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Using the IHI Triple Aim to Manage Populations

April 11 th 2014. Using the IHI Triple Aim to Manage Populations. Trissa Torres MD. Definition. System designs that simultaneously improve three dimensions: Improving the health of the populations; Improving the patient experience of care (including quality and satisfaction ); and

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Using the IHI Triple Aim to Manage Populations

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  1. April 11th2014 Using the IHI Triple Aim to Manage Populations Trissa Torres MD

  2. Definition • System designs that simultaneously improve three dimensions: • Improving the health of the populations; • Improving the patient experience of care (including quality and satisfaction); and • Reducing the per capita cost of health care.

  3. 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.

  4. Potential Triple Aim Population Outcome Measures (6/2011)

  5. Defined Populations: A defined population that makes business sense (e.g. who pays, who provides) around the Triple Aim • Community-Wide Populations: Working in a geographic area to accomplish the Triple Aim for the community Triple Aim Populations

  6. With a show of hands… Which population do you hold yourself accountable for the Triple Aim?

  7. Global Triple Aim Participants

  8. Setup for Population Management • Choose a relevant Population for improved health, care and lowered cost • Identify and develop the Leadership and Governance for a Triple Aim effort • Articulate a Purpose that will hold your stakeholders together • Develop a Portfolio (group) of projects that will yield Triple Aim results

  9. Managing Services for a Population Community, Family and Individual Resources Coordination Goals Delivery of Services at Scale Needs Assessment for Segment Service Design Population Segmentation Population Outcomes Integrator Feedback Loops Feedback Loops

  10. Population Change Packages Assess and segment the population Activate the population Care for the population Address macrosystem factors that will support the population

  11. Learning System for Population Management • System level measures • Explicit theory or rationale for system changes • Segmentation of the population • Learn by testing: PDSA cycles, sequential testing of changes • Use informative cases: “Act for the individual learn for the population” • Learning during scale-up and spread with a production plan to go to scale • People to manage and oversee the learning system with periodic review

  12. Activities of a Population Management Learning System

  13. Readiness • Is the Triple Aim part of your business strategy? • Can you explain how the Triple Aim makes business sense to you? • Is top leadership committed to this? • Does the improvement capability within your organization need further development?

  14. CareOregon’s Triple Aim Learning System "Triple Aim" METRICS Population Health • Global Health Status (SF-1) • Avg Total HRA score • Avg EQ5D score (HRQOL) • Global Rating of Health Care (0-10) • Avg % meeting HEDIS effectiveness of care index target METRICS METRICS • Total PMPM • ED PMPM • Hospital PMPM Experience of Care Cost per Capita

  15. CareOregon:Cost Measures (goals) Drive Projects Population Metrics • Total PMPM cost • Hosp cost/rates • ED cost/rates Projects • Predictive modeling (PM) for case finding • Transitional care follow-up • ED outreach Project Metrics • % enrolled via PM • PAM scores (patient activation) • Readmission/ACSH rates • PAM scores • #days from discharge to f/u appt with PCP • Third-next available appt or % same day access • Clinic specific ED rates Case Management Primary Care Transformation

  16. CareOregon Population Segments Members who are also receiving regular mental health services from a community mental health agency Members who have experienced 3+ hospitalizations and/or 10+ ED visits in the past 12 months Members who receive primary care from one of five safety-net clinics engaged in the implementation of PCPCH Members who meet a complexity threshold as defined by their predicted risk of future medical cost CareOregon Member Population

  17. CareOregon Population Segments:Shared Community Accountability Members who are also receiving regular mental health services from a community mental health agency Community Mental Health Agency Various Social Services Agencies (housing, CD tx centers, disability case managers) Members who have experienced 3+ hospitalizations and/or 10+ ED visits in the past 12 months CareOregon Member Population Members who receive primary care from one of five safety-net clinics engaged in the implementation of PCPCH Members who meet a complexity threshold as defined by their predicted risk of future medical cost Primary Care Practices Combinations of all of the above

  18. STRATEGIC AIM: Better Health/Better Value(Jeff/Karen) Secondary Drivers Strategic Aim • Develop data analytics tools and models to identify and stratify high risk populations; measure results • Map and connect data through the HIE to manage the care continuum Primary Drivers Manage Populations around the Triple Aim Integrated Data Support • Promote effective utilization of services • Access to care • Develop and implement prevention strategies • Implement evidence-based models to manage high risk / high cost populations • Strengthen the health system’s global risk infrastructure Primary Care Medical Home Metrics • Defined Populations • Achieve a 2% reduction in per capita medical expenditure trend from July 2013-July 2015 • Improve moderate and high health risk scores by 2% by year end 2014 • Improve Top box patient satisfaction scores by 10% by year end 2014 • Decrease inpatient utilization of populations by 1% by year end 2014 • Decrease ED visits of populations by 5% by year end 2014 • Development of standardized measurement to decrease obesity rates at the community level across EHR platforms for the following population segments: • - 18-75 year olds with A1c<9.0% for Diabetes 1 and 2 • - 18-84 year olds with BP<140/90 • - 18-75 year olds with BMI above 30.0 • Develop models to facilitate complex care and effective disease management • Manage transitions across the care continuum • Develop and utilize patient and family advisory groups Care Coordination for populations Partnership with Providers • Promote integration to achieve changes in provider culture, redesign payment methods and incentives and meet demands of health care reform • Build relationships with public health and human services – behavioral health payment models • Identify social determinants of health to support Regional Health Improvement Plans • Expand Healthy Lives wellness program to Central Oregon employer community Partnership with Community

  19. Why is the Triple Aim Strategic for You? Do you need to start understanding population management because of new payment models like the ACO? Can it help you organize work that you are already doing? Is there a significant health issue in your community that you have been unable to move? Are businesses collapsing or leaving or not coming because of health care cost?

  20. Building will Is there alarm in the system or region about a particular issue (cost, access, quality, big social problem, economy, etc.)? Who is alarmed and why? Is the alarm broad based? Or, is there massive indifference, resignation or naiveté?

  21. Bolton Primary Care Trust Population 261,037 budget of £369,000,000 Bolton residents have shorter life expectancy than the national average, with significant disparities in the Borough. Biggest contributors to death: Heart disease and stroke, and cancer.

  22. What are we trying to accomplish? • The Aims: • Reduce health inequalities for Cardio-Vascular Disease and improve life expectancy for all residents in Bolton aged 45+ • Work in Partnership between Public Health, Local Authority and Primary Care to improve health experience and wellbeing • Strategies: • Risk assess 100% of all residents aged 45+ for CVD by April 2009 • Smoking cessation activity increased • For patients with risk rating of >20% apply primary care prevention strategies.

  23. Decreased Clinical Variation • Involved Community Health Workers • Involved the local press What worked at scale

  24. Before

  25. After!

  26. Outcomes – MI Admissions BBHC commences

  27. Outcomes - Mortality

  28. Changes in Life Expectancy • Compared with England: • In 2004: 2.3 year gap compared with England • In 2009: 1.8 year gap compared with England • Within the Borough • In 2004: 15 year gap • In 2009: 11.9 year gap

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