The Triple Aim: The Simultaneous Pursuit of Population f p Health, Enhanced Individual Care and Enhanced Individual Care, and Controlled Costs for a Population Frank Federico Executive Director Executive Director
Description Description With rare exceptions, US health care as a system is disjointed, inefficient, and ineffective in promoting population di j i t d i ffi i t d i ff ti i ti l ti health and in providing full value for the resources invested. This occurs despite the good intentions of clinicians, health p g care administrators, and other participants in the system. Other developed nations receive far better value for the resources invested as evidenced by better population health resources invested as evidenced by better population health outcomes, and lower per capita cost of care. During this session, we will learn about IHI’s approach in a model called the Triple Aim and how the model can be integrated into the th T i l Ai d h th d l b i t t d i t th health care reform underway.
Objectives Objectives • Describe the three pillars of IHI’s work in Describe the three pillars of IHI s work in the Triple Aim • List three of the five components identified • List three of the five components identified by the initial work of the Triple Aim team • Discuss two ways that your agency can Di t th t become involved and impact the goals of th the Triple Aim. T i l Ai
Cost of Care and Outcomes Cost of Care and Outcomes • Expenditures twice as much as next most Expenditures twice as much as next most expensive country • US ranks • US ranks ─ 31 st in life expectancy ─ 36 th in infant mortality 36 th i i f t t lit ─ 28 th in male life expectancy ─ 29 th in female life expectancy Berwick et al, The Triple Aim: Care, Health, And Cost, Health Affairs, Volume , p , , , , 27, Number 3
Triple Aim Triple Aim Must focus on: Must focus on: • Improving the experience of care • Improving the health of the population I i th h lth f th l ti • Reducing per capita costs
Three Dimensions of Value Population Health Experience Per Capita of Care Cost
Preconditions Preconditions • Enrollment or an identified population Enrollment or an identified population • Commitment to universality • Existence of an integrator that accepts the E i t f i t t th t t th responsibility of all three aims
Role of Integrator Role of Integrator • Partnership with individuals and families Partnership with individuals and families • Redesign of Primary Care • Population health management P l ti h lth t • Financial management • Macro system integration
To be Successful To be Successful • Goals must be interdependent Goals must be interdependent • Exercise in balance • Use existing resources to benefit all: U i ti t b fit ll ‘Tragedy of the Commons’
“Tragedy of the Commons” Tragedy of the Commons • There are a limited number of resources There are a limited number of resources. • How do we work together to over-ride self interest and focus on the collective interest and focus on the collective benefits using the resources available?
Obstacles to the Pursuit of the Triple Aim Triple Aim • Supply driven demand • New technologies: some with limited benefits over existing and less expensive g p technology • Physician-centric care Physician centric care • Little or no foreign competition to spur domestic change domestic change • Too little application of system knowledge
Drivers of Low Value Health Care Primary Drivers “More Is Better” Culture Supply Driven Demand Low Value No Mechanism to Control Health Care Cost at the Population Level Over ‐ Reliance on Doctors Lack of Appreciation for Lack of Appreciation for a System
Measurement Measurement • Measurement of healthcare quality Measurement of healthcare quality • Measuring cost ─ Measuring per capita cost a challenge M i it t h ll • Measuring health status ─ Need some form of registration or defined population • According to IOM: both still need further development
Potential Triple Aim Outcome Measures 11/09 Dimension Measure Population Health 1. Health/Functional Status: single ‐ question (e.g. from CDC HRQOL ‐ 4) or multi ‐ domain (e.g. SF ‐ 12, EuroQol) 2. Risk Status: composite health risk appraisal (HRA) score 3. Disease Burden: Incidence (yearly rate of onset, avg. age of onset) and/or d d ( l f f ) d/ prevalence of major chronic conditions; summary of predictive model scores 4. Mortality: life expectancy; years of potential life lost; standardized mortality rates. Note: Healthy Life Expectancy (HLE) combines life expectancy and health status into a single measure, reflecting remaining years of life in good health. See http://reves.site.ined.fr/en/DFLE/definition/ Patient Experience p 1. Standard questions from patient surveys, for example: q p y p ‐ Global questions from US CAHPS or How’s Your Health surveys ‐ Experience questions from NHS World Class Commissioning or CareQuality Commission ‐ Likelihood to recommend 2. Set of measures based on key dimensions (e.g., US IOM Quality Chasm aims: Safe, Effective, Timely, Efficient, Equitable and Patient ‐ centered) Per Capita Cost p 1. Total cost per member of the population per month p p p p 2. Hospital and ED utilization rate
Triple Aim Prototyping Sites 4 1 13 36 1 1 1 1 57 Organizations Total!
North American Triple Aim Prototyping Sites Prototyping Sites Last Updated 12/22/2010 • Health Plans • Integrated Delivery Systems (w/o Health Plans) Blue Cross Blue Shield of Michigan (MI) Allegiance Health (MI) CareOregon (OR) Bellin Health (WI) Essence Healthcare (MO) Caldwell Memorial Hospital (NC) Capital Health Plan CaroMont Health System (NC) • Integrated Delivery Systems (w/ Health Plans) Cape Fear Valley (NC) HealthPartners (MN) Cincinnati Children’s Hospital Medical Center (OH) Martin’s Point Health Care (ME) Erlanger Health System (TN) Southcentral Foundation (AK) Fort Healthcare (WI) Vanguard Health System Genesys Health (MI) (Ascension) Wellstar Health System (GA) *Palmetto Health (South Carolina) • Public Health Department St. Charles Health System (formerly Cascade) (OR) * Pueblo Health Department (CO) *Sinai Health System (IL) • Social Services • Safety Net Common Ground (NY) Contra Costa Health Services (CA) • State Initiative Health Improvement Partnership of Santa Cruz Vermont Blueprint for Health (VT) County (CA) • Regional Partner Hidalgo Medical Services (NM) Cedar Rapids, Iowa North Colorado Health Alliance (CO) Michigan Health Information Alliance Primary Care Coalition Montgomery County (MD) • Independent Physician Association Queens Health Network (NY) Taconic IPA (NY) Regional Primary Care Coalition (MD) • Employers/Businesses • Canada QuadGraphics/QuadMed (WI) Q dG hi /Q dM d (WI) C Central East Local Health Integration Network (LHIN) l E L l H l h I i N k (LHIN) Hamilton Niagara Haldibrand Brant (LHIN) Saskatchewan Ministry of Health British Columbia Partners
International Triple Aim Prototyping Sites Prototyping Sites • NHS Blackburn With Darwen PCT • NHS Sefton PCT (NW England) (NW England) (NW England) • NHS North West Ambulance Service • NHS Bolton PCT (NW England) NHS Trust (NW) • NHS East Lancashire Teaching • NHS Torbay Care Trust (SW PCT (NW England) PCT (NW England) England) England) • NHS Eastern and Coastal Kent • NHS Forth Valley (Scotland) PCT (South East Coast England) • NHS Tayside (Scotland) • NHS Knowsley PCT (NW England) • Jonkoping (Sweden) Jonkoping (Sweden) • NHS North Lancashire Teaching • National Healthcare Group PCT (NW England) (Singapore) • NHS Oldham PCT (NW England) • State of South Australia, Ministry of • NHS C NHS Central Lancashire PCT (NW l L hi PCT (NW H Health (Australia) l h (A li ) England) • New Zealand Ministry of Health Last Updated 12/22/2010
Design of a Triple Aim Enterprise Define “Quality” from the perspective of an individual member of a defined population PH Individuals and families The “Triple Aim” The “Triple Aim” Definition of E $ primary care Integration Health care Public health Social Capital Social services Capability Building Per capita System-Level cost reduction Metrics Prevention and Health promotion
Triple Aim History Phase I and II Start with a smaller population Phase I and II Start with a smaller population and begin using the Triple Aim concepts with this population this population Ph Phase III ‐ Triple Aim for Subpopulations III T i l Ai f S b l i Phase IV ‐ Triple Aim for a Region
Readiness • Is the Triple Aim part of your business • Is the Triple Aim part of your business strategy? • Can you explain how the Triple Aim makes C l i h h T i l Ai k business sense to you? • Is top leadership committed to this? • Does the improvement capability within your p p y y organization need further development?
Activities to Get Started • Development of Infrastructure • Development of Infrastructure ( Executive Sponsor, Team Formation, etc.). • Establish Aim Population and Measures • Establish Aim, Population, and Measures. • Align current portfolio of projects with the T i l Ai Triple Aim Initiative. I i i i • Work on Improving Primary Care. • Focus on Cost Control Project.
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