Soldier Centered Medical Home

A. A Soldier Centered Medical Home (SCMH) is the Soldier's version of a PCMH which provides 90% of all Soldier care on site and is the same as all other PCMHs except SCMH's have integrated medical staff from line units and Military Treatment Facilities to make up a full team. It also has augmented behavioral health and physical therapy.
 
Soldiers receive dedicated Soldier care in their Area of Operation (AO), increased physical therapy services, dedicated Behavioral Health, pharmacy and dietitian services, improved care coordination, internal case management services, expanded ancillary care (pharmacy, radiology, and lab), improved medical readiness, and decreased ER utilization.
 
SCMH supports the military’s unique mission and understands the challenges facing Active Duty Soldiers. At SCMH we provide patient-centered, coordinated team-based care to each Soldier with the goal of improving our Soldier population’s overall health and well-being to support a medically ready force – for healthier, stronger, and more resilient Soldiers.

A.  Your SCMH care team includes a Primary Care Manager (PCM) – a Physician, Physician Assistant or Nurse Practitioner – as well as a Nurse (RN and LPN), Medic, Health Technician, Medical Support Assistant (clerk), Pharmacist, Case Manager, Dietician, Behavioral Health Specialist, and Physical Therapist.

A.  A PCM is the leader of your medical home care team. Your PCM is responsible for organizing, coordinating, communicating and monitoring your care across multiple settings with specialty providers and support staff.
 
Seeing your PCM at every visit is important to establish the provider-patient relationship that is the cornerstone of patient centered care. We will make every effort to give you appointments with your PCM. If for some reason your PCM is not available, we will schedule you with another provider within your medical home team who will have access to your medical record and provide continuity of care.

A.  •Your team will have appointments available to meet your needs. You can reach your team in person, by phone, and through secure messaging.
•Your team will assist in coordinating specialty appointments.
•Your health information will be documented in an electronic medical record to ensure all team members and specialists have convenient access to your medical information.
•Your team will help you identify realistic health goals and help you achieve those goals by providing self-management tools and support.
•Your team will provide you with self-care health information, and will assist you with early recognition of potential health problems and prevention of chronic disease.

A.  Take an active role in decisions and activities affecting your health:
 
•Talk with your health care team, ask questions and share your successes and the concerns in taking care of your health.
•Keep your team informed of all health care visits to specialists, dentists and emergency rooms (ER), and let them know if you are admitted to the hospital.
•Make sure you understand your plan of care and develop SMART self-management goals.
•Tell them what medications you are taking.
•Work with your team to maintain or meet your optimum level of wellness.
•Speak up — tell your team what is not working well and what is causing problems.
•Make sure your contact information is up to date in our system.
•Let your team know how they are doing, in person or by completing surveys.
•If you’re unable to keep an appointment, please call your clinic at least 24 hours in advance so we may offer the appointment to another Soldier.

A.  There are multiple ways to receive care in the way that works best for you. Although some health needs require a face-to-face appointment, many things can be conveniently addressed using technology (virtual healthcare).
 
•Face to face appointments: You can schedule an appointment for a same day issue or in the future with your Primary Care Manager (PCM). If you need to be seen during a time when your PCM isn't available, we'll get you in to see one of the providers on your team.
•TRICARE Online Patient Portal allows you to contact your care team via secure messaging and view your own health record through the web. Use TOL to schedule appointments, request prescription refills, and view your test results.
Nurse Advice Line: You can speak to a Registered Nurse if you are unsure whether to seek care for a health condition. The NAL Nurse can help determine if and when you should see a doctor.

A.  •Please ask to speak to the clinic NCOIC or OIC. Our trained staff is ready to assist and address your concerns right away.
•If you do not feel comfortable talking with our staff, you can place an Interactive Customer Evaluation (ICE) Comment online at https://www.ice.disa.mil/. For location, type “Schofield Barracks,” click on “Health,” then choose the appropriate SCMH clinic.
•You may receive a patient satisfaction survey called Joint Outpatient Experience Survey (JOES). This survey is used to gauge the performance of all Military Treatment Facilities. Your feedback, positive or negative, is instrumental in identifying areas of strengths and weaknesses to better serve you.

A.  The team will help you coordinate your appointments with your PCM or other members of the team at each visit.
•Providers will review your medical records prior to the visit to ascertain if test results and specialty reports are available during your visit.
•The team will coordinate care with specialists if needed.
•Your provider may offer education on wellness and health promotion and remind you of visits and age-appropriate wellness screenings.
•The team may inform you if it can meet your needs over the phone or through secure messaging instead of having you come into the clinic.
•Your team is able to provide a list of your current medications and written education materials.
•Your providers may also remind you of military health care readiness requirements such as Periodic Health Assessment.

A.  •Bring your military identification cards with you to your appointment.
•Make a list of your health questions and bring it to your appointment.
•Let your team know if you will need a language interpreter or require special accommodations during the visit.
•Make a list of other health care providers you’ve seen and bring it to your appointment. Include names, addresses, phone numbers, and the reasons you visited.
•Set up appointments with other team members such as a pharmacist, registered nurse, behavioral health specialist, or dietician if needed. Remember, these experts are here to serve you.
•Take a list of all of your medicines to every appointment. Be sure to include prescription, over-the-counter, natural, and herbal medicines and vitamins. This list is especially important if you or your family members are being seen by any other health care provider outside of your clinic.
•Complete any test results (e.g., blood tests, X-rays, MRIs) ordered by your PCM prior to your next appointment
•During your appointment: