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The Triple Aim:

The Triple Aim:. Better Care for Individuals, Better Health for Populations, and Lower Per Capita Costs. The Burning Health Care Platform (Whose hair is on fire?). Is there alarm in the region about a particular issue (cost, access, quality, big social problem, economy, etc.)?

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The Triple Aim:

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  1. The Triple Aim: Better Care for Individuals, Better Health for Populations, and Lower Per Capita Costs

  2. The Burning Health Care Platform(Whose hair is on fire?) • Is there alarm in the region about a particular issue (cost, access, quality, big social problem, economy, etc.)? • Who is alarmed and why? • Is the alarm broad based?

  3. What is at stake for the key players? • Employers (competitiveness) • Cost • Recruiting and retention • Productivity • Employee engagement • Employee Compensation • Consumers • Cost • Experience of care • Access • Better health • Providers • Revenue • Market share • Perverse incentives • Quality and safety • Community • Economy • Social issues • Quality of life • Limited Resources • Health care cost trumps other priorities

  4. Who are the leaders and influencers?Leadership is Critical • Purchaser leadership (Public and Private) • Provider leadership that can rise above disincentives • Leader(s) that: • See the big picture • Assure clear aims • Is honest broker (credible) • Strong with good power base • Keep the puppies in the box • Staff leadership to execute

  5. Hair on Fire: be a leader and driver Drive “LEAN” Drive Community wide improvement Rising tide lifts all boats Provider responsiveness Responsible Community Citizen Business Case Evaluation Employer’s Leadership Role

  6. Findings from Employer Interviews • Healthcare is challenging and not the primary business of non-healthcare employers • Employers and healthcare can partner to develop joint solutions • Data on cost and health is essential for success • Employers want to know the return on investment for health improvement efforts • Employers see the possibility of working more closely with providers (circumventing Plans)

  7. IHI’s Aims Drive the Triple Aim for Populations Strive to achieve the Triple Aim, simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities. Optimize Health Care Delivery Systems Encourage, empower, and enable health care delivery systems to provide truly value-based care that ensures the best health care outcomes at the lowest costs. Build Improvement Capability Build improvement capability into every organization, health care executive, and professional, while driving innovation to dramatically improve performance at all levels of the health care system. Realize Person- & Family-Centered Care Usher in a new era of partnerships between clinicians and individuals where the values, needs, and preferences of the individual are honored; the best evidence is applied; and the shared goal is optimal functional health.

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

  9. “Better care for individuals – as described by all six dimensions of quality in the Institute of Medicine report: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity;” “Better health for populations with respect to educating beneficiaries about the upstream causes of ill health – like poor nutrition, physical inactivity, substance abuse, economic disparities – as well as the importance of preventive services such as annual physicals and flu shots; and” “Lower growth in expenditures by eliminating waste and inefficiencies while not withholding any needed care that helps beneficiaries” Triple Aim DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part 425

  10. Drivers of Low Value Health Care Primary Drivers “More Is Better” Culture Supply Driven Demand No Mechanism to Control Cost at the Population Level Over-Reliance on Doctors Lack of Appreciation for a System Low Value Health Care

  11. Determinants of Health and Their Contribution to Premature Death Proportional Contribution to Premature Death Adapted from: McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood) 2002;21(2):78-93.

  12. Design of a Triple Aim Enterprise Define “Quality” from the perspective of an individual member of a defined population Individual and family The “Triple Aim” Redefined, Higher Capacity Primary Care E $ Integration Infrastructure Social capital Capability Building Health care Public health Social services System-Level Metrics Prevention and Health promotion Per capita cost reduction

  13. Triple Aim Sites Last Updated 2/7/12 • Health Plans CareOregon (OR) Essence Healthcare (MO) Capital Health Plan (FL) • Integrated Delivery Systems (w/ Health Plans) HealthPartners (MN) Martin’s Point Health Care (ME) Southcentral Foundation (AK) • Integrated Delivery Systems (w/o Health Plans) Allegiance Health (MI) Austin Medical Center and the Mayo Clinic (MN) Bellin Health (WI) CaroMont Health System (NC) Cincinnati Children’s Hospital Medical Center (OH) Erlanger Health System (TN) Fort Healthcare (WI) Genesys Health (MI) (Ascension) Nemours duPont Hospital for Children (DE) Palmetto Health (SC) St. Charles Health System (formerly Cascade) (OR) Sinai Health System (IL) University of Chicago Medical Center Urban Health Initiative (IL) • Public Health Department Pueblo Health Department (CO) • Social Services Community Solutions (NY) • Independent Physician Association Taconic IPA (NY) • Safety Net Health Improvement Partnership of Santa Cruz County (CA) Hidalgo Medical Services (NM) Primary Care Coalition Montgomery County (MD) Queens Health Network (NY) Regional Primary Care Coalition (MD) • Regional Partners Michigan Health Information Alliance Western North Carolina Health Network (Asheville, NC) Memphis, TN Contra Costa County, CA • International Erie St. Clair LHIN(Canada) Saskatchewan Ministry of Health (Canada) British Columbia Partners (Canada) Jonkoping (Sweden) NHS Kent and Medway (England) NHS Tayside (Scotland) Northern Ireland Health and Social Care board/Public Health Agency Singapore

  14. Three “Streams” of Work • Triple aim for a defined population that makes business sense • Solving a health problem at a regional scale and developing a sustainable funding source • Triple aim in a region

  15. Getting to Scale - Regional • All the components that are needed to construct a health system are in a region. • Common values are more likely to emerge. • Solutions depend on context, and knowledge of context is more accurate locally. • Platforms for dialogue exist or can be created. • Other health determinants are attributes of a region.

  16. Achieving Triple Aim Regional Results • Purpose • Measurement/intelligence • Portfolio of projects and investments • Integration and governance

  17. Portfolio of Projects and Investments

  18. Specifically On Cost • Cost curves are bent if there is an intention to bend them and a mechanism to act on the intention. Hoping that health promotion and better chronic disease management will “bend the cost curve” is unrealistic. • Rather than creating or aligning incentives among care providers and patients, eliminate disincentives for pursuing a common purpose. • Move from a purpose that derives from payment mechanisms to a payment system that evolves from purpose and service offerings.

  19. Potential Triple Aim Population Outcome Measures 23

  20. Getting Started • Identify population. • Articulate how much by when for each of the three aims. • Develop measures to support your aims. • Develop a portfolio of projects that will accomplish the three aims. • No individual project can accomplish the Triple Aim but a portfolio of projects that are executed well can move closer to the aims. • For a work of this magnitude it must be strategic.

  21. How Would You Build It? • Include any part of the system • Assume that policy and financing are not in the way • Hints: • Adopt a point of view: a person, a community, an employer • Think about “assets”

  22. Examples of Health Problems/Issues • Hospital admissions for asthma in children • Premature birth • Undiagnosed hypertension • Chronic disease with mental health co-morbidity • Frequent “no shows” • Frail elderly

  23. Partners for Better Health Goals 2014

  24. HealthPartners Medical Trend – Health Plan Overall (HealthPartners Commercial Group Fully Insured & Self Insured Per Member Per Month)

  25. TRIPLE AIM: Health-Experience-AffordabilityHealthPartners Clinics Total Cost Index (compared to statewide average) < 1 is better than network average % patients “Would Recommend” HealthPartners Clinics % patients with Optimal Diabetes Control* * controlled blood sugar (perICSI guideline A1C changed from < 7 to < 8 in 1st quarter 2009), BP & cholesterol, AND daily aspirin use, AND non-tobacco user

  26. Saves 364 Hearts,68 Legs & 625 Pairs of Eyes Each Year (Diabetic Population)

  27. The BIG Bolton Health Check • Target patients 45+ years without existing CVD or Diabetes • Health Checks • Primary Care based • Building a register of patients with >20% risk of developing CVD in the next 10 years.

  28. MI Admissions

  29. MiHIA (Michigan Health Information Alliance) • Regional, multi-stakeholder not-for-profit collaborative • Triple Aim in the Region • Chartered Value Exchange • Changed the conversation: increased consciousness and imperative for change • Creating a mindset and ownership of value and accountability to the community • Core funding from employers, project funding from grants Draft for Internal Discussion Purposes Only – 02/20/12 – Page 35

  30. MiHIA: Key Initiatives • Chartered Value Exchange • Community Awareness and Education • Consumer Engagement • Healthy Cities • Health Dashboard • Health Information Technology • Health Information Exchange connection to State backbone • Promotion of Personal Health Records • Patient-Centered Medical Home (PCMH) Draft for Internal Discussion Purposes Only – 02/20/12 – Page 36

  31. MiHIA: Triple Aim • Population Health • LAUNCH – early childhood health screening and improvement • Developmental Assets – Comprehensive Adolescent Health • Together We Can – Integrated Public Health collaboration • Patient Experience • Improve Transitions in Care – Patient Health Planning • Integrate Mental/ Behavioral Health with Medical Homes • Expand use of Community Health Workers • Cost of Care • Baseline data on cost of care for region • Comprehensive diabetes initiative to improve cost Draft for Internal Discussion Purposes Only – 02/20/12 – Page 37

  32. Payment Reform • Catalyst for Payment Reform • Action Briefs and tools for changing the payment system to drive desired results which support Triple Aim

  33. CPR Strategy • Shared Agenda • Payments designed to cut waste or reflective of performance • National Scorecard • 20% by 2020 • Leverage purchasers and create alignment • Model RFI, contracts and plan user groups • Alignment with CMS, CMMI, regional efforts • Implement Innovations • Price transparency • Reduce price variation – reference/ value pricing • Align payment to evidence - maternity www.catalyzepaymentreform.org

  34. Health Plan Sourcing Tools: RFI and Model Contract

  35. Call to Action Triple Aim as part of your strategy Develop the Business Case Leadership Commitment Develop and call out Improvement capability Drive payment reform (e.g. CPR) Maintain role as leader and driver

  36. For More Information… To learn more about the Triple Aim, email Kathryn Brooks at kbrooks@ihi.org For those interested in engaging more deeply in this work, the IHI Triple Aim Improvement Community begins September 1 Learn more on the May 31 and June 12 free informational calls. Visit http://www.ihi.org/tripleaim

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