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• Preface
• Figures and Tables
• Summary
• Acknowledgments
• Abbreviations
• Chapter 1: Introduction: Background
• Study Objective
• Methods
• Organization of the Report
• Chapter 2: History and Authorities for External Medical Care and Training: History
• Legal Authorities and Department of Defense Policy Guidance for Military-Civilian Agreements
• Liability Issues
• Chapter 3: Information from the Medical Training Facility Data Call: Chapter 4: Types of Agreement and Review of Selected Agreements: Mechanisms for External Medical Care Resource Sharing and Training
• Review of Selected Agreements
• Chapter 5: Findings from Stakeholder Discussions, Including Site Visits
• Common Themes from Stakeholder Discussions
• Chapter 6: Conclusions and Recommendations: 1: Update and expand Office of the Surgeon General and Army Medical Command policy guidance for external resource-sharing agreements and gratuitous training agreements
• 2: Identify appropriate proponent for external resource-sharing agreements and for gratuitous training agreements
• 3: In the short term, identify potential untapped opportunities related to different types of external practice, especially external resource-sharing agreements, and raise awareness to encourage their use when justifiable in medical treatment facility business plans
• 4: For longer-term policy purposes, conduct a quantitative assessment of the costs and potential efficiencies associated with care provided in the Military Health System compared with those in different civilian options, such as those examined in this initial qualitative study
• : If such analysis warrants, encourage the expansion of agreements to include a wider range of Army medical professionals and medical teams
• 6: Maintain the current scheme of decentralized management, but consider a mechanism for central visibility of agreements
• 7: Facilitate mechanisms to share experiences and learn lessons about different types of sharing and training agreements
• APPENDIXES: A. Organizations Consulted
• B. Office of the Surgeon General and Army Medical Command Policy Guidance on Department of Veterans Affairs–Department of Defense Sharing Agreements
• C. Office of the Surgeon General Policy Guidance on Gratuitous Training Agreements
• D. Details of Findings Related to Medical Treatment Facilities
• Bibliography.

"Army medical professionals must maintain the high level of proficiency required to fulfill the Army's medical missions of supporting military operations and providing beneficiary care. Because beneficiary care demands in a U.S. medical treatment facility (MTF) do not mirror those in a combat setting and sometimes can exceed the MTF's capacity, some MTFs enter into agreements with local civilian facilities to meet shortfalls in beneficiary care or training. The study's objective was to assess Army medical practice in U.S. Department of Veterans Affairs and non-Veterans Affairs civilian facilities and suggest opportunities for improving military-civilian synergies"--Back cover.

• Introduction
• Methods and data
• Asthma populations and practices at the baseline
• The guideline implementation process
• Effects of guideline implementation
• Synthesis of findings from the demonstration
• Appendix A. Hypotheses for effects of improved asthma care practices
• Appendix B. Evaluation methodology
• Appendix C. Modules of the climate survey
• Appendix D. Physician questionnaire
• Appendix E. Analyses of asthma metrics.

In partnership with the Army Medical Department (AMEDD), RAND researchers worked to implement clinical practice guidelines in treatment of three common ailments (asthma, diabetes, and low back pain). This report is an evaluation of the asthma practice guideline demonstration. It documents the extent to which intended actions were implemented, assesses short-term effects on clinical practices, and measures the quality and limitations of available data for monitoring practice improvements and clinical outcomes. The authors found that, although the implementation scored some notable successes, resource limitations and organizational barriers curbed overall progress. They conclude that allowing for flexibility, monitoring the facilities consistently, and training providers thoroughly are the keys to implementing the practice guidelines throughout AMEDD. The also concluded that patient education was an area in need of improvement.