There is an African proverb that states, “It takes a village ...” This maxim also holds true for the holistic approach required for soldiers who are ready, lethal and able to meet the Army’s needs.
Initiatives from the Army’s SHARP, Ready and Resilient Directorate; the U.S. Army Training and Doctrine Command’s Holistic Health and Fitness Program; and the U.S. Army Futures Command’s Soldier Lethality Cross-Functional Team recognize the importance of a holistic approach to soldier lethality. The emphasis is on building the physical supremacy, cognitive dominance and emotional resilience required for a soldier to excel in a multidomain operation. This requires a whole-of-Army approach to understand the human dimension of warfare. A community approach toward investing in our most prized weapon system, the U.S. soldier, supports Army Chief of Staff Gen. James McConville’s priority of placing people first.
While many appreciate the historic mission Army Medicine has fulfilled to “conserve the fighting strength,” the story is more complex. New initiatives from across the Department of the Army are expanding the approach to health and readiness to ensure that the soldier remains the most prized weapon system on today’s and tomorrow’s battlefield. From an enterprise perspective, the Military Health System can be viewed as an employer-based provider and payer of care, one of the largest in the nation, caring for 9.4 million beneficiaries. For Army Medicine, that employer happens to be an expeditionary Army where readiness of the force is the most critical population health outcome.
Therefore, unlike CEOs of a civilian hospital, a military medical treatment facility commander is required to also serve as an installation’s director of health services. Over the past decade, as Army Medicine has transitioned from a health care system to a system for health and readiness, the roles of the director of health services have dramatically shifted and expanded. Army Medicine is no longer the traditional “find it and fix it” civilian medical clinic, but rather a community focused on:
- Prediction, preemption and prevention.
- Early identification and intervention.
- Evaluation and treatment.
- Rehabilitation and reintegration after injury and disease.
These changes empower a medical treatment facility to act as both a health care network and an agent of public health. It can expand health outside brick-and-mortar facilities and operate where people live, love and labor to best translate health care delivery into readiness through physical, cognitive and emotional health. This model of approaching health from the installation level is population-focused, emphasizes health care collaboration, and focuses on improving the main population outcome (readiness) for beneficiaries.
This article will outline and highlight the non-health care delivery roles and responsibilities of the director of health services to build a medically ready force and improve community and installation health at the operational level (working with the senior commander, garrison commander, senior military leaders and community partners to identify health readiness gaps) and the tactical level (facilitating solutions between the medical unit and installation resources to maintain, restore and improve physical, cognitive and emotional readiness, health and wellness based on identified installation priorities).
Soldier Support
The most powerful weapon system in the Army will always be the soldier. Spurred by 2017 National Defense Authorization Act legislative changes, Army medical treatment facilities have effected installation-level changes to ensure soldiers are physically, mentally and emotionally ready to “Fight Tonight.”
One of the main health issues that impacts readiness is musculoskeletal injuries. In 2017, active-duty soldiers experienced 1,821 new injuries for every 1,000 person-years, affecting over half of all soldiers each year, according to the Army’s “2018 Health of the Force” report. The impact of injuries is staggering and typically results in about 10 million limited-duty days per year. To address this, the director of health services works with U.S. Army Forces Command partners to support and coordinate early identification efforts, and to profile review boards, physical training curriculums and other programs. These efforts, coupled with physical therapists embedded within the brigade, have dramatically decreased the injury burden on readiness.
The “2018 Health of the Force” report also says 15% of soldiers have a behavioral health disorder. To address these conditions, the director of health services must appoint a senior behavioral health officer as the installation director of psychological health to leverage all available behavioral health capabilities, providing collaborative, full-spectrum services. The installation director of psychological health leads the Behavioral Health Working Group within the Community Ready and Resilient Council (CR2C), synchronizing a broad array of spiritual-, community-, mental health- and family-oriented programs to form a continuum of preventive inpatient or outpatient care.
Integrated behavioral health consultants within primary care medical homes provide routine behavioral health support for outpatient medicine clinics, including smoking cessation, sleep hygiene, non-medication pain management and healthy living. The Army’s practice of embedding behavioral health staff far forward has also improved medical readiness outcomes. Pre- and post-deployment transitions are known periods of stress on soldiers and their families.
Because of the close relationships with organic unit behavioral health and chaplain assets, embedded teams are able to ensure early comprehensive services are provided to soldiers and families in need. This provides a stable environment for mission focus and, ultimately, readiness. Early detection and treatment resulted in a significant decrease in the number of inpatient behavioral health bed days utilized by service members.
The director of health services programs supports the unique readiness challenges of female soldiers, who make up 15% of the active-duty force. In addition to Army Medicine’s mandate to provide high-quality care for pregnant women, additional programs ensure female soldiers are physically, cognitively and emotionally ready after delivering a baby.
One example is Pregnancy Postpartum Physical Training (P3T), an Army-unique, standardized, holistic, physical training and educational program to help soldiers maintain fitness during pregnancy and postpartum recovery. Nearly 70% of P3T participants surveyed affirmed the program’s efficacy in helping them pass elements of their fitness tests, and 29% said it influenced them to remain in the Army, according to the “2016 Health of the Force” report.
Another program, called Centering Pregnancy, groups women with similar delivery dates whose extended families are not close enough geographically to support them. Also, recognizing the critical role of nutrition on development and readiness, the director of health services at Fort Riley, Kansas, invited a representative from the Women, Infants and Children program into the post hospital to help ensure optimal nutrition during and after pregnancy.
Army Medicine is also moving from isolated programs that address individual medical concerns to holistic programs that incorporate a range of them. For example, if a soldier has previously struggled with weight gain and body composition, programs such as Fit for Performance and Army Wellness Centers are in place to augment medical treatment to help ensure a fit and ready soldier returns to the force.
Similar programs exist for soldiers who become ill and struggle with passing Army physical fitness tests. The Move to Health program builds the patient-provider relationship and synchronizes treatment with many of the Army Medicine, garrison and community resources addressing exercise and nutrition, family and community, and behavioral health resources to improve soldier rehabilitation and reintegration after illness or injury.
Army Medicine’s Performance Triad promotes daily habits for improved sleep, activity and nutrition. A 2016 National Training Center study found that company-sized elements that did not integrate sleep-management strategies failed to receive a rating of above average (a rating of 4 out of 5) for sleep habits—a significant threat to cognitive dominance and emotional resilience. A variety of data-driven strategies, ranging from techniques for sleep banking to reverse-cycle training to targeting the use of chemical interventions such as caffeine, are provided to leaders to improve the sleep quantity and quality of their units. Nutrition and activity targets and tips are also emphasized to provide reasonable and effective strategies for improvement. The Performance Triad has a significant preventive health impact and strongly improves readiness.
Leader Support
Leader support and engagement is key to successfully improving overall and individual health readiness. At Schofield Barracks, Hawaii, the senior commanding general’s quarterly executive CR2C was tri-chaired by the garrison commander and the director of spiritual health with the director of health services to identify and address the health readiness needs of the post. These needs are then communicated with CR2C working groups to fully synchronize available installation resources behind the Army’s best practices, allowing quicker adoption of readiness-building practices.
The 25th Infantry Division at the Schofield Barracks CR2C implemented a “flipped classroom” concept for its council, in which the data-driven CR2C slides were viewed before the meeting, allowing the council to become a discussion forum for health-readiness challenges, gaps, requirements and solutions.
“The flipped CR2C has allowed subject-matter experts from the physical, behavioral, spiritual, social and family working groups to better understand the needs of the command teams that they support,” said Col. Steve Dawson, U.S. Army Hawaii garrison commander. “The true value of the flipped CR2C is the dialogue that occurs between the brigade commanders, senior leaders and working group subject-matter experts. It is during this dialogue that the commanders share the wisdom that they gleaned from their health of the force data.”
Army Medicine has also been leading the charge to translate data to wisdom for division, brigade, battalion and company command teams by creating dashboards and tools to better understand medical readiness and inform decision-making by unit leaders. The new e-profile facilitates leader-provider conversations, enhances profile review board processes and helps ensure data can inform readiness decisions.
According to Whitfield East’s 2013 monograph, A Historical Review and Analysis of Army Physical Readiness Training and Assessment, the most important aspect of unit physical training is to awaken the warrior spirit each morning. Programs in which physical therapists, occupational therapists and dietitians work with line leadership to enhance unit physical training can be successful.
As detailed in the “2018 Health of the Force” report, soldiers from the 3rd Battalion, 7th Field Artillery Regiment, 25th Infantry Division, experienced a 72% decrease in musculoskeletal injuries after evidenced-based approaches to physical reconditioning were implemented. Additionally, the “medical day” during the Company Commander/First Sergeant Pre-Command Course provides leaders with tools to enhance readiness.
Community, Installation Support
Fundamentally, readiness starts at home. To help create cultural change aligned with Army priorities on readiness, communities of excellence are developed to build a culture that embraces a holistic approach to building soldier and family readiness. Across an installation, the health care system supports Soldier and Family Readiness Groups, Senior Spouse Groups, school programs and other outreach efforts that ultimately facilitate readiness. At Schofield Barracks, for example, a nonprofit organization called Warriors at Ease was integrated into unit physical training, recovery programs at the medical treatment facility and community-based events to integrate yoga into training and promote overall health and wellness. This program quickly grew in popularity across the installation.
At the installation level, the medical treatment facility, along with members across the installation, supports the creation of Healthy Army Communities. One example is the Creating Active Communities and Health Environments toolkit. It has three tools to assess the physical environment and policies on installations related to nutrition, physical activity and tobacco: the Military Nutrition Environment Assessment Tool, the Promoting Active Communities tool and Quantitative Indicators for Tobacco Systems.
The medical treatment facility’s dietitian supports the implementation of DoD’s Go for Green program to improve healthy options at dining facilities and vending machines to promote readiness. All these tools apply choice architecture and build on scientific principles to assess and improve the environments where people live, work and play, increasing visibility and ability to make the healthy choice the easy choice.
Fundamentally, Army Medicine exists to save lives on the battlefield and generate readiness for an expeditionary Army to fight and win our nation’s wars. As the director of health services, the medical treatment facility commander exists to enable human performance optimization and build a more lethal and resilient force by focusing on maintaining, restoring and improving the physical, cognitive and emotional readiness of our soldiers.