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Medical management of medical holdover patients.

In Oct 03, a series of media reports alleged poor treatment of Reserve Component (RC) Soldiers at several installations, most notably, Forts Stewart and Knox. Congressional interest soon led to hearings on the matter. The term "languishing" became popular as the reports claimed substandard housing, poor access to medical care, and discriminatory treatment toward RC Soldiers. The Army Surgeon General (TSG), LTG Peake, immediately directed personal, on-site General Officer evaluations of each medical treatment facility (MTF) caring for what would soon become known as Medical Holdover (MHO) Soldiers. *

Those evaluations revealed several things. Foremost was that we had a large number of MHOs: 4,852 as of 25 Oct 03. In the early days of the Global War on Terrorism, mobilized RC Soldiers who were unfit to deploy, had to remain at the mobilization station. They stayed there until they were sufficiently healed ("fixed") to deploy, or until they went through the medical evaluation board (MEB)/physical evaluation board (PEB) process. Many of the MHOs on hand at the end of Oct 03 had never deployed. (This is what led to the term MHO: the Soldiers were "held over" at the mobilization station.)

The evaluations also revealed that many of the MHO Soldiers were living in barracks appropriate for transient, mobilizing populations. These billets, however, were not conducive to the healing process. Some of the Soldiers had nuclear chains of command. Their units were in Theater, with no rear detachment at the mobilization station or home station. Data from the MTFs showed that MHOs received access to care equal to or better than their active component counterparts, and in accordance with TRICARE access standards. For the MHO population, however, TRICARE access standards were insufficient to prevent rapid accumulation of even more MHOs.

Several immediate actions followed the evaluations. The Assistant Secretary of the Army for Manpower and Reserve Affairs (ASA[M&RA]) assumed oversight of all MHO operations, and created a MHO Tiger Team. Forces Command was made the executive agent for MHO (though it took several months to fully implement this). Installation Management Agency assumed responsibility for command and control of MHOS, and tasked each installation garrison commander to establish a MHO unit. Like the rest of the MHO program, these units have evolved over time, and are now referred to as Medical Retention Processing Units (MRPU). The Assistant Chief of Staff for Installation Management also directed that MH0 Soldiers be housed in so-called Tier I housing. Tier I housing is climate controlled, has a modern latrine in the same building, and has no more than four Soldiers to a room.

The ASA(M&RA) in conjunction with the Army G-1 developed policy that now allows the Army to send home mobilized Soldiers if they are medically unable to deploy. Dubbed The 25 Day Rule, this policy allows the Army to send RC Soldiers home if their pre-existing conditions are found in the first 25 days of mobilization. If their conditions are discovered after Day 25, the Soldiers should be retained on active duty for treatment.

The Surgeon General also took immediate action. Recognizing that TRICARE access standards were insufficient to meet the access needs of MHO Soldiers, LTG Peake mandated enhanced access standards for MHO patients. These were, and remain, 72 hours for all specialty referrals, 1 week for all diagnostic studies, and 2 weeks for scheduled surgeries. Additionally, he directed that all MEB performed on MHOs should be done within 30 days of the time the permanent profile was written until the MEB was mailed to the PEB. The usual standard for that process is 90 days.

These were all necessary and appropriate interventions. However, the one thing none of them accomplished was to get the Soldiers home. Healing takes time, and so does processing a MEB/PEB. Mobilized Soldiers therefore remained on installations for months to achieve final disposition. Therefore in Dec 03, the acting Secretary of the Army approved a plan to create the Community Based Health Care Organizations (CBHCO). The CBHCOs have been described as installations without real estate, and MTFs without clinics. Their mission is to allow healing mobilized Soldiers to live in their own homes, provide Title X work for them near their homes, and acquire health care for them from the Soldiers' home communities. The pilot project began in Arkansas, California, Florida, Massachusetts, and Wisconsin. Each CBHCO was staffed with 30-35 personnel, primarily mobilized Guardsmen, half for command and control, the other half for case management and medical processing. Each provided care for up to 300 Soldiers within their respective state boundaries. The program subsequently expanded such that each CBHCO was responsible for a multi-state region. It expanded again to add three more CBHCOs in Alabama, Utah, and Virginia, and extended capacity to 500 patients per CBHCO. Notably, the CBHCOs do not fall under MEDCOM. Rather, they belong to FORSCOM. The MEDCOM provides technical support to and quality assurance for the CBHCOs.

Despite these interventions, concern over MHO remained high. The MHO became a weekly part of the Army leadership's "Balcony Briefing" in the Army Operations Center, and a bi-weekly meeting on the Director of the Army Staff's calendar. As well, trips to Capitol Hill by members of the "MHO Team" became commonplace as members of Congress and their staffs repeatedly asked for information on MHO. ([dagger])

One reason that interest remained high is that Soldiers continued to have problems. For instance, when a Soldier came to the end of his mobilization orders, the only mechanism to keep him on active duty to receive medical treatment was Active Duty Medical Extension (ADME). The ADME Program, however, was designed for Guardsmen and Reservists injured during annual training or on drill weekend. It was never designed to accommodate the thousand of Soldiers in MHO. Thus, when Soldiers came to the ends of their ADME orders many "fell off" their orders and sustained gaps in their pay and benefits. Manpower and Reserve Affairs and Army G-1 subsequently created Medical Retention Processing (MRP). The MRP is a streamlined process in which mobilized Soldiers volunteer to remain on active duty to receive medical treatment, and in which extensions of orders are automatic after the first 179 days.

Because MHO was an important issue, the ASA (M&RA) directed the MHO Team to visit every site providing care to MHOs, and assess performance of the MTFs and MRPUs. Between Aug 04 and Dec 04, the team conducted more than 40 site visits. Each included multiple sensing sessions with patients. Findings included problems with access to care, perceptions that RC Soldiers received a different priority for care than active component Soldier, rear detachments that refused to allow their Soldiers to go to the MRPUs, MHO Soldiers who were. assigned jobs not commensurate with their rank and skills, and inconsistencies in assignments of MHO Soldiers. Some were assigned to MRPUs, while others were assigned or attached to MTF medical hold detachments/companies. These issues have all been addressed, but some recur as new units mobilize/ demobilize, and personnel change over and have to learn the rules and processes of MHO.

One thing that frustrates both the command and control and the clinical side of MHO is Soldiers who "fight their Boards." These are Soldiers who take advantage of every process and appeal available at every stage of healing and the MEB/PEB process to remain on active duty, and to garner every bit of disability possible. The MHO Team found that Soldier fight their Boards for a variety of reasons. Perhaps the most noble is the Soldier who derives a great deal of self-esteem from serving. Today's Army is, after all, all volunteer. The notion of a Golden Wound, one that guarantees separation from the Army is less acceptable to an all volunteer force. Another type of Soldier who fights his Board is one who knows he cannot return to his civilian job because of his disability. That Soldier prolongs things in an effort to continue to provide for himself and his family. The lesson learned for those Soldiers is that we must provide benefits counseling early, clearly, and often. We must balance that, however, against giving the appearance that we are trying to rush the Soldier's healing process. The Soldier who in-processes one day, and meets the Physical Evaluation Board Liaison Officer the next day is likely to develop that perception.

The current status of MHO is that we have nearly 5,600 on hand. About 1,700 are at the CBHCOs, and the remainder is on our installations, receiving care from our MTFs. The avenge MHO patient has tour patient encounters per month. The number already processed through the system since 1 Nov 30 is almost 16,000. Approximately 10,000 were successfully returned to the Army, fit for further duty. The rest underwent MEBs. The average patient spends 182 days in MHO. Those who are released from active duty (REFRAD) spend approximately 158 days. Those who require a Board action, however, require approximately 335 days. Of those 335 days, only 161 are dedicated solely to healing. The remainder is required for the MEB, PEB, and subsequent administrative processing.

The future of MHO, then, must include even more efforts to streamline administrative processing. ([section]) Reducing the amount of time required to obtain 20-year letters, calculate accurate retirement points, and generate DD 214s are among current goals. Thus far, the Army Medical Department's (AMEDD) stance has been "don't mess with healing time." That is probably good advice for anyone and everyone outside the AMEDD. Within the AMEDD, however, the data on MHO must be used to point out both best and not so best practices. Those best practices have to be applied at every site that cares for MHOS. Moreover, they must be applied in such a way that no MHO Soldier feels he or she is being given "The bum's rush" with regard to treatment.

The future must also include plans to conduct MHO operations without the assistance of mobilized Guard and Reserve Soldiers. Funds to hire personnel are scarce, but RC Soldiers available for CONUS missions are becoming even scarcer. The AMEDD, as well as the Army, and Health Affairs must plan on having MHOS long after the war in Iraq ends. Predictive analyses performed by flue Surgeon General's Decision Support Cell show that for any given daily cohort of MHO patients, at least 1% of them will still be in MHO 411 days later.

In the aggregate, or at the level of the individual patient, MHO is a good news story. The AMEDD has provided, and continues to provide, quality care to large numbers of mobilized RC Soldiers. Some are unable to attain retention standards, and have to proceed to MEB/PEB. The majority, however, heals. Those Soldiers rejoin their units and continue to serve. It is an effort everyone who helps care for MHO Soldiers can be proud of.

* Medical Holdover refers to a RC Soldier. mobilized for the Global War on Terrorism, who needs to remain on active duty to receive medical treatment. This should not be confused with a Soldier who, in accordance with AR 40-40 is assigned to the MTF medical hold company or detachment.

([dagger]) The currant MHO team is a subset of the original MHO Tiger Team, and consists of officers, civilians, chief warrant officers, and noncommissioned officers from Manpower and Reserve Affairs, Forces Command, Office of The Surgeon General, Medical Command, Installation Management Agency, and Human Resources Command.

([double dagger]) RC Soldiers were receiving a different standard: they were being put at the head of the line for care, in front of active component Soldiers. However, because they were being asked "Are you Guard or Reserve?" they perceived adverse discrimination. We Stopped asking the question.

([section]) Thus far, the AMEDD has hired additional assistant Physical Evaluation Board Liaison Officers, the Physical Disability Agency has created a fourth, roving PEB, and Human Resources Command has placed 37 noncommissioned officers at the mobilization stations to assist with processing orders and personnel actions for MHOs.

COL Michael A. Deaton, MC, USA ([dagger])

([dagger]) Medical Corps, U.S. Army. Colonel Deaton is assigned to the Office of The Surgeon General with duty at the Pentagon, Washington DC.
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Author:Deaton, Michael A.
Publication:U.S. Army Medical Department Journal
Date:Apr 1, 2005
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