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TRIPLE AIM Is it achievable?

TRIPLE AIM Is it achievable?. The Triple Aim. Healthcare Dollar Spend. Healthcare Dollar Spend National Health Expenditures, 2010. Source: http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx. HealthCare Partners (HCP) Population Management.

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TRIPLE AIM Is it achievable?

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  1. TRIPLE AIM Is it achievable?

  2. The Triple Aim

  3. Healthcare Dollar Spend

  4. Healthcare Dollar SpendNational Health Expenditures, 2010 Source: http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx

  5. HealthCare Partners (HCP) Population Management • Top 2-5% of patients at risk • Target the right patient population for high risk needs • Early identification • Provider education to Identify Patients • Care Management – Locally focused Population Health identifying Patients with MD offices • Ensure high patient satisfaction • Expectation-≥50% “completely satisfied”

  6. HCP Population Management • Predictive Modeling Tools • Proprietary – “Opportunity List” – Claims data • Hospital, SNF, ER • PCP visits • Number of chronic conditions • Number of medications • Intensive outreach efforts to identify patients • Create coordinated path to care • Inter-disciplinary Care Meetings

  7. HCP Inpatient Strategy Does not own Hospitals/Skilled Nursing Facilities (SNFs) Partner with Facilities Focus on collaboration, care and service On site Hospitalists and Care Managers Long term Hospital/SNF Partnerships > 10 years

  8. HCP Hospitalist/SNFist Program • Model – MD and Care Manager • Established over 30 years ago • About 100 employed hospitalists and several dozen contracted • Diverse training backgrounds • In California – Continuous coverage 24/7 • Approximately 30 contracted hospitals (network) • Dozens of contracted skilled nursing facilities (SNF’s) • Out of Area (OOA) Unit for non-network coverage and repatriation of patient

  9. HCP Outpatient • Primary Care • Group Model • Independent Physicians - IPA • Ambulatory Care Management (ACM)/Disease Management • Urgent Care Centers • Operated by HCP employed staff • Comprehensive Care Programs

  10. HCP Integrated Comprehensive Care Programs • Comprehensive Care Clinic • House Calls • Palliative Medicine consults • ESRD • Contracted home-based palliative care services • Close relationships with community hospices

  11. HCP Comprehensive Care Programs

  12. HealthCare Partners (HCP)Care Model

  13. HealthCare Partners Transitional Care Management

  14. HCP CCC OutcomesCalifornia 2010-2012

  15. HCP House Calls OutcomesCalifornia 2008-2012

  16. HCP ESRD Program Management of Pre ESRD and ESRD Patients • Reduction of avoidable Hospitalization and unnecessary utilization • Emergency vascular interventions • Catheter related infections • Early access • Palliative Care and Advanced Care Planning

  17. HCP ESRD Outcomes California 2008-2012

  18. HCP High Risk Program Impact

  19. Team Approach

  20. Opportunities for the Comprehensive Care Program • Increase capacity • See all patients who their MD would “not be surprised if they died in the next year” • 24/7 in home assessment when appropriate • Enhance the adoption of a common care plan • All involved clinicians, especially specialists • Rooted in patient/family values and goals • Ensure we are measuring the right things

  21. QUESTIONS

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