Achieving the Triple Aim:

1
Achieving the Triple Aim

• The Simultaneous Pursuit of Population Health,
  Enhanced Individual Care, and Controlled Costs
  for a Population

2
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
3
Three Dimensions of Value
Population Health
Experience of Care
Per Capita Cost
4
Operational Definitions

• Individual Experience
• Population Health
• Inflation of Per Capita Costs

5
Patient Experience Score
They give me exactly the help I want (and need)
exactly when I want (and need) it Population
includes adults in the Hows Your Health?
database, aged 19-69
Current Average
Patients with Income Problems
Best Ideal Micro Practice
Younger Patients (19-49)
Older Patients (50-69)
better
29
16
72
worse
100
0
20
40
60
80
Percent of Patients Who Responded Strongly
Agree to the Phrase Above
Number of patients in sample 11,784 individuals
who took the survey both in a clinical setting
and individuals who chose to go to the Hows Your
Health website. Note The phrasing above has
been modified by John Wasson to read, I receive
exactly the care I want and need exactly when and
how I want and need it. Response rates differ
across systems based on disease burden and method
of survey administration.
Source John Wasson (March 2007), Hows Your
Health? http//www.howsyourhealth.org
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Functional Health Outcome Score
worse
better
Source Centers for Disease Control and
Prevention (CDC) National Center for Chronic
Disease Prevention and Health Promotion, Division
of Adult and Community Health, Health-Related
Quality of Life Surveillance --- United States,
1993-2002
7
Annual Inflation Rate (Percent) Selected Health
Plans
Plan C
Plan D
Plan B
Plan A
Plan E
2 4 6 8 10 12 14
Annual Inflation Rate
8
Triple Aim ModelCan We Begin with the Individual
and Scale Up?

• Act with the Individual and Family
• Learn for the Population

Design and Coordination of Care
Individual Experience
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Macro-Integrator

• It may or may not be a new structure or
  organization.
• It pulls together the resources to support a
  defined population.
• It builds alliances and coalitions.
• It optimizes the Triple Aim for the sake of a
  defined population.
• It works with and helps to improve micro-systems
  to support individuals.

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Triple Aim Macro-Integrators

• Hospital-Based Systems
• Cincinnati Childrens Hospital Medical Center
  (OH)
• Bellin Health (WI)
• Genesys Health (MI) (Ascension)
• Integrated Health Systems
• Group Health (WA)
• HealthPartners (MN)
• Health Plans
• CareOregon (OR)
• New York-Presbyterian System SelectHealth, LLC
  (NY)
• State Initiative
• Vermont Blueprint for Health (VT)

• Safety Net
• CareSouth Carolina (SC)
• Contra Costa Health Services (CA)
• North Colorado Health Alliance (CO)
• Primary Care Coalition Montgomery County (MD)
• Queens Health Network (NY)
• International
• Jönköping (Sweden)
• Bolton Primary Care Trust (England)

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Bellin Focus Population
Description
Size
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Triple Aim Design Components

• Individuals and families
• Redesign of primary care services and
  structures
• Population health management
• Cost control platform
• System integration

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1. Individuals and Families

• Enable individuals and families to better manage
  their own health.
• For medically and socially complex patients,
  establish partnerships among individuals,
  families and caregivers, including identifying a
  family member or friend who will be supported and
  developed to coordinate services among multiple
  providers of care.
• Jointly plan and customize care at the level of
  the individual targeted to the best feasible
  outcomes.
• Actively learn from the patient and family to
  inform work for the population.

14
Bus Pass 23 versus ED 1400

• Member was seen in the ED 21 times in Dec.
  2007.
• History of heroin use, transportation barriers
  to receiving Methadone treatment and from seeing
  her PCP on a regular basis.
• We bought a bus pass.
• No ED visits for two months and she is much more
  engaged in CD treatment and her PCP relationship.
  

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2. Redesign of Primary Care Services and
Structures

• Have a team design for basic services that can
  deliver at least 70 of the necessary medical and
  health-related social services to the population.
• Deliberately build an access platform for maximum
  flexibility to provide customized health care for
  the needs of patients, families, and providers.
• Cooperate and coordinate with other specialties,
  hospitals, and community services related to
  health.

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Primary Care Access PlatformBellin Health System
Emergency Department
Fast Care Clinics
Clinic Hours
Phone Access with 24 / 7 Scheduling and Triage
Access Platform
16
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3. Population Health Management

• Efficiently customize services based on
  appropriate segmentation of the population using
  a health risk assessment tool or equivalent.
• Use predictive models that take into account
  situational factors and medical history to deploy
  resources to high-risk individuals.
• Work with the community to strongly advocate for
  smoking prevention, healthy eating, exercise, and
  reduction of substance abuse.
• Set and execute strategic initiatives related to
  reducing inequitable variation in outcomes or
  undesirable variation in practice.

18
Part of Children with obesity and obese during
the school years of 2004-05, 2005-06, 2006-07,
Jönköping County
Per cent
Age 4 Age 6 Age 10 Age 13-14 Age
16
born yearborn yearborn year
Age 4
The first measure is the NOW-situation
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4. Cost Control Platform

• Achieve 1-3 inflation yearly for per capita cost
  by developing a strong relationship with a group
  of specialists committed to reducing overuse of
  unnecessary health care and who focus on care
  coordination with families and the rest of the
  health care team.
• Achieve lowest decile performance in the
  Dartmouth Atlas measures by breaking or
  countering incentives for supply-driven care.
• Reward health care providers, hospitals, and
  health care systems for their contribution to
  producing better health for the population and
  not just producing more health care.

20
Target Consumer Price Index (about 3) 2008-2010
projected values
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5. System Integration

• Match capacity and demand for health care and
  social services across suppliers.
• Insure that strategic planning and execution with
  all suppliers including hospitals and physician
  practices are informed by the needs of the
  population.
• Develop a system of ongoing learning and
  improvement.

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Primary Care Prevention Pathway for CVD
Social Marketing Campaign
Community Programmes Neighbourhood action
plans, Ageing Well, Heart Alert, Smoke free
Bolton etc..
Workplace Health Programme
Awareness Raising
Identification
Intervention
Additional Support
Physical Activity Support Programme
Food Access Bolton
Graduate Mental Health Workers
Weight Management
Alcohol Services

Relapse Management
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Triple Aim Worksheet