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Using the IHI Triple Aim to Manage Populations
Objectives Gain an overall understanding of general principles for working with populations around the Triple Aim Learn more about populations, purpose and governance as it relates to the Triple Aim We want you to think about our work together as building a system to care for populations and not simply as a “project”
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.
Setup for Population Management 1 .Choose a relevant Population for improved health, care and lowered cost 1 .Identify and develop the Leadership and Governance for a Triple Aim effort 1 .Articulate a Purpose that will hold your stakeholders together 4.Develop a Portfolio (group) of projects that will yield Triple Aim results
Managing Services for a Population Community, Family and Individual Resources Coordination Goals Needs Delivery of Service Assessment for Services at Segment Design Scale Population Population Segmentation Outcomes Integrator Feedback Feedback Loops Loops
Learning System for Population Management System level measures 1. Explicit theory or rationale for system changes 2. Segmentation of the population 3. Learn by testing: PDSA cycles, sequential testing of 4. changes, Shewhart time series charts Use informative cases: “Act for the individual learn for 5. the population” Learning during scale-up and spread with a production 6. plan to go to scale People to manage and oversee the learning system 7. with periodic review
Activities of a Population Management 8 Learning System
Choose a relevant Population for improved health, care and lowered cost
Triple Aim Participant Populations Community- Defined Wide Populations Populations Triple Aim Results • 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
“Defined” Population Examples Employees Members of a health plan All the individuals who use a particular FQHC All the uninsured who use a hospitals ER ACO Other?
Observations About Defined Population Some heath care workers tend to pick a population by focusing on a disease, i.e. heart failure patients If you use a disease to pick your population remember that for the those patients you are going to manage the Triple Aim and not just a disease, i.e. this is not just a heart failure “project”
Do you have a clear reason for choosing your defined population? How will working with this population work in your present business model? What business skills do you hope to gain by working with this population? What are your future growth plans for this population? ( Example: Working with employees will give us skills to manage an ACO population in the future )
Geographic Region Population Examples A City: Memphis, TN Primary Care Trust, England Everyone who lives within a certain zip code/postal code 14 County region in Michigan *The key idea is that your population is everyone within the geographic boundary
Do you have a clear reason for choosing your geographic population? 1. How will you work on the multiple determinants of health for this population? 2. Can health care also play a significant role in improving the health of this population? 3. Is the population of interest defined by geographic boundaries - anyone living within the boundary is in the population whether or not they are currently engaged with the health care system? 4. How will you address health equity issues?
POPULATION SEGMENTATION
Population Segmentation Examples “ Bridges to Health Model” – Splits populations into 8 segments Healthy 1. Maternal-infant health 2. Acutely ill, likely to return to health 3. Chronic conditions with normal daily function 4. Serious relatively stable disability 5. Short decline to death 6. Repeated exacerbations, organ system failure 7. Multi-factor frailty, with or without dementia 8. Lynn, Joanne, Straube, Barry M., Bell, Karen M., Jencks, Stephen F. and Kambic, Robert T., Using Population Segmentation to Provide Better Health Care for All: The 'Bridges to Health' Model. Milbank Quarterly, Vol. 85, No. 2, pp. 185-208, June 2007.
Population/Cost Segments 100% 90% Long, dwindling course Organ system failure 80% Short period of decline 70% near death Stable, significant 60% disability Chronic condition, normal 50% function Acutely ill mostly curable 40% Maternal & infant 30% Healthy 20% 10% 0% % Population % Cost Source: Lynn J, Straube BM, Bell K, Jencks SF, Kambic RT in Milbank Quarterly, Vol 85 No. 2, 2007 (pp. 185-208)
Population Segments Employers Children 600,000 Population Seniors Low Income
Alberta Health Services Triple Aim Population: High risk and high cost population Segments: Older tri-morbid adults Frail older adults Young adults with addictions and mental health concerns Child-bearing women High needs children Complex infants and toddlers These clusters total approximately 4623 in Edmonton Eastwood
Care Delivery Needs Differ Across The 21 Population Source: Yvonne Zhou
*Nominal Range of Frail Elders in a Population of 500,000 Number over 65yrs of age = – 500,000 x % over 65 years of age = 500,000 x 13.1% = 65500 Number of frail elderly = – 65500 x (5% - 10%) = 3275 - 6550 * An example of subdividing the population further
An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital- >health system… A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. Cannot be defined by a clinical condition (Diabetes) or issue Note: The size of the rectangles is meant to be indicative of (readmissions). population size, not cost.
An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital- >health system… A population, for which claims A sub-population, data exists and achieving Triple high cost and or Aim results will not result in high utilization perverse economic loss. people from the larger population. People who have “fallen through the cracks” of our “rescue - care” system. Cannot be defined by a clinical condition (Diabetes) or issue Note: The size of the rectangles is meant to be indicative of (readmissions). population size, not cost.
An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital- >health system… Sub-groups, people A population, for which claims A sub-population, from the high cost data exists and achieving Triple high cost and or high utilization sub- Aim results will not result in high utilization population that can perverse economic loss. people from the be stratified based larger population. upon relatively similar needs. People who have “fallen Sub-groups through the based more on cracks” of our needs and less “rescue - care” on conditions. system. Cannot be defined by a clinical condition (Diabetes) or issue Note: The size of the rectangles is meant to be indicative of (readmissions). population size, not cost.
An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital- >health system… Interventions intended to address the needs of high Sub-groups, people cost high utilization sub- A population, for which claims A sub-population, from the high cost groups, Plan Do Study Act data exists and achieving Triple high cost and or high utilization sub- cycles. Aim results will not result in high utilization population that can perverse economic loss. people from the be stratified based larger population. upon relatively similar needs. People who have “fallen Sub-groups through the based more on cracks” of our needs and less “rescue - care” on conditions. system. Some interventions will work and some will not. All should result in learning and start on the smallest Cannot be defined by a clinical practical scale. condition (Diabetes) or issue Note: The size of the rectangles is meant to be indicative of (readmissions). population size, not cost.
Alberta Health Services Overall Population: – The Eastwood area of Edmonton (health service area Z4.2C),in the inner north east of the city, with a population of 68,813 in 2011. Subpopulations: – People of all ages from this area with repeat presentations to Emergency Departments of Royal Alexandra Hospital or North East Health Centre
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