatives and
processes to improve patient safety.
– Collaborates with team members to optimize Medical Command
(MEDCOM) performance metrics for clinical pharmacy and the
Army Medical Home (AMH) team’s performance metrics (e.g.,
polypharmacy, charting completion, peer review standards,
performance improvement programs).
– Participates in Process Improvement (PI) initiatives.
– Contributes to organization committees.
Medical Staff Teaching
– Delivers education and training to staff
o Addresses medication therapy management and other
medication related topics of interest.
Student/Residency Teaching
– Provides teaching/training to pharmacy, nurse practitioner,
physician assistant, and/or medical students as assigned.
Performs medication distribution functions to include filling, checking,
counseling, and dispensing of outpatient prescriptions if required.
Daily Tasks:
 Attends daily huddles for overview of the day.
 Attends or leads team huddle and reviews schedule with core team.
 Actively screens enrolled patients for polypharmacy risks, medication
adherence, and appropriate monitoring, etc., through Tri-Service Workflow
(TSWF) Alternate Input Method (AIM) forms, face-to-face encounters,
telephone interviews; if available, Virtual Health Video Teleconference (VTC),
emergency room visits and hospital discharges.
 Verifies patient with the Joint Commission (TJC) patient safety goals using the
two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Provides evidence-based care to referred patients.
 Documents the encounter, to include a list of current medications along
with a medication action plan, in the Electronic Health Record (EHR).
45
Clinical Pharmacist
 Utilizes TSWF AIM forms to support documentation and applies appropriate
diagnosis and procedural codes and disposition documentation to visits.
 Reviews daily telephone consults (T-con) and secure messages (SM).
 Utilizes clinical information management/information technology enablers
(e.g., Medical Applications and Solutions (MAPS 2.0), SM, voice
recognition, and macro tools) to efficiently optimize the available time for
patient interaction.
 Coordinates and collaborates with team, specialists, and Family members
to develop and maintain a goal-oriented, comprehensive care plan.
 Reviews and interprets laboratory reports to determine medication
therapy course of actions.
 Educates team, pharmacy, nurse practitioner, physician assistant, and
medical students and residents on evidence-based medical care.
Weekly Tasks:
 Reviews weekly clinic schedule (current and future) with AMH team to
facilitate alignment of patients that do not require face-to-face visits or
require earlier appointments.
 Reviews and interprets laboratory reports to determine if the patient
requires follow-up care or a referral to the team.
 Participates in educational opportunities.
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/Functional Cost Codes (FCC) to report
time.
 Liaison between AMH clinic and pharmacy department.
Monthly Tasks:
 Downloads/analyzes all Polypharmacy Medication Analysis & Report Tool
(Poly-MART) reports.
 Participates in departmental peer-review.
 Participates in morbidity and mortality reviews.
 Participates in pharmacy meetings to ensure being informed of changes and
advocates for team and patients (e.g. Pharmacy and Therapeutics (P&T),
Sole Provider and Medication Use Evaluation (MUE) committees, pharmacy
working groups, etc.).
 Completes monthly, quarterly, and yearly mandatory training requirements.
46
Clinical Pharmacist
 Ensures currency of all licensure standards to include Basic Life Support
(BLS), Continuing Medical Education (CME), and Continuing Education Units
(CEU).
 Provides feedback to team members and pharmacy department on progress
and goals.
 Completes timely performance evaluations for those that they precept to
include all students and residents.
 Communicates scheduled absences (e.g., sick and annual leave) to team.
47
Clinical Pharmacy Technician/Pharmacy Specialist (68Q) (CBMH)
Clinical Pharmacy Technician/68Q
Background:
 Standardized position description (PD) Clinical Pharmacy Technician
– Pharmacy Technician (Community Based Medical Home [CBMH] only)
Position series/grade: GS-0661-06, PD: MC345574
– Future revision pending
 Military Rank: SPC (Specialist) (CBMH only)
 Mandatory Training:
– Extension for Community Health Outcomes (ECHO) monthly training
 Clinical Pharmacy Technician will complete all mandatory training per
Appendix 3 Army Medical Home (AMH) Training to Annex R to Operations
Order (OPORD) 16-02 Army Medical Home (AMH), 29 October 2015.
Clinical Pharmacist Technician Roles and Functions:
 Direct Patient Care:
– Contacts patients via phone (reviews medical record, assesses risk
and need for clinical pharmacy visit, and documents in the Electronic
Health Record [EHR]).
– Collaborates with Primary Care Provider (PCM) or Clinical Pharmacist
for further actions.
 Indirect Patient Care:
– Assists the Clinical Pharmacist in data collection (e.g., Medication Use
Evaluation [MUE], drug class review, and Adverse Drug Reaction
[ADR]).
– Conducts drug information inquires (e.g., drug formulary, available
dosage forms, and availability of medication)
– Prepares educational materials for patients and PCMs.
 Improves quality of care delivered within the organization.
– Participates in population health initiatives to improve patient safety.
– Assists with acquiring/managing patient lists that may benefit from clinical
pharmacy services intervention.
– Collaborates with team members to optimize Medical Command
(MEDCOM) performance metrics for clinical pharmacy and the Army
Medical Home (AMH) team’s performance metrics (e.g.,
polypharmacy, performance improvement programs, etc.).
– Participates in Process Improvement initiatives.
 Performs medication distribution functions for outpatient prescriptions if required
Daily Tasks:
 Attends team huddles (pharmacy or AMH) for overview of the daily tasks.
47
Clinical Pharmacy Technician/Pharmacy Specialist (68Q) (CBMH)
 Verifies patient with the Joint Commission (TJC) patient safety goals using
the two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Manages Clinical Pharmacist appointment schedule (e.g.,
scheduled appointments, appointment reminders, and
cancellations/no-shows)
– Polypharmacy Medication Analysis & Report Tool (Poly-MART) reports
for eligible beneficiaries.
– Other specialized clinical pharmacy clinics (e.g., lipid,
anticoagulation, etc.)
 Manages clinical pharmacy consults (e.g., prioritizes, schedules, and
documents response in EHR.
 Updates and maintains polypharmacy/patient tracking log.
 Processes, completes, and conducts follow-up with special/non-formulary
drug requests
 Manages Sole Provider patient list, faxes documents to prescription services
and updates log/comments.
 Documents patient encounters (typically generating telephone consult [T-con]),
in the EHR. Utilizes Tri-Service Workflow (TSWF) Alternate Input Method
(AIM) forms to support documentation and forwards to the Clinical Pharmacist
for review/signature as appropriate.
 Reviews daily telephone consults and telephonic messages.
Weekly Tasks:
 Participates in professional educational opportunities.
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
Monthly Tasks:
 Downloads/analyzes all Poly-MART reports.
 Manages clinical pharmacist appointment schedule (e.g., monthly
appointment template).
 Completes monthly metrics report/counts.
 Consolidates data collection for Clinical Pharmacist and/or PCM interventions.
 Updates and organizes shared drive folders.
 Updates the clinical pharmacy announcements (e.g., email, social
media, newsletter, etc.).
 Coordinates Clinical Pharmacist peer-review process
48
Clinical Pharmacy Technician/Pharmacy Specialist (68Q) (CBMH)
 Organizes Pharmacy & Therapeutics (P&T)/Sole Provider materials/handouts
 Participates in pharmacy meetings to (e.g., P&T, Sole Provider
committee, pharmacy working groups, etc.).
 Completes monthly, quarterly, and yearly mandatory training requirements.
 Collaborates with team to meet measurable performance metrics/standards.
 Provides timely feedback to team members and the pharmacy department
on status of progress and goals.
 Communicates scheduled absences (e.g., sick and annual leave) to team.
 Ensures currency of all licensure standards (Pharmacy Technician
Certification [CPhT]) to include Basic Life Support (BLS).
49
Medical Technician (Laboratory, CBMH)/Medical Laboratory Specialist (68K)
Medical Technician Laboratory/68K
Background:
 Standardized position description (PD) Medical Technician, Community
Based Medical Home (CBMH).
– Position series/grade: GS-0645-07, PD: MC345760
 Military Rank: E3-E5 (Private First Class [PFC]/Sergeant [SGT])
 MLT/68K will complete all mandatory training per Appendix 3 Army
Medical Home (AMH) Training to Annex R to Operations Order (OPORD)
16-02 Army Medical Home (AMH), 29 October 2015.
Daily Tasks:
 Verifies patient with the Joint Commission (TJC) patient safety goals using
the two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Performs a wide range of moderately difficult and complex laboratory
examinations and procedures in accordance with Standard Operating
Procedures (SOP) to include hematology, urinalysis, chemistry, and
serology.
 Performs Startup/Shut down of lab analyzers.
 Performs daily maintenance and temperature checks of reagents and
equipment.
 Performs Quality Control and ensures acceptability prior to performing
patient samples.
 Performs phlebotomy on a wide age range of individuals; selects proper type
of anticoagulants and amount of blood to be drawn.
 Performs testing of hematology samples.
 Performs testing of chemistry samples.
 Performs testing of urinalysis to include urine chemistries, urine hCG,
and manual microscopies.
 Performs testing on serology testing on Influenza A/B, Respiratory
Syncytial Virus (RSV), Mononucleosis, and perform rapid Streptococcus
A testing.
 Reports all results in accordance with standard operating procedures.
 Ships samples using appropriate packaging devices to ensure compliance
with applicable regulations and prevent contamination of personnel handling
packages.
 Re-stocks and cleans laboratory and phlebotomy room.
Weekly Tasks:
 Performs weekly maintenance per standard operating procedure.
50
Medical Technician (Laboratory, CBMH)/Medical Laboratory Specialist (68K)
 Checks eyewash stations and reports deficiencies to be rectify to the
appropriate supervisor.
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
Monthly Tasks:
 Manages the quality control and process improvement (PI) programs for
the laboratory.
 Submits monthly quality control documents for review by Medical
Director or designee.
 Performs monthly maintenance IAW standard operating procedure.
Additional Tasks:




Manages inventory and orders supplies as needed.
Performs calibration of analyzers IAW standard operating procedure.
Performs external proficiency testing as required.
Prepares and maintains laboratory for regulatory agency inspections such
as College of American Pathologists (CAP) and the Joint Commission
(TJC).
 Participates in educational programs established by the laboratory as part
of a continuing program of self-development.
 Performs lot-to-lot validation of new reagents as needed when new supplies
are received.
51
Registered Dietitian Nutritionist (RDN)
RDN
Background:


Standardized position description (PD) Dietitian
– Position series/grade: GS-0630-11, PD: MC402973 (with
modifications) Military Rank: LT/CPT (Lieutenant/Captain)
Dietitian Nutritionist will complete all mandatory training per Appendix 3 Army
Medical Home (AMH) Training to Annex R to Operations Order (OPORD) 1602 Army Medical Home (AMH), 29 October 2015.
Daily Tasks:
 Participates in daily huddles and promotes nutrition as a core component
of a System for Health.
 Accepts warm hand-offs from Primary Care Managers (PCM) and
other members of the healthcare team.
 Verifies patient with the Joint Commission (TJC) patient safety goals using
the two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Faceto-face or non-face-to-face).
 Performs nutrition assessment of patients.
 Provides comprehensive medical nutrition therapy based on disease state
and nutrition assessment findings.
 Completes Electronic Health Record (EHR) notes/Tri-Service Workflow
(TSWF) Alternate Input Method (AIM) forms within guidelines of 72 hours.
 Reviews daily telephone consults and messages.
 Responds to requests/inquiries in secure messaging system.
 Maintains up-to-date nutrition handouts in the medical home.
 Supports Performance Triad efforts as necessary.
 Participates in multidisciplinary working groups.
 Collaborates with team members to optimize team’s performance metrics
(e.g., safety/quality, access to care, readiness, and efficiency).
 Precepts dietetic interns and residents in accordance with evidencebased Medical Nutrition Therapy.
Weekly Tasks:
 Provides group Nutrition Education Classes such as weight management,
heart healthy nutrition, diabetes management, and others.
 Conducts Fit for Performance Program/Nutrition Counseling in accordance
with the Army Body Composition Program (Army Regulation [AR] 600-9),
and Army Public Health Center (APHC) guidance.
52
Registered Dietitian Nutritionist (RDN)
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet
(DMHRSi) compliance. Utilizes appropriate Medical Expense and
Performance Reporting System (MEPRS) code/functional cost codes
(FCC) to report time.
 Liaison between AMH clinic and nutrition department.
Monthly Tasks:
 Submits patient schedule (accounting for projected annual leave and
other absences).
 Participates in peer review, journal club, and other department-mandated
quality control initiatives.
 Meets licensure requirements to include Basic Life Support (BLS),
Continuing Medical Education (CME) and Continuing Education Units
(CEUs).
 Completes monthly, quarterly, and yearly mandatory training requirements.
 Participates in performance improvement (PI) projects.
 Balances workload to assist Military Treatment Facility (MTF) RDNs with
health and wellness services, Military Nutrition Environment Assessments
(m-NEAT), Foodservice Menu Board Meetings, Child and Youth Services
(CYS) consultation, and Community Health Promotion Council meetings, if
needed.
 Balances workload to provide health and wellness services (if primary RDN on
installation) m-NEAT, Foodservice Menu Board meeting input, CYS
consultation, and Community Health Promotion Council meeting input, if
needed.
53
Physical Therapist (PT)
PT
Background:




Standardized position description (PD) Physical Therapist
– Position series/grade: GS-0633-12, PD: MC398231
Military Rank: 1LT/CPT/MAJ/LTC (First
Lieutenant/Captain/Major/Lieutenant Colonel)
Must be U.S. licensed physical therapist with graduate-level degree
Physical Therapist will complete all mandatory training per Appendix 3 Army
Medical Home (AMH) Training to Annex R to Operations Order (OPORD) 1602 Army Medical Home (AMH), 29 October 2015.
Daily Tasks:
 Attends or leads team huddle and reviews Musculoskeletal Injury (MSI)
schedule with core team and Physical Therapy Assistant to ensure coverage,
plan for procedures and support of patient care.
 Collaborates with team members to optimize the team’s performance
metrics (e.g., safety/quality, access to care, readiness, and efficiency).
 Verifies patient with the Joint Commission (TJC) patient safety goals using
the two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face.
 Provides immediate consultative services for patients with function-limiting
MSIs.
 Collaborates with Primary Care Managers (PCM) to ensure optimal
diagnostic studies and referrals/consultations for MSIs.
 Provides evidence-based care to enrolled population.
 Completes Electronic Health Record (EHR) notes/Tri-Service Workflow
(TSWF) Alternate Input Method (AIM) forms within guidelines of 72 hours.
 Reviews daily telephone consults (T-cons) and telephonic messages.
 Utilizes clinical information management/information technology enablers
(e.g., Medical Applications Process Solutions (MAPS) 2.0, secure
messaging (SM), voice recognition, and macro tools) to efficiently optimize
the available time for patient interaction.
 Coordinates and collaborates with team, specialists, community resources,
and Family members to develop and maintain a goal-oriented,
comprehensive, and comprehensible integrated plan of care.
54
Physical Therapist (PT)
 Reviews diagnostic studies (complete and incomplete) and provides guidance
to team for follow-up care.
 Teaches medical, nurse practitioner, and physician assistant students
and residents evidence-based MSI care.
 Reviews the Medical Readiness Assessment Tool (MRAT) for active
component Soldiers to identify non-recovering and more complex patient
presentations.
 Writes appropriate physical profiles utilizing eProfiles.
 Teaches and re-enforces self-efficacy model and therapeutic compliance.
Weekly Tasks:
 Reviews schedule for current week and the following week in order to screen
for patients that do not need to be seen or need to be seen sooner (e.g., postoperative, acute vs. chronic MSI, etc.).
 Reviews diagnostic studies (complete and incomplete) and provides guidance
to team for follow-up care.
 Participates in grand rounds educational opportunities.
 Contributes expertise to health and wellness services, including
educational classes.
 Adjusts triage thresholds to maintain ready access to care for acute MSIs.
Monthly Tasks:
 Reviews monthly report for outstanding diagnostic studies (incomplete)
and provides guidance to team for follow-up care.
 Participates in departmental peer-review.
 Participates in departmental morbidity and mortality reviews.
 Attends clinic meetings to ensure informed of changes and advocates for
team and patients.
 Completes monthly, quarterly, and yearly mandatory training requirements.
 Ensures currency of all licensure standards to include Basic Life Support
(BLS), Continuing Medical Education (CME), and Continuing Education Units
(CEU).
 Provides feedback to Physical Therapy Assistant (PTA)/Physical
Therapy Specialist (68F) on their progress and goals.
 Completes timely performance evaluations for those that they supervise
to include clinical students and rotating residents.
 Communicates scheduled absences (e.g., sick and annual leave) to team.
 Reviews AMH compliance with Low Back Pain (LBP) imaging compliance
as defined by the Healthcare Effectiveness Data and Information Set
(HEDIS®) measure and Veterans’ Affairs (VA)/Department of Defense
(DoD) Clinical Practice Guidelines (CPG).
 Meets with Medical Treatment Facility (MTF) PT service chief to
review performance.
55
Physical Therapy Assistant (PTA)/Physical Therapy Specialist (68F)
PTA/68F
Background:




Standardized position description (PD) Physical Therapy Assistant (PTA)
– Position series/grade: GS-0636-70, PD: MC396352
Military Rank: E3-E6 (Private First Class [PFC], Specialist
[SPC],Sergeant [SGT], and/or Staff Sergeant [SSG])
Recommended Training:
– Physical Therapy Assistant (PTA)
– Certified Personal Trainer (CPT)
– Certificate of Advanced Proficiency in Musculoskeletal or
Neuromuscular Physical Therapy
– Forward Musculoskeletal Care Course
– Master Fitness Trainer Course
– Tactical Strength and Conditioning Symposium and Facilitator Course
– Basic Healthcare Administration Phase 1&2 - Army Training
Requirements and Resources System (ATRRS) 6I-F13/340-F8
PTA will complete all mandatory training per Appendix 3 Army Medical
Home (AMH) Training to Annex R to Operations Order (OPORD) 16-02
Army Medical Home (AMH), 29 October 2015.
Daily Tasks:
 Essential tasks and duties are interchangeable with the scope of practice and
competency training per MEDCOM Regulation 40-50, Career Management
Field (CMF) 68 Clinical Baseline Competencies for Enlisted Medical
Personnel Performing Direct Patient Care at the Military Treatment Facility,
dated 10 November 2016.
 Prepares assigned rooms for clinic schedule (e.g., computer ready, room
stocked for the days clinic, etc.).
 Attends clinic huddle for overview of day and individual team to review
scheduled patients with Physical Therapist.
 Verifies patient with the Joint Commission (TJC) patient safety goals using the
two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Pre-screens patients and places in PCM room for evaluation.
 Provides exercise training, modality application, health coaching, and
educational material as directed by Physical Therapist.
 Follows current approved protocols and standardized exercise prescription.
 Documents and codes all patient care performed in the Electronic Health
Record (EHR) utilizing the AMH Medical Expense Performance Reporting
System code.
56
Physical Therapy Assistant (PTA)/Physical Therapy Specialist (68F)
 Coordinates patient care across multiple settings (e.g., specialty, behavioral
health, surgical services, etc.), schedules follow-up appointment if
applicable, provides directions sheet for additional medical care/diagnostic
testing: lab, radiology, referral management, pharmacy, etc.
 Performs general office duties such as answering telephones, taking
dictation, and completing forms.
 Completes end-of-day tasks:
– Restocks and cleans assigned areas of responsibility to prepare for
next day’s schedule.
– Reviews, at a minimum, the next day schedule screening paperwork.
Weekly Tasks
 Collaborates with Physical Therapist to review the following:
– Referral reports
– Submitted Defense Medical Human Resource System internet and
Time cards - Automated Time Attendance and Production System (biweekly)
– Post-operative patients care
 Restocks/reorders supplies, handouts, braces, and other equipment needed
to perform patient care.
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
Monthly Tasks:
 Assists Physical Therapist in monitoring productivity.
 Submits schedules and/or changes in schedules for clinic providers.
 Monitors training requirements for staff.
Annual Tasks:
 Assesses and completes Clinic Competency/Orientation checklist
 Maintains Military Occupational Specialty-Qualifications
 Monitors Competency Assessment Folders and assists staff to
update information as needed.
57
Internal Behavioral Health Consultant (IBHC)
IBHC
Background:




Standardized position description (PD) Clinical Psychologist, Internal
Behavioral Health Consultant
– Position series/grade: GS-0180-13, PD: MC384120
Standardized position description (PD) Clinical Social Worker, Internal
Behavioral Health Consultant
– Position series/grade: GS-0185-12, PD: MC383835
Mandatory Training:
– PCMH IBHC will complete mandatory orientation distance learning training
and in-person training prior to seeing patients as an IBHC in the Army
Medical Home (AMH) in accordance with OTSG/MEDCOM Policy Memo
16- 065, 11 August 2016, Enclosure 1 - Primary Care Behavioral Health
(PCBH) Integration Role Definitions and Training, 25 May 2016.
IBHC will complete all mandatory training per Appendix 3 Army Medical
Home (AMH) Training to Annex R to Operations Order (OPORD) 16-02
Army Medical Home (AMH), 29 October 2015.
IBHC Roles and Functions:
 Collaborates with the Primary Care Manager (PCM) and other AMH team
members in identifying, triaging, and managing AMH patients with medical
and/or behavioral health problems that would benefit from brief, focused
interventions.
 Provides behavioral health consultation to the PCM by screening and
interviewing patients and conducting brief, solution-focused interventions
within the Primary Care Behavioral Health Consultation Model.
Daily Tasks:
 Attends daily huddle for overview of the day.
 Screens and interviews patients by performing psychological and
bio-psychological evaluations.
 Formulates behavioral health interventions appropriate to a primary care
setting and assists with the implementation and monitoring of treatment plans
with PCMs and the healthcare team.
 Provides timely and succinct feedback to PCMs regarding patient findings
and recommendations.
 Verifies patient with the Joint Commission (TJC) patient safety goals using
the two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Faceto-face or non-face-to-face.
58
Internal Behavioral Health Consultant (IBHC)
 Provides concise documentation of care and recommendations in the
patient’s Electronic Health Record (EHR) within 72 hours of encounter.
 Provides focused follow-up visits including relapse and prevention education.
 Provides on-going consultation services for a sub-set of patients who
require ongoing monitoring and follow-up.
 Refers patients to specialty behavioral health clinics as clinically appropriate.
 Documents in the EHR encounter and codes all services in the EHR using the
Tri-Service Workflow (TSWF) Alternate Input Method (AIM) forms and
Department of Defense (DoD) established provider specialty codes, Health
Insurance Portability and Accountability Act (HIPAA) taxonomy codes, Medical
Expense and Performance Reporting System (MEPRS) codes, diagnosis
codes, and Healthcare Common Procedure Coding System codes.
Weekly Tasks:
 Maintains Automated Time Attendance and Production System
(ATAAPS)/Defense Medical Human Resource System-internet (DMHRSi)
compliance. Utilizes appropriate Medical Expense and Performance
Reporting System (MEPRS) code/functional cost codes (FCC) to report
time.
Monthly Tasks:
 Participates in required IBHC sustainment training conference calls.
 Attends local IBHC staff meetings.
 Ensures currency of all licensure standards to include Basic Life Support
(BLS), Continuing Medical Education (CME), and Continuing Education Units
(CEUs).
 Participates in departmental peer-review.
 Completes monthly, quarterly, and yearly mandatory training requirements.
 Develops, teaches, and provides oversight for classes that promote
education and skill building to enhance psychological and physical health
and promote behavioral change related to improved health status.
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Behavioral Health Care Facilitator (BHCF)
BHCF
Background:




Standardized position description (PD) Behavioral Health Care
Facilitator Position series/grade: GS-0610-11, PD: MC437474
Mandatory Training:
– BHCF Tri-Service Training – Three Phases in accordance with
OTSG/MEDCOM Policy Memo 16-065, 11 August 2016, Enclosure 1 Primary Care Behavioral Health (PCBH) Integration Role Definitions and
Training, 25 May 2016:
o Phase I: Orientation and Self-Guided Preparatory Training (at MTF)
o Phase II: Residential Training with PCBH-D and completion of
FIRST- STEPS test cases: BHCF Activation
o Phase III: Expert Trainer Accreditation
BHCF will complete all mandatory training per Appendix 3 Army Medical
Home (AMH) Training to Annex R to Operations Order (OPORD) 16-02
Army Medical Home (AMH), 29 October 2015.
BHCF will complete Phase II training prior to accepting patients for
care facilitation in the Army Medical Home (AMH).
BHCF Roles and Functions:
 Collaborates with the Primary Care Manager (PCM), the Internal Behavioral
Health Consultant (IBHC), and the patient (e.g., with a working diagnosis of
depression, anxiety, Post Traumatic Stress Disorder (PTSD) or alcohol
misuse).
 Facilitates communication between the PCM, the IBHC, and the
External Behavioral Health Consultant (EBHC) or specialty provider.
 Functions as a liaison between the PCM and the EBHC or specialty provider
on the following:
– PCM requests or questions regarding the direction of care for the
patient.
– Consultative recommendations to the PCM that the EBHC or specialty
provider may have regarding:
o Treatment plan changes.
o Additional complex behavioral health issues.
 Assists and supports the patient in adhering to PCM and IBHC treatment
plan and or interventions prescribed.
 Assists the patient in medication adherence through education; education
should include but not limited to the following:
– Reviews why the medication was prescribed.
– Reviews mechanism of action of medication.
60
Behavioral Health Care Facilitator (BHCF)
– Reviews schedule of frequency of medication.
– Evaluates patient expectations.
– Informs the patient those side effects are usually mild and improve over
time.
– Assists with side effect management.
– Educates patient the benefits appear slowly.
– Reviews and educates patient on non-addictive and addictive properties of
medications, if any.
– Notifies PCM or BHCF if patient has thoughts on stopping a medication.
– Reviews the goals of treatment - remission; this may require a few
changes and on-going patient education/support.
 Encourages engagement and adherence with counseling options available
at and around the MTF, options such as:
o EBHC, IBHC, Military One Source, Military & Family Life
Counseling (MFLC) Program and Chaplin Services.
 Maintains Caseload in Psychological and Behavioral Health Tools for
Evaluation Risk and Management (PBH-Term) as known as FIRST-STEPS.
o Expected caseload of 60-80 patients.
Daily Tasks:
 Attends:
– Morning Team Huddle:
o Updates Army Medical Home (AMH) team members of
scheduled patients that need contact or have
recommendations pending.
o Updates AMH team members of patients seen in
Emergency Department (ED) overnight.
 Collaborates with Team Registered Nurse (RN) to ensure
patients assigned to the team receive appropriate follow-up care.
 Closes the loop on patients seen in ED during afternoon team
huddle with the health care team.
 Verifies patient with the Joint Commission (TJC) patient safety goals using the
two approved patient identifiers: Full name and date of birth (DOB).
Appropriately addresses patient by title/rank (for direct patient care: Face-toface or non-face-to-face).
 Reviews:
– Caseload in FIRST-STEPS for current day’s scheduled patient
telephone consults.
o Verifies patient appointments since last contact/visit in
Electronic Helath Record (EHR).
o Verifies the previous patient encounters documented since the
last contact/visit in EHR.
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Behavioral Health Care Facilitator (BHCF)
o Ensures medication evaluations are scheduled 28 days after the
start of new antidepressant medications. BHCF will book an
appointment in EHR, if not already scheduled.
o Verifies prescribed medications and compares the dispense date
with current date to aid in medication compliance.
 Assesses:
– The response and adherence to the current prescribed plan of care.
– Educational deficits regarding medication management.
– Engagement with recommended Behavioral Health (BH) services.
– Barriers to the prescribed plan of care.
– The need to staff with IBHC or EBHC.
 Monitors:
– All BH, ensuring the following:
o Accuracy and completeness of MEDCOM 774.
o Reviews electronically screened patients for disposition.
o Collects all referrals to BHCF or IBHC.
o Positively endorsed suicidal ideations reviewed in EHR closing
the loop by ensuring connected care.
– Attempts to contact patient as scheduled, enters contact attempts in
FIRST-STEPS and EHR for each contact or attempt to contact.
– Prescribed medication supply to ensure adequate patient supply and
no discrepancy exists.
o Collaborates with the Clinical Pharmacist, when necessary, to
ensure patient adheres to prescribed medications.
– Adherence with IBHC, BH, and PCM appointments.
– Secure Messaging (SM) clinical box to facilitate communication with
patients and other care providers.
– Care Point Antidepressant and Sleep Medication Lists:
o Annotates prescribing clinic in care point.
o Compares list to current caseload:
 Meets with PCM regarding discrepancies.
 Adds patients to the BHCF caseload when discrepancies are
identified.
– EHR for New Referrals:
o Completes any referrals for the PCBH-Care Facilitation services.
Weekly Tasks:
 Ensures team has submitted Defense Medical Human Resource Systeminternet (DMHRSi) and Time cards - Automated Time Attendance and
Production System (ATAAPS) bi-weekly.
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Behavioral Health Care Facilitator (BHCF)
 Reviews:
– Caseload for Internal Behavioral Health Consultant (IBHC) for staffing
purposes following the Primary Care Behavioral Health (PCBH)
Guidelines.
o New Referrals:
 Reviews cases that would benefit from IBHC services.
o Established Cases:
 With a change in status:
 Fails to progress as expected.
 No Symptom improvement (typically over a 4 week
timeframe if engaged in counseling or on medications)
– Caseload for EBHC staffing purposes following the PCBH Guidelines.
o New Referrals
o Established Cases:
 With a change in status.
o Fails to progress: No symptom improvement (typically over a 4week timeframe if engaged in counseling or on medications) and
PCM notified of lack of progress.
o Requests Case Closure from PCM in the following situations:
 Meets remission criteria.
 Separation from Service.
 Engaged in Specialty Care (Medication Management outside of
Primary Care and expected to remain in specialty care).
 Permanent Change of Station (PCS)/Deployment.
 Lost to follow-up.
 Fails to respond to BHCF attempts to contact patient (after four
[4] attempts/four [4] weeks). The time-period may be longer if
the patient is in unit mission.
 Attends:
– Staffing
o BHCFs are to staff cases with the designated IBHC during
scheduled staffing time (times should be built into the provider’s
weekly schedule).
o BHCFs are to staff cases with the designated EBHC during
scheduled staffing time. (Staff times should be built into the
EBHC’s weekly schedule).
o EBHC and BHCF will determine throughout the week, which cases
will be staffed based on PCBH guidelines:
 A minimum of two Behavioral Health Staffing notes with the
EBHC per enrolled patient required.
 The initial referral.
 To close a currently enrolled case.
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Behavioral Health Care Facilitator (BHCF)
o Staffing days, the BHCF will enter each patient as a walk-in
appointment in EHR using “Future” category for the patient who will
be staffed that day.
o The provider for these appointments should be the
brigade psychiatrist, EBHC, or designee.
– Posts staffing
o BHCF will record staffing document in Psychological and
Behavioral Health Tools for Evaluation Risk and Management
(PBH-TERM), known as FIRST-STEPS and document staffing in
the patients EHR record.
 Documentation in the EHR will reflect the staffing and EBHC’s
recommendations for the patients (If available for that day,
otherwise, documented the next business day prior to the
encounter completion).
o The BHCF will communicate with the PCM, via telephone consult
(T- con), any medication or treatment modality changes in the
recommendations made by EBHC during staffing.
o The BHCF will communicate with the PCM, via T-con, any
treatment modality changes in the recommendations made by
IBHC during staffing.
Monthly Tasks:
 Assesses:
– The need for training of all AMH team members.
o Provides initial and updated training as needed.
 Monitors:
– Medical Record – Primary Care Behavioral Health Screening
MEDCOM FORM 774, OCT 2012, supply in clinic (until clinic
converts to electronic documentation). Orders forms as needed to
maintain supply.
 Attends:
– Monthly BHCF call as scheduled.
– Monthly meeting with local PCBH team members.
 Engages and collaborates with team on Patient Caring Touch System (PCTS).
 Participates and/or assigned as Performance Improvement (PI) representative.
64
Glossary Acronym Definition
1LT ─ First Lieutenant
ACC ─ Acute Care Clinic
ACR ─ American College of Radiology
AD ─ Active Duty
ADR ─ Adverse Drug Reaction
AED ─ Automated External Defibrillator
AFGE ─ American Federation of Government Employee
AIM ─ Alternate Input Method
AMEDD ─ US Army Medical Department
AMH ─ Army Medical Home
AO ─ Action Officer
APFT ─ Army Physical Fitness Test
APHC ─ Army Public Health Center
APNP ─ Advanced Practice Nurse Practitioner
APRN ─ Advanced Practice Registered Nurse
APV ─ Ambulatory Procedure Visit
ATC ─ Access to Care
ATRRS ─ Army Training Requirements and Resources System
ATAAPS ─ Automated Time Attendance and Production System
BH ─ Behavioral Health
BHCF ─ Behavioral Health Care Facilitator
BLS ─ Basic Life Support
CAF ─ Competency Assessment File
CAP ─ College of American Pathologists
CBO ─ Competency Based Orientation
CCP ─ Comprehensive Care Plan
CEEP ─ the Capital Expense Equipment Program
CES ─ Civilian Education System
CEU ─ Continuing Education Unit
CG ─ Commanding General
CHRTAS ─ Civilian Human Resources Training Application System
CHUP ─ Chronic Pain, High Utilizer, and Polypharmacy
CME ─ Continued Medical Education
CMS ─ Clinical Management System
CMTM ─ Comprehensive Medication Therapy Management
CNOIC ─ Clinical Nurse Officer-in-Charge
COR ─ Contracting Officer’s Representative
CPG ─ Clinical Practice Guidelines
CPT ─ Captain
CPT ─ Certified Personal Trainer
CSD ─ Clinical Support Division
CSM ─ Command Sergeant Major
CYS ─ Child and Youth Services
DL ─ Distance Learning
65
Glossary cont’d.
DMLSS ─ Defense Medical Logistics Standard Support
DMRSi ─ Defense Medical Human Resource System internet
DPMAP ─ DoD Personnel Management and Appraisal Program
DTMS ─ Digital Training Management System
DTS ─ Defense Travel System
EBCH ─ External Behavioral Health Consultant
ECHO ─ Extension for Community Healthcare Outcomes
ED ─ Emergency Department
EHR ─ Electronic Health Record
EO ─ Equal Opportunity
EOD ─ End of Day
FCC ─ Functional Cost Codes
FDA ─ Federal Drug Administration
FORSCOM ─ United States Army Forces Command
FPPE ─ Focused Provider Performance Evaluation
FTE ─ Full Time Equivalent
FTR ─ Future
FY ─ Fiscal Year
GPM ─ Group Practice Manager
GS ─ Government Service
hCG ─ human Chorionic Gonadotropin
HEDIS® ─ Healthcare Effectiveness Data and Information Set
Hgb A1C ─ Glycated Hemoglobin
HIPAA ─ Health Insurance Portability Accountability Act
HLD ─ High-Level Disinfection
HR ─ Human Resource
HRC ─ Human Resource Command
HRO ─ High Reliability Organization
IAW ─ In Accordance With
IBHC ─ Internal Behavioral Health Consultant
IC ─ Infection Control
ICE ─ Interactive Customer Evaluation
IDP ─ Individual Development Plan
IG ─ Inspector General
IRIS ─ Integrated Resource and Incentive System
IV ─ Intravenous
LBP ─ Low Back Pain
LPN ─ Licensed Practical Nurse
LTC ─ Lieutenant Colonel
LVN ─ Licensed Vocational Nurse
MAJ ─ Major
MAPS ─ Medical Applications and Process Solutions
MEDCOM ─ Medical Command
MEDPROS ─ Medical Protection System
MEPRS ─ Medical Expense and Performance Reporting System
66
Glossary cont’d.
MFLC ─ Military & Family Life Counseling Program
MHS ─ Military Health System
MHSPHP ─ Military Health System Population Health Portal (CarePoint 4G® MHSPHP
application)
m-NEAT ─ Military Nutrition Environment Assessment
MODS ─ Medical Operations Data System
MRAT ─ Medical Readiness Assessment Tool
MS ─ Medical Service
MSG ─ Master Sergeant
MTF ─ Military Treatment Facility
MOD ─ Medical Officer on Duty
MOS ─ Military Occupational Specialty
MSA ─ Medical Support Assistant
MSI ─ Musculoskeletal Injury
MSTC ─ Medical Simulation Training Center
MUE ─ Medication Use Evaluation
NAL ─ Nurse Advice Line
NCM ─ Nurse Case Manager
NCOIC─ Non-commissioned Officer-in-Charge
NP ─ Nurse Practitioner
NPC ─ Nurse Practice Council
NRC ─ Nuclear Regulatory Commission
NREMT® ─ National Registry of Emergency Medical Technicians
OIC ─ Officer-in-Charge
OPORD ─ Operational Order
OPPE ─ Ongoing Provider Performance Evaluations
ORT-3 ─ Outpatient Record Transmission Tracking Tool
PA ─ Physician Assistant
PAD ─ Patient Administration Department
PAP test ─ Papanicolaou test
PAO ─ Public Affairs Officer
PBAC ─ Program Budget Advisory Committee
PBH-TERM ─ Psychological and Behavioral Helath – Tools for Evaluation, Risk and
Management
PCM ─ Primary Care Manager
PCS ─ Permanent Change of Station
PCBH ─ Primary Care Behavior Health
PCMH THT ─ Patient Centered Medical Home Team Huddle Tool
PCTS ─ Patient Caring Touch System
PD ─ Position Description
PH-RN ─ Population Health - Registered Nurse
PI ─ Process Improvement
PM ─ Practice Manager
PMRM ─ Practice Management Revenue Model
67
Glossary cont’d.
POCT ─ Point-of-Care Testing
Poly-MART ─ Polypharmacy Medication Analysis & Report Tool
PPA ─ Provider Productivity Application
PPS ─ Prospective Payment System
PROC ─ Procedure
PT ─ Physical Therapy
P&T ─ Pharmacy & Therapeutics
PTA ─ Physical Therapy Assistant
PTSD ─ Post Traumatic Stress Disorder
R&A ─ Review and Analysis
RDN ─ Registered Dietitian Nutritionist
RM ─ Resource Management
ROUT ─ Routine
RPA ─ Request for Personnel Actions
RRT ─ Rapid Response Team
RVU ─ Relative Value Unit
SCMH ─ Soldier Centered Medical Home
SFC ─ Sergeant First Class
SM ─ Secure Messaging
SOP ─ Standard Operating Procedure
SPD ─ Sterile Processing and Distribution
SPEC ─ Specialty
TAPES ─ Total Army Performance Evaluation System
TARA ─ Technology Assessment and Technology Analysis
TeamSTEPPS® ─ Team Strategies and Tools to Enhance Performance and Patient
Safety
T-con ─ telephone consult
TDA ─ Table of Distribution
TJC ─ the Joint Commission
TOL ─ TRICARE Online
TOC ─ TRICARE Operations Center
TRADOC ─ Army Training and Doctrine Command
TSWF ─ Tri-Service Workflow
UCC ─ Urgent Care Clinic
UPC ─ Unit Practice Counsel
VA/DoD ─ Department of Veterans’ Affairs/Department of Defense
VTC ─ Video Teleconference
WMSNi ─ workload Management System for Nursing – internet
WTU ─ Warrior Transition Unit
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Army Medical Home Patient Care Workflow
AMH Workflow – Patient Access
69
AMH Workflow – Patient Access cont. KEY
70
AMH Workflow – Patient Appointment Process
71
AMH Workflow – Patient Appointment Process cont. KEY
72
AMH Workflow – Patient Transition of Care
73
AMH Workflow – Patient Transition of Care cont. KEY
74
AMH Workflow – Patient Network/Transition of Care
75
Army Medical Home (AMH) Competency Based Orientation (CBO) Documents:
AMH Core CBO
(Double Click on Note for CBO)
AMH CNOIC/NCOIC CBO
(Double Click on Note for CBO)
AMH Nursing Personnel (RN/LPN/LVN/68C) CBO
(Double Click on Note for CBO)
AMH Health Care Specialist (68W) CBO
(Double Click on Note for CBO)
AMH Medical Support Assistant (MSA) CBO
(Double Click on Note for CBO)
AMH Nurse Case Manager (NCM) CBO
(Double Click on Note for CBO)
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AMH CBO Documents cont’d.:
AMH Population Health Registered Nurse (PH-RN) CBO
(Double Click on Note for CBO)
AMH Clinical Pharmacy Technician/68Q (CBMH) CBO
(Double Click on Note for CBO)
AMH Physical Therapy Assistant (PTA)/68F CBO
(Double Click on Note for CBO)
AMH Behavioral Health Care Facilitator (BHCF) CBO
(Double Click on Note for CBO)
AMH Medical Technician (Laboratory)/68K (CBMH) CBO
(Double Click on Note for CBO)
77