Transformation Using the Triple Aim Framework: A MultiCountry Perspective

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Transformation Using the Triple Aim Framework
A Multi-Country Perspective

• Carol Beasley
• Institute for Healthcare Improvement

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Three Dimensions of Value
Population Health
Experience of Care
Per Capita Cost

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Design of a Triple Aim Enterprise
Define Quality from the perspective of an
individual member of a defined population
PH
The Triple Aim

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Health care Public health Social services
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Design of a Triple Aim Enterprise
Define Quality from the perspective of an
individual member of a defined population
PH
The Triple Aim

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Health care Public health Social services
System-Level Metrics
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Potential Triple Aim Outcome Measures 6/09
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Triple Aim Phase 1
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Phase 1 Concept Design and Projects

• Acting with individuals learning for populations
• Definition of focus populations
• Moving one or more of the three aims in a desired
  direction

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Case Presentation 1

• 48 yr old female Discouraged
  and skeptical
• Homeless, living in a shelter
  at coast, unable to manage
• COPD, HTN, new DM, chronic
  pain (on methadone), recent pneumonia, hx of ETOH
  abuse, heavy tobacco use
• 5-6 recent admissions for recurrent pneumonia and
  hypoglycemia O2 sats on admission were as low as
  56 often left AMA
• Member has DME O2, nebulizer, cane
• Missed a pulm consult due to transportation

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The Population - Individual Challenge

• How do we create reliable, reproducible
  standardized, efficient population
  interventions.
• that respond to unique individual needs?

Standardized Reproducible
Unique Individualized
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CareSupport Design Principle Mass Customization

• Create a stable but still flexible and adaptive
  population solution space
• Act for the individual in a holistic,
  efficient manner
• Bring in customer to co design interventions
• The help I want and need, when and how I
  want and need it.
• Keep cost equation favorable
• Custom but not Boutique. Services
  delivered for most efficient/ effective
  population impact

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Scaling Up Intake Efficiency
Current Way
Improved Way
Old Way
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Case 1 Actual Overall PMPM
CareSupport Interventions
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Measurement at the PopulationPMPM for
CareSupport
N652
N546
N431
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Triple Aim Phase 2
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Phase 2 Detailed Design

• Patients and families
• Primary care
• Prevention and health promotion
• Cost control
• System integration

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Cost Control Drivers of a Low-Value Health System
Low Value
High Cost
Low Quality
Supply- Driven Demand
No mechanism to control cost at the population
level
New drugs and tech ? outcomes
Over- Reliance On Doctors
Under- valuing system design
Insignificant role for individuals and families
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Improving Specialty Care
1.Training for physicians 2.Deployment of patient
decision support technologies (decision aids)
Shared Decision Making with Patient Improved
Process of Care Care Coordination
1.Identification of opportunity 2.Evidence-Appropr
iateness Criteria 3.Consensus Building 4.Reliable
Design 5.Education 6.Internal score
cards 7.External score cards 8.Tools for
deployment

• Measures
• PROM
• Utilization Rates
• Population Cost

Decreasing Overuse
1.Written service agreements between Primary
Care and Specialty Care 2.Patient Primary Care
Pact
Patient Reported Outcome Measure
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Learning from Individual Patients

• HealthPartners 10 Case Review of Heart Failure
  Patients

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HealthPartners Results for Heart Failure

• Heart Failure Core Measure (all or none bundle)
  at 100
• Measure is the same value for all populations
  (white vs of color)
• Readmission rate for CHF patients is low

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Elements for a perfect score must include all of
the following 10 criteria

• Symptoms Worsening Instructions at Discharge
• Weight Monitoring Instructions at Discharge
• LVF Assessment
• ACEI for LVSD
• Adult Smoking Cessation Advice/Counseling

• All Discharge Instructions
• Activity Instructions
• Diet Instructions at Discharge
• Follow-up Instructions at Discharge
• Medications Instructions at Discharge

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Description Reports readmissions within 30 days
for patients discharged from the hospital with a
primary diagnosis of HF who were readmitted
within 30 days of discharge with a primary
diagnosis of Heart Failure
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Despite our great results, 10 case review
shows another story for some individuals
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Findings

• Lack of coordination of care across providers and
  specialties.
• One patient called the nurse care line 23 times
  for various reasons
• Multiple medications and issues with adherence
• Lack of communication and understanding
• Financial challenges
• Continuity of care challenges.
• Lack of connection with vended programs for
  telemedicine and other health plans.
• Triggers for case management are claims based
  and not timely.
• Follow up visits after hospital discharge are not
  always scheduled and/or completed (due to health
  and social issues)
• One year impact
• 10 patients had 27 inpatient admissions and 4
  separate ED visits.
• Two of the patients had 8 admissions each

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Opportunities/Actions

• Medical Home (between visit care)
• EMR enhancement to flag multiple calls
• Automate referral process to the Medication
  Therapy Management Program (opt-out instead of
  opt-in)
• Review and improve communication and system
  connections so they are made earlier.
• Medical Home will include outreach to patients
  and follow-up after discharge. Home care services
  could be used more often. Insert tools into EMR
• Trigger Tool developed and implemented at
  hospital. Explore option to use similar tool in
  ambulatory care.

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Conclusions

• Failures were often a result of lack of
  communication lack of EMR tools, information
  for patients, sharing information with other
  parts of the organization
• Social issues play a huge factor (finances,
  transportation, personal responsibilities)
• Measures only tell a portion of the story

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Triple Aim Phase 3
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Sub-Population Focus

• Employed people lt 65 years old
• People gt 65 years old
• People with high social deprivation
• Children and families

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Design Needs by sub PopulationFirst Draft
All cells are important for all sub populations.
Blank means only minor differences in approach.
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Phase 4 Regional Redesign

• NHS Regions
• Canadian Provinces
• Australian state
• US
• States Vermont Washington, DC, Colorado,
  Minnesota
• Counties Brown County, WI Genesee County, WI
  Santa Cruz County, CA Hamilton County, TN
• Hospital Referral Regions How Do They Do That?
  sites

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Population Served by Your Enterprise

• NHS East Lancashire commissions services and
  provides care for 382,000 people.
• In 2006/07 it was predicted that by 2011 there
  would be a life expectancy gap across East
  Lancashire of 16 years 9 months for males and 14
  years 6 months for females
• In October 2007 a Health Summit was held in East
  Lancashire and a target agreed to Save a Million
  Years of Life by 2011 to halve the life
  expectancy gap between East Lancashire and the
  England average

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Changes Being Implemented for your Population?

• Focus on 5 key areas
• Cardio Vascular Disease Prevention and early
  intervention for people at high risk
• Infant Mortality - Understanding the causes for
  the high rate to inform effective action
• Drugs Effective partnership working to improve
  treatment outcomes and prevention
• Alcohol Social Marketing Campaign to reduce
  alcohol consumption Know when to say when
• Geographical Inequalities Targeting areas of
  deprivation to improve services, access to
  services and health and well being

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SMYL - Year 1 Results
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Triple Aim Phase 4?
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Components of a Learning System for the Triple
Aim

• System level measures
• Explicit theory or rationale for system changes
• Segmentation of the population
• Learn by testing changes sequentially
• Use informative cases Act for the individual
  learn for the population
• Learning during scale-up and spread
• Periodic review
• From Tom Nolan PhD, IHI

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Three Dimensions of Value
Population Health
Experience of Care
Per Capita Cost