The National Intrepid Center of Excellence (NICoE): pioneering the use of Integrated Practice Units for addressing traumatic brain injury

Thomas DeGraba1, Tracey Perez Koehlmoos2, Cathaleen Madsen2,3, Aroon Karra4, Michael Dinneen5

1National Intrepid Center of Excellence, Bethesda, Maryland, USA. 2Uniformed Services University of the Health Sciences, F. Edward Hebert School of Medicine, Bethesda, Maryland, USA. 3Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA. 4Deloitte Consulting, LLC, Arlington, Virginia, USA. 5Office of the Assistant Secretary of Defense for Health Affairs, Falls Church, Virginia, USA.

Introduction Methods

Results

Conclusions

The concept of an Integrated Practice Unit (IPU) was developed by Porter and Lee in 2013 as a way to improve outcomes and save costs through coordinated, whole-patient care. This study describes the development of a tool derived from Porter’s and Lee’s work that enables measurement of a facility against concrete IPU criteria for the Military Health System (MHS). It then tests the tool against the National Intrepid Center of Excellence (NICoE), a military facility where patients with traumatic brain injury (TBI) receive coordinated, interdisciplinary care in a TBI and behavioral health, intensive outpatient program (IOP).

The MHS IPU assessment tool was developed by adapting the 78 characteristics of the patient-centered specialty practice (as described by the National Committee for Quality Assurance) to the 10 characteristics of the IPU as described by Porter and Lee, resulting in 17 MHS IPU recognition criteria. The resulting IPU tool was then applied to the TBI IOP at NICoE, a known center of coordinated care, to provide a real-world test of the tool as well as to determine NICoE’s status as an IPU. NICoE staff members evaluated the ability of the Center to meet each set of criteria using one of three responses: yes, partial, or no.

Discussion

Criteria # of Sub-Criteria

# Met Criteria # of Sub-Criteria

# Met

CondiZon-centered care spanning the full cycle of care

3 3 Oversight of patient's care by clinician with deference to expertise

2 2

Structure and governance 1 1 Measurement of outcomes (clinical and patient reported), costs, care processes, and patient experience using a common platform, and accept joint accountability for results.

2 1+1 partial

Co-located care with common electronic health records (EHR) and workflows

3 2+1 partial

Regular team meetings to discuss patient care, process improvement, cost control

2 1+1 partial

Integration of prevention and patient engagement, elimination of barriers

4 2+1 partial+1 NA

Total 17 12+4 partial +1 NA

Of 17 elements, 5 measures related to organization and coordination of care, 3 to communication and recording, 4 to administration and oversight, and 4 to patient engagement. The greatest strengths for NICoE lay in coordination of care and patient engagement, while greatest opportunities for improvement lay in cost education for the care team, tracking/ follow-up of outside care, and electronic health record issues.

This IPU assessment tool captures strengths and gaps of an integrated care facility within the MHS. Continued evaluation with this tool should increase care effectiveness at NICoE and enable evolution of care pathways for TBI. Iterative refinement of the tool is expected to inform transformation of care in the MHS and potentially across the United States.

DISCLAIMER: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions or policies of the Uniformed Services University of the Health Sciences (USUHS), the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF), Deloitte Consulting, LLC, and its subsidiaries; the National Intrepid Center of Excellence (NICoE), the Department of Defense (DoD), or the Departments of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations does not imply endorsement by the U.S. Government. The authors declare no conflict of interest.