Title: Transformation Using the Triple Aim Framework: A MultiCountry Perspective
1Transformation Using the Triple Aim Framework
A Multi-Country Perspective
- Carol Beasley
- Institute for Healthcare Improvement
2Three Dimensions of Value
Population Health
Experience of Care
Per Capita Cost
3Design of a Triple Aim Enterprise
Define Quality from the perspective of an
individual member of a defined population
PH
The Triple Aim
E
Health care Public health Social services
3
4Design of a Triple Aim Enterprise
Define Quality from the perspective of an
individual member of a defined population
PH
The Triple Aim
E
Health care Public health Social services
System-Level Metrics
4
5 Potential Triple Aim Outcome Measures 6/09
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7Triple Aim Phase 1
8Phase 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
9Case 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
10The Population - Individual Challenge
- How do we create reliable, reproducible
standardized, efficient population
interventions. - that respond to unique individual needs?
Standardized Reproducible
Unique Individualized
11CareSupport 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
12Scaling Up Intake Efficiency
Current Way
Improved Way
Old Way
13Case 1 Actual Overall PMPM
CareSupport Interventions
14Measurement at the PopulationPMPM for
CareSupport
N652
N546
N431
15Triple Aim Phase 2
16Phase 2 Detailed Design
- Patients and families
- Primary care
- Prevention and health promotion
- Cost control
- System integration
17Cost 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
18Improving 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
19Learning from Individual Patients
- HealthPartners 10 Case Review of Heart Failure
Patients
20HealthPartners 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
21Elements 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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23Description 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
24Despite our great results, 10 case review
shows another story for some individuals
25Findings
- 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
26Opportunities/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.
27Conclusions
- 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
28Triple Aim Phase 3
29Sub-Population Focus
- Employed people lt 65 years old
- People gt 65 years old
- People with high social deprivation
- Children and families
30Design Needs by sub PopulationFirst Draft
All cells are important for all sub populations.
Blank means only minor differences in approach.
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44Phase 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
45Population 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
46Changes 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
47SMYL - Year 1 Results
48Triple Aim Phase 4?
49Components 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
50Three Dimensions of Value
Population Health
Experience of Care
Per Capita Cost