1. Host Nation Medical Care Lessons Learned Medical Director, TAO-P

2. TRICARE Pacific 2 Hope is never a good plan.

3. TRICARE Pacific 3 Frequently Encountered Problems Patients The doctor wouldn’t explain things  Doctor/Patient relationship & communication (The “Sensei”) The nurses wouldn’t listen or help  Language barriers and the role of nursing The facility was old and dirty  Sometimes old and, yes, sometimes dirty I couldn’t get pain medications readily  Differing standards (the epidural) I couldn’t eat the food I couldn’t find the clinic I had to wait forever

4. TRICARE Pacific 4 Frequently Encountered Problems MTF Staff The standard of care is unacceptable  Prolonged hospital stays  Delay in interventional treatments  Technology-Practice disconnect  Diagnosis not shared with patient  Medications disguised I can’t get timely or complete reports  Lack of formal medical communication standard  Language barriers

5. TRICARE Pacific 5 Frequently Encountered Problems Host Nation Providers We’re not always sure what the patient or MTF provider wants.  What service is desired, in what time frame, etc.? We have a difficult time communicating in English.  Fluency often better than willing to admit We don’t understand your insurance plans. We can’t get paid on time.  They are not in our network and have no obligation to play by our rules. They expect payment on or near point of discharge.

6. TRICARE Pacific 6 Solutions Long Term Relationship Investments Communications Managing Expectations No One-Size-Fits-All Solution

7. TRICARE Pacific 7 Invest in Long Term Relationships It’s all about “Relationships” HN: In place for a lifetime, US: 2-3 years Who needs whom? Drinking Green Tea Build both professional and social relations  Reciprocal medical rounds  Publishing = legitimacy  Nurse exchange programs  Recognition (awards & the Base mystique)  Social (Golf and the 19 th hole)

8. TRICARE Pacific 8 Communication Necessary, but can be problematic  “Sorry, No beds available for admission” Cultural norms  Direct vs oblique  Formal vs informal  Verbal vs written  Many providers do not send reports, much less details Sub-rosa communications  Medical Staff to HN Staff  The Good, the Bad and the Ugly  MTF HN employees  Risk/Benefit Ratio  The Japanese Intern  Use, Don’t Abuse

9. TRICARE Pacific 9 Managing Expectations Patient Limit patient surprises  Patient Guides to HN Health Care  What to expect with facility, wait times, visits etc.  How to communicate with HN staff Nurse vs Doctor  How to help yourself  MTF HN employee assistance and tracking  Travel assistance  Communications assistance  Records assistance  Reports back to MTF provider and command Seek patient experience and address their concerns

10. TRICARE Pacific 10 Managing Expectations MTF Providers MTF Provider education  Need to understand HN culture and medical capabilities  Build knowledge and pass it along (Preferred Providers)  Listen to MTF HN employees  Listen to patient experiences MTF/HN Provider relationship building  Engage HN counterparts before sending pts.  How to communicate, receive reports, etc.  Call/Message HN provider to set case expectations  Provide relevant case information and expectation for care  Make sure patient hand delivers all labs, films, etc.  Provide follow up on cases  Publish! Medical Quality Assurance and Review  US standards vs HN standards?  Role of the MTF Provider and MTF HN employee

11. TRICARE Pacific 11 Managing Expectations HN Providers Be clear on desired end state for patient experience  The Mayo Clinic perception Find comfort level for communication  Written or verbal Payment  Make sure our patients understand their requirements  Supplemental Funds, Payment at Discharge  Just-In-Time hospital operations