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TRIPLE AIM Is it achievable?

Explore the effectiveness of HealthCare Partners' population management, inpatient strategy, outpatient care, and comprehensive programs in achieving the Triple Aim goals of improving patient experience, population health, and reducing costs.

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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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