By Yan Kennon

Naval Hospital Jacksonville Public Affairs Senior Writer

Naval Branch Health Clinic (NBHC) Mayport now offers a diabetes team and an osteoarthritis team, as part of an ongoing value-based care pilot program initiated at Naval Hospital (NH) Jacksonville in 2016.

This innovative, value-based strategy focuses on the results that matter most to patients:  feeling healthy, being able to do daily activities, and fulfilling life roles like work and family.

The value approach organizes care around patients with similar needs and medical conditions.  NBHC Mayport has developed two multidisciplinary teams (called integrated practice units or IPUs), for diabetes and osteoarthritis.  

Value-based care focuses on doing what's right for patients, in ways convenient and acceptable to them.  The goal is improved patient outcomes, increased readiness, higher patient satisfaction, and improved value with optimal resource utilization.

 "Our diabetes and osteoarthritis teams will help keep our Navy and Marine Corps family healthy, ready and on the job," said Capt. Evelyn Tyler, NBHC Mayport officer in charge.  "It's all about providing better health outcomes." 

Each IPU consists of a dedicated team of providers who are focused on that condition.  The team is responsible for the full cycle of care - outpatient, inpatient (at NH Jacksonville's hospital) and support services - for that condition.  The team uses evidence-based strategies to monitor treatment and enable patients to reach their health goals.  The diabetes team includes a physician, pharmacist, behavioral health specialist, dietician, and diabetic nurse educator.  The osteoarthritis team includes a pain management specialist physician, physical therapist, behavioral health specialist, dietician, and a wellness nurse.  Both teams include a care navigator to help patients along the way.

IPU patients can expect to see personalized care plans that include their unique goals, individual and group appointments with the team, fewer appointments in general (to save patients' time), and enhanced communications.

In addition to the common quality measures that physicians use (like procedure success rates), the clinic will also track patients' reports over time, of how well they're able to do daily activities.

Patients enrolled in either IPU also remain part of their Medical Home Port team.  This includes access to the appointment line (904-270-3248); 24/7 Nurse Advice Line (800-TRICARE or 

800-874-2273); access to a wide range of online services (including emailing the doctor) with TRICARE Online Patient Portal Secure Messaging ( or; TRICARE pharmacy home delivery (; and customer relations, to help improve the care experience (904-270-4282).  

Both the diabetes and osteoarthritis IPUs are currently enrolling patients with the most complex cases, who can gain the greatest benefit from the value-based care approach.  Patients can ask their primary care manager (PCM) about joining the IPU.  To find out more, call the hospital's diabetes IPU at 904-542-7636, or the clinic's osteoarthritis IPU at 904-270-4371.

NBHC Mayport is one of NH Jacksonville's six health care facilities located across Florida and Georgia.  NH Jacksonville's priority since its founding in 1941 is to heal the nation's heroes and their families.  The command is comprised of the Navy's third largest hospital and five branch health clinics across Florida and Georgia.  Of its patient population (163,000 active and retired sailors, soldiers, Marines, airmen, guardsmen, and their families), about 85,000 are enrolled with a primary care manager and Medical Home Port team at one of its facilities.  To find out more or download the command's mobile app, visit