Performance Triad: Advancing the System for Health...2016/03/30 · Action Officer / e-mail / phone...

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Performance Triad: Advancing the

System for Health

COL Deydre S. Teyhen, DPT, PhD, OCSMarch 30, 2016

1


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Why a System for Health?• Healthcare costs rose from 4.95 GDP in 1960

to 16.4% in 2011 (20% by 2020)

• Healthcare costs contribute to over 50% of all

personal bankruptcies

• While U.S. spends more on healthcare, yet

World Health Organization ranks U.S. as only

#37; behind countries such as Costa Rica,

Colombia, and Greece

• Healthcare costs exceed 10% of DoD budget

• A 5% reduction in hypertension would save

$25 billion in 5 years

• Reducing sodium intake to 2,300 mg/day

would save $18 billion annually in healthcare

• Increasing physical activity to 2.5 hours per

week and a 5-7% reduction in weight could

decrease incidence of diabetes by 58%

Cost, Quality, Prevention


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The Elephant in the Room

• Chronic preventable diseases– 160 million Americans

– 78% healthcare costs

Ex: Obesity, Cardiovascular disease (Hypertension, Stroke, Heart disease), Diabetes, Cancer

• EPIC Study (23,000) : 4 behaviors

1. Not smoking

2. Exercise 3.5 hrs/week

3. Healthy diet (veggies, fruits, whole grains, low intake of meats)

4. Maintain BMI < 30

– RRR: 93% DM, 81% MI, 50% strokes, 36% cancer

ChronicPreventable

Disease

Ford et al. Healthy living is the best revenge: findings from the EPIC study. Arch Intern Med 2009: 169:1355-62. pmid: 19667296


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“If we had a pill that conferred all the proven health benefits of exercise, physicians would provide it to every patient and our healthcare system would find a way to make sure every patient had access to this wonder drug.”

Exercise is Medicine

--Robert E. Sallis, MD, MPH, FACSMExercise is Medicine Task Force Chairman


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Exercise is Medicine

• All-cause and cardiovascular related death

• Cardiovascular disease

• Type 2 Diabetes

• Cancer (breast/colon)

• Osteoporosis

• Depression/anxiety

• Dementia

Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ. 2013;347(oct01_1):f5577. doi:10.1136/bmj.f5577.


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“On this diet, you

can eat all the steak

you want, but a slice

of bread will kill you.

On this other diet,

you can eat all the

bread you want, but

a steak will kill you.”

Nutrition Confusion


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In Defense of Food

“Eat food, mostly plants, not too much.”-Michael Pollen

Performance Triad - Return on Readiness

< 5 hours sleep for 5 days (or 1 day without sleep)

correlatesto a 20% decrease in

cognitive ability (memory & decision-making)

43K active duty (~12 BCTs)

are non-deployable due to medical profiles

10% decrease in overweight Soldiers

enables FORSCOM 90% deployable goal

$137M annually to replace Soldiers

discharged due to weight control

($75.9K per new recruit)

Just one sleepless night (< 4 hours) can impair

performance as much as a 0.10%

blood-alcohol level

$4.2B to train and replace all Soldiers BMI > 30* (currently 78,734

active duty Soldiers) who are 36% less likely

to deploy

5+ fruit & vegetables is associated with a 5-fold increase in mental well-

being compared to 1 portion

Programs to improve health can result in a

$3.27 return on investment for every

$1.00 spent on prevention

Fatigue was a contributing factor in

628 Army accidents and 32 Soldier deaths (FY 11-

14)

10 million limited days of duty of COMPO 1

Soldiers on duty limiting profiles

Overweight recruits are 47% more likely to

become injured and use 49% more healthcare

resources in first 90 days

Performance Triad Pilot study baseline reports

99.6% of Soldiers do not meet all target

behaviors

Performance Triad: Optimizing Human Performance & Unit Readiness

MEDICAL READINESS

Overall, 17% of Soldiers were classified as not medically ready.

Non-readiness ranged from 12% to 23% across installations.

HEALTH OUTCOMES

Overall, 55% of Soldiers were diagnosed with an injury.

Roughly 1,295 new injuries were diagnosed per 1,000 Soldiers.

Injury rates ranged from 1,062 to 1,648 per 1,000 across installations.

Injury Incidence

MedicallyNon-Ready

Overall, 15% of Soldiers were diagnosed with a behavioral health disorder.

Behavioral Health disorder rates ranged from 9% to 20% across installations.

Behavioral Health

Overall, 14% of Soldiers were diagnosed with a chronic condition.

Chronic disease rates ranged from 12% to 21% across installations.

ChronicDisease

PERFORMANCE TRIAD

Overall, installations had an average sleep score of 67 out of 100 based on Soldier

responses to GAT questions assessing sleep duration, sleep satisfaction, and being

bothered by poor sleep. Scores ranged from 64 to 74 across installations.

Sleep

Overall, installations had an average activity score of 81 out of 100 based on Soldier

responses to GAT questions assessing exercise frequency, exercise intensity,

resistance training, and BMI. Scores ranged from 79 to 85 across installations.

Activity

Overall, installations had an average nutrition score of 69 out of 100 based on Soldier

responses to GAT questions assessing healthy eating, breakfast, recovery snacks

and water consumption. Scores ranged from 67 to 75 across installations.

Nutrition


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5559

3530

57 58

3027 28 27 29 30

15 13

3743

13 12

0

10

20

30

40

50

60

70

Males Females Males Females Males Females

Sleep Activity Nutrition

GAT (n = 176,796)Males: 148, 841 (84.2%); Real-Age: +9.0 years, APFT: 261Females: 27,955 (15.8%); Real-Age: +2.5 years, APFT: 246


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“Disregarding the underlying causes and treating only risk

factors is somewhat like mopping up the floor around an

over-flowing sink instead of turning off the faucet, which is

why medications usually have to be taken for a lifetime.”

-Dr. Mark Hyman, Dr. Dean Ornish, Dr. Michael RoizenHyman M, Ornish D, Roizen M. Lifestyle medicine: treating the cause of disease. Altern Ther Health Med 2009;15:12-14.


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15

Performance Triad Holistic Approach to Facilitate Personnel Health Readiness

Performance Triad Holistic Approach

McKinsey Global Institute (2014)

READINESS

Facilities

Policies &

Process

Army

Culture:

Standards

& Values

Lead,

Coach,

Teach,

Mentor, &

Model

Goals &

Commitment

Self

Development

Unit &

Institutional

Training

Training

Support

Performance Triad: Enabling the Human Dimension with Optimized Soldiers ISO Unit Readiness

Performance Triad Builds Partnerships across Commands, Programs, and Initiatives to Help Ensure Existing Tools and Resources are Easily Accessible for the End-Users across the Total Army

Performance Triad Partnership Building


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Performance TriadSleep | Activity | Nutrition


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P h y s i c a l F i t n e s s a n d H e a l t h

C o g n i t i v e F i t n e s s a n d H e a l t h

E m o t i o n a l F i t n e s s a n d H e a l t h

2 4 / 7 S o c i e t y

Social, Family, and Spiritual Success

M a i n t a i n Y o u r E d g eT h e To t al A r m y Fa m i l yS o l d i e r s , C i v i l i a n s , R e t i r e e s ,

a n d T h e i r F a m i l i e s


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G A R

Performance Triad

Performance Triad

+ Wellness Ctr

Performance Triad

+Medical

Performance Triad: Optimizing Human Performance & Unit Readiness


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Army Wellness Center

Linked with Patient Centered Medical Home

Leveraging Technology to Increase, Readiness, Performance, and Resiliency

Health AssessmentsRisk StratificationWellness QuestionnairesBiometric Screening

Physical FitnessExercise TestingExercise Prescription

Healthy NutritionMetabolic TestingWeight ManagementNutrition Education

Stress ManagementEducationBiofeedback

General Wellness EducationHealthy Lifestyle HabitsWellness CoachingGood Sleep Habits

Tobacco EducationTobacco Free Living


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Disease Centered vs. Person-Centered

Delivery of Health-Collaborative partnership-Empowered self-healing-Healthy lifestyles and habits

Social Networks-Friends-Spouses/family-Army Leaders/Unit

Healthy Environments-Public health focused-Behavioral economics-Lifespace

Delivery of Healthcare-Focused on disease, illness and injury

Prevention-Focused on disease prevention (immunizations, cancer screenings)

MTF-Injury and illness treatment-Chronic care management

“Find Disease and Fix it” “Predict and Personalize”

GOAL: Improve readiness, resilience, performance

GOAL: Maintain absence of disease and restore to previous state


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Move to Health ModelGoal: “change the conversation”

from a disease and injury-centric

approach to a personalized,

proactive, person-centered approach

that is focused on promoting the

health and wellness of the Total

Army Family.


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Personalizing Total Force Fitness


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http://bipartisanpolicy.org/library/teaching-nutrition-and-physical-activity-medical-school-training-doctors-prevention/


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• “I am so much better able to connect with patients using these approaches”

• “It opened up the dialogue quickly.”

• “Patients said, ‘thank you, I can tell you really care about me’ and ‘you really listened to me.’ ”

• “Patient came up with his own plan.”

5-Apr-16Name/Office Symbol/(703) XXX-XXX (DSN XXX) / email address January 2015

2.8

3.4

2.8

2.0

2.3

3.2

3.7

3.0

2.5

2.9

0

0.5

1

1.5

2

2.5

3

3.5

4

Self-Efficacy PerceivedBenefits

InstitutionalSupport

Attitudestoward Holistic

HealthMedicine

OverallPreparedness

Pre

Follow-up

Change in outcomes: Pre- to 2 Month Follow-Up

Note: Bolded means indicate significant change pre- to 2 month, p< .01 (two tailed)


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Military Nutrition Environment Assessment

Tool

Promoting Active Communities

Quantitative Indicators for Tobacco Systems

+++

Assesses an

installation’s

environment and

policies towards

healthy eating

Evaluates an

installation’s built

environment, policies,

and programs related

to physical activity

Assesses an

installation’s policies

and environment

promoting tobacco

free living

Presentation

templates

Factsheets

Excel spreadsheet

Facilitator’s Guide

Creating Active Communities & Healthy

Environments (CACHE) Toolkit


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[email protected]


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Serving to Heal...Honored to Serve!

[email protected]


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Sleep Activity Nutrition

CBT-I Coach PRT MyFitnessPal

Mindfulness Army Physical Readiness Training FM 7-22

Loseit

Virtual Hope Box NOFFS: Navy Operational Fitness and Fueling System

Fooducate

Sleep Diary Tactical Breather CookingPlanit

Sleep Time* Breathe2relax Cookpad

Apps


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Professional Soldier Athlete

Goal: Improved unit readiness, performance, stamina, and health through enhanced and improved sleep, activity, and

nutrition.

Putting it All Together

Personal Health Behaviors: Foundation for physical and cognitive performance

Modular Program: Tailored,

awareness, education,

motivation, & messaging

Line Leader Focused: Coaching & mentorship training and tools

Support: Toolkits, MFTs,

MRTs, AWC, SCMH, RD,

PT/OT, etc

Leverages Technology:

Personal Readiness

Devices, Applications

Challenges: Learning

through doing and

competitions


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• Strong evidence supports that sleep, activity,

and nutrition are key enablers to physical,

cognitive, and emotional dominance, resilience,

and personal readiness

• Healthy lifestyle choices (sleep, activity, and

nutrition) promote personal health, well-being,

and brain health

• Army Medicine is transitioning from a healthcare

system to a System for Health

Closing Thoughts . . .

“No nation has ever survived, and no nation ever will survive, whose people are not physically, mentally, and morally fit for survival”

- U.S. Army Training Manual No. 1 (1922)

HEALTH FACTORS

Overall, 13% of Soldiers were classified as obese.

Obesity ranged from 9% to 18% across installations.Obesity

Overall, 32% of Soldiers reported tobacco use.

Tobacco use ranged from 13% to 40% across installations.Tobacco

Overall, 10% of Soldiers were diagnosed with a sleep disorder.

Sleep disorder rates ranged from 5% to 14% across installations.

SleepDisorders

Overall, 2% of Soldiers were diagnosed with a substance abuse disorder.

Rates ranged from 1% to 3% across installations.

SubstanceAbuse

Overall, 17 new chlamydia infections were reported per 1,000 Soldiers.

Reported chlamydia rates ranged from 7 to 28 per 1,000 across installations.Chlamydia

HEALTHCARE DELIVERY

Overall, 2% of Soldier hospital admissions were classified as preventable.

Rates ranged from 1% to 5% across installations.

PreventableHospital

Admissions

P3 & Readiness: Army End StrengthJan 2015 Army End Strength

491,910

FY 17 Proj. Army End Strength 450,000

MRC3/4 Reductions Required To Maintain FY 15 deployable end

strength

360,000MRC 1/2

TTHS+*:

45,00010%

MRC 3/445,000

10%

343,800MRC 1/2

TTHS+*:

45,00010%

MRC 3/461,20013.6%

375,301MRC 1/2

TTHS+*:

49,75310%

MRC 3/466,85613.6%

375,301MRC 1/2

TTHS+*:

45,00010%

MRC 3/429,6996.6%

The Performance Triad Sweet Spot

Return on Readiness


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Predictive Analytics

Deployment Readiness & Medical Costs*

*Data Source: Army OTSG, G8/9, Innovative Clinical Analytics Medical Readiness Assessment Tool (MRAT) data pull (data timeframe: MAR 13- FEB 14 & MAR 14-AUG 14; 302,214 AC

Soldiers) 15 JAN 15

MNR = Medically Not Ready (MRC 3-4)

Re

lati

ve

Ris

k o

f M

NR

(in

cre

as

e in

pe

rce

nt)

Risk Factor

100%

0%

50%

75%

25%

200%

300%348%

>5

INJ

86%

279%

Increase in MND in AC by Risk Factor

16%

81%1-4

INJ

179,582

16,148

64,799

18,892

= 10K Soldiers


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Obesity in America


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Diabetes in the United States

• 14% of US Adults

with Diabetes

• 38% of US Adults

with Pre-Diabetes

Menke A et al. Prevalence of and trends in Diabetes among adults in the United States, 1988-2012. JAMA 2015;314:1021-1029.


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Potential

Capability

Actual

Capacity

Team

Performance

Are You Fully Charged?


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Go For Green


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HPRC


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Operation Supplement Safety


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• DVA’s strategic goal: “provide Veterans

personalized proactive and patient-driven

health care”– Contracted U of Wisconsin who developed

20-hr “Whole Health” course to start the

cultural shift in the VHA ($2 million)

• DVA’s successful pilot in FY 13 (23 courses) resulted in continued funding for 5 additional years. Outcome data showed:– 80% of providers changed patient interactions after the course

– 90% of changed encounters received positively by patients

– Improved self-efficacy among clinicians (2 months after course) in discussing non-pharmacologic approaches to:

• Pain, Depression, GI disorders

– Most commonly reported change—Changing Conversation (open-ended question)

Dep. of Veteran Affairs (DVA) Solution


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Move to Health

• Me - Self-Care– Performance Triad

– Emotional

– Family

– Social

– Spiritual

• Total Army Family– Spouses

– Friends

– Family

– Leaders/Peers

• MTF– Predict and Prevent

– Chronic care management

– Complimentary and Alternative treatments

– Integrated and Streamlined

• Lifespace– The Built environment that supports healthy lifestyles and early intervention

“Changing the Conversation in Army Medicine”


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Our Job…Total Army Family


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What should you eat?


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The Best Diet?

• Optimal diet?

• Carbs?

• Fat?

• Protein?

• Paleo?

• Vegan?

• Vegetarian?

• Pegan?

• Pescatarian?

• Mediterranean?

• DASH?


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The Healthiest Diet for Diabetes?


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Saturated Fats and CV Disease


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Calorie in = Calorie Out?

200 Calories


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Sleep Problems and Their

Impact on U.S.

Servicemembers

Troxel W. et al. Sleep Problems and Their Impact on U.S. Servicemembers: Results of a Cross-Service Survey. Santa Monica, CA: RAND Corporation, 2015.


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Coping with Sleep and Fatigue

Troxel W. et al. Sleep Problems and Their Impact on U.S. Servicemembers: Results of a Cross-Service Survey. Santa Monica, CA: RAND Corporation, 2015.


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This is your Brain…on Exercise


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System for Health:

Enabling Land Power Through the Human Dimension

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Arm

y M

edic

ine:

Rea

din

ess

Pla

tfo

rmLa

nd

po

wer

Req

uir

emen

ts

Performance Triad Delivery of Health Healthy Environments

Enhanced Performance &

Readiness of the Force

Enables Health of Soldiers,

Families, and Retirees

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TSG 44 PRIORITIES: Readiness and Health | Healthcare Delivery | Force Development | Take Care of our Soldiers, DA Civilians, and Families

HealthcareTo

Health


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• 75% of American youth are unfit for military service; up from 50% in WWII

• 66% of all military personnel are overweight and 12% are clinically obese.

• Over 20,000 Soldiers are medically non-deployable

• 10 million limited duty days; up to 80% from preventable conditions

• Healthcare costs currently exceed 10% of DoD budget

• 1,815 Soldiers were discharged in FY12 due to failing to meet height/weight standards; with a recruiting and training cost loss of over $98 million

Impact on National Security


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EXAMPLE

PERFORMANCE TRIAD WEEK


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SUNDAY

TO DO DAILY:

WatchRead


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MONDAY

TO DO DAILY:


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TUESDAY

TO DO DAILY:


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WEDNESDAY

TO DO DAILY:

Post pics of Monday’s P3 Triangle Send encouraging texts to workout buddy Share favorite healthy new recipe


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THURSDAY

TO DO DAILY:


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FRIDAY

TO DO DAILY:


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SATURDAY

TO DO DAILY:

Take the dog for a runFarmers market with kidsFamily nap to catch up on sleep


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Sleep Needs-Across the Ages

• Newborn (0-3 months)

– 14-17 (11-19)

• Infant (4-11 months)

– 12-15 (10-18)

• Toddler (1-2 years)

– 11-14 (9-16)

• Pre-school (3-5 years)

– 10-13 (8-14)

• School-Age (6-13)

– 9-11 (7-12)

• Teenager (14-17)

– 8-10 (7-11)

• Young Adult (18-25)

– 7-9 (6-11)

• Adult (26-64)

– 7-9 (6-10)

• Older adult (65 and older)

– 7-8 (5-9)

http://www.sleepfoundation.org/ Updated 2015

http://www.sleepfoundation.org/


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• How much?

• How often?

• What type?

• What intensity?

• What about for

weight loss?

• With chronic

disease?

• Standing?

Prescribing Exercise


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Move2Health

Mission: provide a training course targeted initially at the PCHM

and SCMH teams to “change the conversation” from a disease

and injury-centric approach to a personalized, proactive,

person-centered approach that is focused on promoting the

health and wellness of the Total Army Family

Objectives:

• Enhance team’s capabilities to provide person centered care

• Increase patient satisfaction

• Increase PCMH team satisfaction

• Improve clinician’s resiliency

• Does NOT increase PCMH workload

Performance Triad: Advancing the System for Health...2016/03/30 · Action Officer / e-mail / phone...

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Transcript of Performance Triad: Advancing the System for Health...2016/03/30 · Action Officer / e-mail / phone...