m11: the ihi triple aim in a region - eventpilot...

11/16/2011

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M11: The IHI Triple Aim in a

Region

23rd Annual National Forum onQuality Improvement in Health Care

John Whittington, MDBruce Bradley, MBA

Niñon Lewis (Richartz), MSThese presenters have nothing to disclose

Session Objectives

• Understand the framework that IHI uses

for regions to accomplish the Triple Aim

• Share lessons learned from working with

Triple Aim regional sites

• Describe the linkages between this work

and national initiatives such as care

coordination and Accountable Care

Organizations

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Your Aims?

What We REALLY Want You to Get

Out of This….

• Motivation to pursue the Triple Aim within

your region

• An opportunity to address who, where,

what, why, when, and how for your

regional population

• An understanding of community-based

approaches to achieving the Triple Aim

• Practice in getting started

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Minicourse Agenda

IHI Triple Aim in a Region

8:30 – 8:45AM Welcome and Roadmap for the Day

8:45 – 9:45AM Understanding the Triple Aim Framework

9:45 – 10:45AM Casing the Joint: Understanding Regional Context

10:45 – 11:00AM Break

11:00 – 11:45AM Harnessing Collective Action: Understanding Community Assets

11:45 – 12:30PM Lunch

12:30 – 2:30PM Achieving the Triple Aim in a Region: Governance, Purpose,Measures, and Portfolio

2:30 – 2:45PM Break

2:45 – 3:45PM Putting it Together: Projects That Require Collective Action

3:45 – 4:00PM Wrap Up

Understanding the Triple Aim

Framework

John Whittington, MD

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Objectives

• How relevant is health care to health:

presently and potentially

• Understand the basic framework for the

Triple Aim in a region

• Identify the regional population that you

want to work with

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Three Dimensions of Value

PopulationHealth

Experienceof Care

Per CapitaCost

Triple Aim

• “Better care for individuals – as described by all six dimensions of

quality in the Institute of Medicine report: safety, effectiveness,

patient-centeredness, timeliness, efficiency, and equity;”

• “Better health for populations with respect to educating

beneficiaries about the upstream causes of ill health – like poor

nutrition, physical inactivity, substance abuse, economic disparities

– as well as the importance of preventive services such as annual

physicals and flu shots; and”

• “Lower growth in expenditures by eliminating waste and

inefficiencies while not withholding any needed care that helps

beneficiaries”

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services 42 CFR Part 425

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Determinants of Health and Their

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.

Proportional Contribution to Premature Death

MI Admissions

125 111 99 83 79 67 66 81 670

20

40

60

80

100

120

140

Jan - Mar 2008 Apr - Jun 2008 Jul - Sep 2008 Oct - Dec 2008 Jan - Mar 2009 Apr - Jun 2009 Jul - Sep 2009 Oct - Dec 2009 Jan - Mar 2010

Nu

mb

er

of

spe

lls

wit

h a

dis

cha

rge

da

te in

th

e p

eri

od

Period (based on discharge date)

Emergency admissions to Royal Bolton Hospital with acute myocardial infarction as the primary diagnosis

Number of spells Trend

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Impact to date:

• MI admissions reduced by close to 50%

• CVD mortality reduced by over 20%

• IGT: Health trainer intervention- it can be reversed

Disease Registers

This is a public health approach to primary care.

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page 16

KP Colorado:

CVD Care Management Reduces Mortality

Pharmacotherapy 2007;27:1370-1378.

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Bellin Results

Learning: Bellin Health found that by creating health awareness, engagement, and accountability strategies with employees, they were able to save over $13 million over a 8 year period (benchmarked to the Mercer index norm) and improve overall objective health measures by 11 percent (HRA scores).

Median Household Income

and Family Health Care Premium

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Design of a Triple Aim Enterprise

Define “Quality” from

the perspective of an individual member

of a defined population

The “Triple Aim”

Health care Public health

Social services

Per capita

cost reduction

Integration

Social Capital

Capability Building

System-Level

Metrics

$E

PH

Definition of

primary care

Individuals and

families

Prevention and Health

promotion

Potential Triple Aim Population Outcome Measures

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Dimension Measure

Population Health

1. Health Outcomes: � Mortality: Years of potential life lost; Life expectancy; Standardized mortality

rates

� Health/Functional Status: single question (e.g. from CDC HRQOL-4) or

multi-domain (e.g. SF-12)

� Healthy Life Expectancy (HLE): combines life expectancy and health

status into a single measure, reflecting remaining years of life in good health

2. Disease Burden: Incidence (yearly rate of onset, avg. age of onset) and/or prevalence of major chronic conditions

3. Risk Status: Behavioral risk factors include smoking, alcohol, physical activity, and

diet. Physiological risk factors include blood pressure, BMI, cholesterol, and blood

glucose. (possible measure: a composite Health Risk Appraisal (HRA) score)

Experience of Care

1. Standard questions from patient surveys, for example: � 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 1. Total cost per member of the population per month

2. Hospital and ED utilization rate and/or cost

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Questions ?

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Global Triple Aim Participants

Current Triple Aim Regions

1. Michigan Health Information Alliance (MiHIA)

2. Asheville, NC/Western North Carolina Health Network

3. Memphis, TN

4. Contra Costa County, CA

…Plus a host of TA Classic organizations working at the regional level

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Rationale for a Regional Focus

• All the components that are needed to construct a health system are in a region.

• Common values are more likely to emerge.

• Solutions depend on context, and knowledge of context is more accurate locally.

• Platforms for dialogue exist or can be created.

• Other health determinants are attributes of a region.

Achieving Triple Aim Regional Results

• Purpose

• Measurement/intelligence

• Portfolio of projects and investments

• Integration and governance

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Portfolio of Projects and Investments

Initiative Typical projects Typical investments

Capability building

Regional intelligence Data from ambulances, data from EDs

Fund a few positions to receive, maintain, and analyze the data for the community

Timely knowledge of community health status

Primary care Redefinition of primary care

Connections with community resources

Longitudinal experience of care

Care for the socially complex

Community based health promotion and care mgt.

Development of new skills in the workforce

Payment and cost control

Improving healthand lowering cost for employees

Health risk appraisals, and health coaching

Driving cost savings through population health

Community health Falls with harm in the community

Integration of existing efforts, ACO savings

Cooperation, improvement skills, joint investing

Specifically On Cost

• Cost curves are bent if there is an intention to bend

them and a mechanism to act on the intention.

Hoping that health promotion and better chronic

disease management will “bend the cost curve” is

unrealistic.

• Rather than creating or aligning incentives among

care providers and patients, eliminate disincentives

for pursuing a common purpose.

• Move from a purpose that derives from payment

mechanisms to a payment system that evolves

from purpose and service offerings.

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Components of a Learning System

for the Triple Aim

1. System level measures

2. Explicit theory or rationale for system changes

3. Segmentation of the population

4. Learn by testing changes sequentially

5. Use informative cases: “Act for the individual learn

for the population”

6. Learning during scale-up and spread

7. Periodic review

From Tom Nolan PhD, IHI

Model for Improvement

Act Plan

Study Do

What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?

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Multiple Plan-Do-Study-Act (PDSA) Cycles

Hunches

Theories

Ideas

Changes That Result

in Improvement

A P

S D

A P

S D

Small Scale Test

Follow-up Tests

Wide-Scale Tests

Implementation

of Change

A P

S D

A P

S D

5X Scale-up – Reduce cost and improve

care for socially complex Number of people System issues to address

5 1. Form a team of volunteers

2. Find people through referrals

25 1. Full time team

2. Redesign of practice

3. Cooperation of hospitals for data

4. Assess outcomes

125 1. Grant funding for operations

2. Consistent population outcomes

625 1. ?

3125 1. ??

15,625 1. ???

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Questions ?

Action Step 1

• Identify a population for which your organization/region/coalition is responsible

• Describe the population demographics (size, age segmentation, SES, and major health issues)

• Discuss data sources

• Discuss this at your table

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Three Dimensions of Value

PopulationHealth

Experienceof Care

Per CapitaCost

“Casing the Joint”: Understanding Regional Context

Bruce Bradley, MBA

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Objectives

• Understand the “burning platform” within

your region

• Identify key players, leaders, and

influencers

• Understand what is at stake for each

player

• Understand existing support systems and

work already in progress

Understanding Regional Context

• Burning Platform, or who’s hair is on fire?

• What are the biggest issues (perceived and real)

• Demographics and Data

• Who are (should be) key players?

• What is at stake for the key players?

• What are existing support systems?

• Who are the leaders and influencers?

• What work is already in progress?

• Other Issues

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The Burning Platform(Whose hair is on fire?)

• Is there alarm in the 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?

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What are the biggest issues?

• Cost

• Access

• Quality

• Public Health issue

• Education

• Big social problem

• Economy (uninsured)

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Demographics and Data

• Define region

• Population

• Socioeconomic

• Existing data available on:─ Health status

─ Procedure rates

─ Health care cost

─ Disease prevalence

─ Other (education, crime rate, etc)

• Resources for data collection and analysis─ Problem/opportunity identification

─ Track progress

Who are the Key Players?

• Health Systems and hospitals

• Physician organizations (medical societies, PHOs, large physician groups)

• Public Health agencies

• Educational institutions

• Consumer groups

• Unions

• Employers

• Public employers

• Medicaid

• Health care coalitions

• Business groups

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What is at stake for the key players?

• Employers (competitiveness)� Cost

� Recruiting and retention

� Productivity

� Employee engagement

• Consumers� Cost

� Experience of care

� Access

• Providers� Revenue

� Market share

� Perverse incentives

� Quality and safety

• Community� Economy

� Social issues

� Quality of life

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What are existing support systems?

• Existing Coalitions

� Multi-stakeholder?

� Employer dominated/led

� Provider dominated/led

� Non health care, but interested

(e.g. chamber of commerce)

• Individual organizations

� Employer

� University

� Government agency

• Infrastructure

� Staff resources

� Project management

� Data

� Logistical

� Financial

� Quality improvement/technical

assistance

• Funding sources

Who are the leaders and influencers?

Leadership is Critical

• Purchaser leadership

• Provider leadership that can rise above

disincentives

• Leader(s) that:

� See the big picture

� Assure clear aims

� Is honest broker (credible)

� Strong with good power base

� Keep the puppies in the box

• Staff leadership to execute

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What work is already in progress?

• Inventory of existing projects and

initiatives

• What community services are being used?

• Connections between need and services?

• Integration or coordination among projects

and agencies?

• Measures

• Progress reports and results

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Other issues

• Funders engaged or interested

• Communication mechanisms (internal & external)

• Learning systems and testing

• Key stakeholders sustained at the table

• Obstruction

• Constructive or destructive competition

• Trust

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Questions ?

Action Step 2

• Complete the Regional Context Check List

• Discuss this at your table

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Let’s Break

Welcome Back!





10:45 – 11:00AM Break


11:45 – 12:30PM Lunch


2:30 – 2:45PM Break


3:45 – 4:00PM Wrap Up

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Harnessing Collective Action: Understanding Community

Assets

Niñon Lewis (Richartz), MS

Objectives

• Understand the shift from “isolated impact”

to “collective impact”

• Understand the difference between needs-

focused community assessments and

assets-focused community assessments

• Begin to assess and map the assets within

your community or region

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When we started out…

• This is much bigger than any one

organization or outsider can “fix”

• Where could collective action help achieve

the Triple Aim?

• How do we turn collective action into

results?

Where Are the “Edges” of Your System?

Public Health

Employers

Social

Services

Health Plans

PCMH

Specialty

Other Schools

Community

organizations; faith

communities

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Montgomery County, MD

County HHS

Primary Care

Hospital

Fire and Rescue

Public Housing

Associates in Process

Improvement

Community Center

County Epidemiologist

Council on Aging

Top 14 Frequent Locations 2/1 - 3/31/2011

Montgomery County Fire and Rescue

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What is collective action/impact?

• The commitment of a group of important

factors from different sectors to a common

agenda for solving a specific social

problem

• Collaboration is nothing new!

─Public-private partnerships, multi-stakeholder initiatives, social sector networks, etc.

• The non-profit sector most frequently

operates using an approach we call

"isolated impact"

What is collective action/impact?

• Common Agenda

• Shared

Measurement

Systems

• Mutually Reinforcing

Activities

• Continuous

Communication

• Backbone Support

Organizations

Achieving Triple Aim in a Region:

Purpose/Aims.

Measurement/ intelligence.

Portfolio of

projects and investments.

Integration and governance

and a learning system to drive

the work.

Kania & Kramer, 2011

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Using Collective Action to Get Results

• Recognizing areas for collective action

─What is everybody working on now?

─Data to motivate collective action

Measures for Collective Action

• HCI

• Readmissions

• Infant mortality

• Readiness for school

• Disease burden

• Ratio: commercial insurance

increases/wage increases

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Using Collective Action to Get Results

• Recognizing areas for collective action

─What is everybody working on now?

─Data to motivate collective action

• Getting from collective action opportunity

to a portfolio by understanding assets…

A Shift From Needs-Focused Assessment

• A need is defined as a gap or difference

between a current situation and the ideal or

desired situation.

• Most needs assessments are used to identify

what the gaps are within a community, how to

prioritize those gaps, and how to make

decisions about which needs can be

addressed through a particular intervention.

• Sounds great, right?

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• Needs-focused assessments risk defining an organization, neighborhood, or community by its problems - that generally require outside expertise and resources to "fix." (Roehlkepartain, 2005)

• Needs-focused assessments can have negative effects even when a positive change is intended because they force community leaders to highlight their communities' worst side in order to attract resources.


Needs Assets

• Focus on deficiencies • Focus on strengths

• Result in fragmentation of

responses to local

deficiencies

• Build relationships among people,

groups, and organizations

• Make people consumers of

services; builds dependence

on services

• Identify ways that people and

organizations give of their talents

and resources

• Give residents little voice in

deciding how to address

local concerns

• Empower people to be an integral

part of the solution to community

problems and issues

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Moving to Asset-Focused Assessment

• Asset-Based Community Development

(ABCD):

─Built on the notion that communities have

never been built on their deficiencies,

rather on the capacities and assets of the

people and the place

─Does not imply ignoring problems and

needs and throwing out rational, strategic

planning; rather it is a rallying point for

collective action

Key Elements of An Assets/Strengths-Based Approach

1. Focus on the capacities or gifts that are present in the community, not what is absent

2. Stress local leadership, investment, and control in both the planning process and the

outcome

3. Surface both formal, institutional resources (such as programs, facilities, and financial capital) as well as individual, associational, and informal strengths and resources

4. Seek to link the strengths and priorities of all partners, including the people

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Beginning Your Assessment

• Primary Building Blocks:

─Assets and capacities located inside the community, largely under community control

• Secondary Building Blocks:

─Assets located within the community, but largely controlled by outsiders

• Potential Building Blocks:

─Resources originating outside the neighborhood, controlled by outsiders

Needs-Focused Map

McKnight & Kretzmann, 1996

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Assets-Focused Map

McKnight & Kretzmann, 1996

Beginning Your Assessment

• Who is doing work now?

• Who are the movers and shakers? Who gets things

done?

• How has the community met challenges or accomplished

goals in the past?

• Where are the sources of community pride?

• What is the nature of social connectedness, cohesion

and affiliation among neighbors (social capital)

• What are the prominent community values and interest

groups?

• What are the perspectives on what a healthy community

is?

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Memphis Matrix of Secondary Building Blocks: Current Health and Health Care Initiatives

Memphis Secondary Building Blocks: Integration of the Faith Community, Business, and Social

Services

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Questions ?

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Action Step 3

• Complete the Community Asset Mapping

Tool

─Consider the formal and informal connections between organizations

─Ask yourself “where would collective action help?”

• Discuss with your table

Let’s Break for Lunch

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Welcome Back!





10:45 – 11:00AM Break


11:45 – 12:30PM Lunch


2:30 – 2:45PM Break


3:45 – 4:00PM Wrap Up

Achieving the Triple Aim in a Region: Governance, Purpose,

Measures, and Portfolio


Bruce Bradley, MBA

Niñon Lewis (Richartz), MS

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Objectives

• Understand the role of governance in driving Triple

Aim results in a region

• Explore and establish a regional purpose to guide

the work of a Triple Aim regional coalition of

stakeholders

• Understand the role of regional-level measurement,

and the relationship between project-level and

system-level measurement

• Understand and build a portfolio of projects that

together will achieve the Triple Aim strategy within

your region

Rationale for a Regional Focus

• All the components that are needed to construct a health system are in a region.

• Common values are more likely to emerge.

• Solutions depend on context, and knowledge of context is more accurate locally.

• Platforms for dialogue exist or can be created.

• Other health determinants are attributes of a region.

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Achieving Triple Aim Regional Results

• Governance and Integration

• Purpose



ON GOVERNANCE

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Governance to Drive Results

• Governance and Leadership

• Prerequisites of Regional Governance

• Establishing Regional Governance

Structures

• Managing Regional Governance

Structures

• Sustaining Regional Governance

Structures

Governance and Leadership

• Success of Triple Aim in a Region

dependent upon intertwined relationship of

effective governance structure and strong

credible leadership

• Built upon clear understanding of Purpose

• Ability to keep Purpose as the focal point

for the end game

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Prerequisites of Regional

Governance

• Understanding the stakeholders

• History of the region re health system

reform

• Familiarity with dynamics of health system

related politics

• Knowledge of community leadership

• Assessment of strength and weaknesses

of governance structure(s) of existing

organization(s) (if any)

Establishing Regional Governance Structures

• Range of structures which may already be established and can change over time as the organization matures─ Informal working committee

─ Subsidiary or committee of an existing organization

─ Independent 501 (c) (3) corporation

• Transition driven by─ Need for permanent staff

─ Need for entity to apply for and receive funding

─ Need for complete independence as an organization

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Managing Regional Governance Structures

• Goals─ Goals for common good vs. individual self interest

─ Clear goals required to manage conflict

─ Find common ground for competing interests

─ Common commitment

─ Stretch

• Leadership─ Direct, persuade, motivate, organize (rather than do)

─ Hold CEO accountable (governance committee)

─ Diversified, collective leadership

• Accountability─ “Volunteers”, but driven by their agendas

─ Financial

─ Public recognition

─ Seat at the table

Sustaining Regional Governance Structures

• Compelling reason to be at the table

• Environment/culture attractive to committed leaders, stakeholders and professional staff

• Effective design and use of committees

• Ability to attract and manage funding─ Start up or sustained

─ Dependence

─ Conflict

─ Deflection from real goals

─ Grants management

• Ability to attract other resources

• Policies

• Evaluation

• PDSA, learning systems

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ON PURPOSE

Challenges for Working in a Region

• Cooperating among competitors, and engineering cooperation without violating anti-trust regulations;

• Establishing regional governance structures that are effective and sustainable;

• Integrating health care with public health and social services so that the range of health determinants is addressed;

• Finding an effective way to involve businesses and unions in the effort;

• Developing business models and transition strategies that allow innovative care providers to remain or become financially viable as the demand or cost for high-intensity care is reduced

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Example Purpose Statements

• Improve the health of the population while maintaining or improving

experience of care and lowering costs. We will begin by focusing on

high risk and high cost members of the population whose care often

adversely influences health care margins.

• Reduce health care costs while maintaining experience, thus allowing

sustainable investments in other determinants of health. We are

motivated to pursue this purpose by a belief that in the next several

years the combination of the economic situation and the changes in

the Patient Protection and Affordable Care Act will force severe cuts

in payment. We want to get ahead of the trend.

• Move the health care system towards more public accountability for

health and cost to align actions of health care systems with their

stated mission statements. Initial motivation came from the state

Medicaid officials and the Chamber of Commerce.

Questions ?

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Action Step 4

• Draft a regional purpose statement

• Be sure to include the “why”

• Discuss with your table

ON MEASUREMENT & INTELLIGENCE

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101

Four Stages of Measurement Development

1. Exploration

2. Selection/development of practical population-level measures across the three dimensions and the collection of data

3. Integration of measurement into a learning system to support work on the Triple Aim

4.The data collected over time on measures indicate improvement


102

Dimension Measure

Population Health


rates









Experience of Care



2. Set of measures based on key dimensions (e.g., US IOM Quality Chasm aims:

Safe, Effective, Timely, Efficient, Equitable and Patient-centered)



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Resources

• Potential Triple Aim Outcome Measures – Some Detail

• Data sources (with links)

103

104

Population Health

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105

Population Health

1. Risk Status: 2. Disease Burden 3. Health Outcomes

Bellin Health:

Health Dashboard Measures

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107

Population Health

1. Risk Status: 2. Disease Burden 3. Health Outcomes

CareOregon: Stability of Diabetes and

Hypertension

108

1,780 1,936 2,308

909

1,0281,156

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Potential Sources of Data on Incidence

and/or Prevalence of Chronic Illness

• Disease management registries

• Health records

• Claims

• Population surveys (self report)

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110

Population Health

1. Risk Status 2. Disease Burden3. Health Outcomes

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Single Question Health Status

Would you say that in general your health is:

Excellent, very good, good, fair, poor

CDC HRQOL-4

Self Assessed (Single Question) Health StatusGenesys Health Plan

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Relationship Between Single Question

and Cost

“Predicting Mortality and Healthcare Utilization with a Single Question”, DeSalvo et. al., Health Services

Research 40:4 (August 2005)

113

Using Single-Q Health Status from HCAHPS Survey

Source: Robert Mangel,

Ph.D., and Wenbin Mo,

Ph.D., National Service

Quality, 2010

Data for all 2007 inpatient survey

respondents, with 2.5 year f/u

114

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Options for Single Question Health Status

• From CAHPS survey

• In HRA

• In care experience survey

• Vital sign at point of care or after visit survey

• At enrollment and follow-up annually at re-enrollment or in birthday greeting (call, card, internet)

115

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Years of Potential Life Lost (YPLL) Queens Health Network - 2000-2007

(Jamaica and Northwest, Southeast, Southwest, and West Queens)

Prepared by Bureau of Vital Statistics, NYC Dept of Health and Mental Hygiene, May 28, 2009

Year 2000 2001 2002 2003 2004 2005 2006 2007

YPLL 74,755 78,888 72,374 71,827 66,603 67,235 66,137 62,104

Population (in millions)

1.385M 1.387M 1.384M 1.385M 1.385M 1.385M 1.397M 1.403M

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page 118

KP Colorado:

CVD Care Management Reduces Mortality

Pharmacotherapy 2007;27:1370-1378.

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Potential Sources of Data on Deaths

• Hospitals within integrated system

• Affiliated health plans

• Social Security

• State vital statistics

• Local health departments

For calculation of Life Expectancy and Healthy Life Expectancy (HLE):

Sullivan Method http://www.ehemu.eu/pdf/Sullivan_guide_final_jun2007.pdf

119


120

Dimension Measure

Population Health


rates









Experience of Care






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121

Experience of Care Drivers

Overall Experience:CAHPS

• Health Plans Survey “Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 12 months?”https://www.cahps.ahrq.gov/content/products/PDF/CAHPS_AMB_PG_041310.pdf

• Hospital Survey: -“Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?”

-“Would you recommend this hospital to your friends and family?”http://www.hcahpsonline.org/Files/Appendix%20D%20-%20CAHPS%20Hospital%20Survey%20(English).pdf

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Overall Experience: “HowsYourHealth”

“When you think about your health care, how much do you agree or disagree with this statement “I receive exactly what I want and need exactly when and how I want and need it”?

(MD or employer can give persons an access code)

John Wasson, MD, Dartmouth College - http://www.howsyourhealth.org/

Study by Dr. John WassonThe key components to getting strong agreement to

“I receive exactly . . .”

124

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Martin’s Point HealthCare

HowsYourHealth

US Family Health Plan and MP Primary Care

125

Martin’s Point Healthcare

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Care Experience Measures Dashboard - KP Example

127


128

Dimension Measure

Population Health


rates









Experience of Care






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Healthcare Cost Drivers

HealthPartners Medical Trend – Health Plan Overall Comparison to Milliman Benchmark

*2010 trend is less than 5%

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Potential Sources of Data on Cost

• Claims data from health plans and Medicare

• For integrated systems without a health plan: -Data available within the system (hospital, ED and

primary care)

-Collaboration with affiliated health plans, Regional Health

Information Organization (RHIOs) or ACOs

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132

Component Measure(s)/Goals Data SourcePopulation Health

Experience of Care

Per Capita Costs

Worksheet for Documenting Population Outcome Measures

Run Charts Welcomed!

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ON PORTFOLIO

Portfolio: Definitions

• A hinged cover or flexible case for carrying

a collection of loose papers

• The diversified collection of securities held

by an investor designed to spread risk

• For our purposes:

─The set of projects, investments, and capacities that together are sufficient to achieve the Triple Aim

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Comment

• No single project can accomplish the

Triple Aim

• Sometimes people try to force or make a

project work on all three aims when it

really is just focused on one or two of the

aims

• Grandiose goals and underwhelming

portfolio projects

Attributes of an Effective Portfolio of Projects

• Risk matches the goals

• Diversified

• Periodically rebalanced with new insights

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How to Start

PopulationHealth

Experienceof Care

Per CapitaCost


Projects Investments Capability building

Population Health

Experienceof Care

Per Capita Cost

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Comment

• How many projects should you focus on?

• Hypothesis just a few key projects in each

area can make a big difference

The Model and the Portfolio

Define “Quality” from

the perspective of an individual member

of a defined population

The “Triple Aim”

Health care Public health

Social services

Per capita

cost reduction

Integration

Infrastructure

Social capital

Capability BuildingSystem-Level

Metrics

$E

PH

Definition of

primary care

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Individual and

family

Prevention and

Health

promotion

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Initiative Typical projects Typical investments

Capability building

Regional intelligence Data from ambulances, data from EDs

Fund a few positions to receive, maintain, and analyze the data for the community

Timely knowledge of community health status

Primary care Redefinition of primary care

Connections with community resources

Longitudinal experience of care

Care for the socially complex

Community based health promotion and care mgt.

Development of new skills in the workforce

Payment and cost control

Improving healthand lowering cost for employees

Health risk appraisals, and health coaching

Driving cost savings through population health

Community health Falls with harm in the community

Integration of existing efforts, ACO savings

Cooperation, improvement skills, joint investing

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CareOregon’s Triple Aim Learning System

Learning

Learning

•Global Rating of Health

Care (0-10)

•Avg % meeting HEDIS

effectiveness of care

index target

•Total PMPM

•ED PMPM

•Hospital PMPM

•Primary PMPM

•Specialty PMPM

•Global Health

Status (SF-1)

•Avg Total HRA

score

•Avg EQ5D score

(HRQOL)

METRICS

METRICS

METRICS

Two Primary Triple Aim Initiatives1. Case management for socially

complex2. Primary care transformation

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143

An Integrated Measurement System for the Triple Aim

Projects

Project Metrics

•Metric a

•Metric b

•Metric c

System

(population)

Metrics

•Metric A

•Metric B

•Metric C

Aim

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

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Diversification To Mitigate Risk of Innovation

• All elements of the model under

consideration

• Short term impact with longer term scale-

up and spread plan

• Long term infrastructure building

What is Already in Your Portfolio?

• For your chosen population, what are you

doing now?

• Are there project goals that align with your

Triple Aim goals?

• Discuss at your tables for 5 minutes and

make some notes.

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Where Are the “Edges” of Your System?

Public Health

Employers

Social

Services

Health Plans

PCMH

Specialty

Other Schools

Community

organizations; faith

communities

5X Scale-up – Reduce cost and improve

care for socially complex Number of people System issues to address

5 1. Form a team of volunteers

2. Find people through referrals

25 1. Full time team

2. Redesign of practice

3. Cooperation of hospitals for data

4. Assess outcomes

125 1. Grant funding for operations

2. Consistent population outcomes

625 1. ?

3125 1. ??

15,625 1. ???

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Attributes of an Effective Portfolio of Projects

• Risk matches the goals

• Diversified

• Periodically rebalanced with new insights

Some Observations To Date…

• Portfolio development within each region seems to follow a similar path:

1. An assessment of community work:

a. Current projects where collective action might

accelerate progress. “Go to where the energy is.”

b. Gaps.

2. Consideration of benefits and costs of collective action: *If

an existing community project has clear aims, measures,

change ideas, strong day-to-day leadership and has been

able to integrate the work with other community

organizations, then the Triple Aim coalition might create

unnecessary friction.

• Per Capita cost is the area of the portfolio on which it is hardest to gain traction

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Questions ?

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Action Step 5

• Fill out the Triple Aim Regional Portfolio

Worksheet

• For each of your portfolio projects, consider

what new perspectives you might be able to

take. Gather ideas from your table

companions.

• Review your portfolio of projects and

consider:─ What investments will be required to succeed?

─ What capabilities will need to be built or

enhanced?

Let’s Break

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Welcome Back!





10:45 – 11:00AM Break


11:45 – 12:30PM Lunch


2:30 – 2:45PM Break

2:45 – 3:45PM Putting it Together: Building an Execution and Learning System for a Regional Triple Aim Portfolio

3:45 – 4:00PM Wrap Up

Putting it Together: Projects

that Require Collective Action


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Objectives

• Understand a community approach to

working on a project

• Apply this community approach to one

project of your choosing

Where are we?

• Purpose



• Integration and governance

• So at this point if you are a community

working together to accomplished all of the

above.

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AH Commitment to Health Improvement

History:2000-2005

• “HIO” created as ‘compact among patients, physicians, employers, the health system & health plan’

• Focused mainly on employer-based health improvement

• Dedicated department created

Next Steps:2011-• Community Wellness

Campaign• Overarching

Population Health Metric

• Integration with CIN/JCMR

Progress:

2006-2010

•Governance-level board committee

•Re-visioning with a broader focus on community

•HIO Coordinating Council

•Community Action Plan launch

•Invited to join IHI ‘Triple Aim’initiative

•2010 AHA Foster McGaw Award Recipient

AH Commitment to Health Improvement

History:2000-2005

• “HIO” created as ‘compact among patients, physicians, employers, the health system & health plan’

• Focused mainly on employer-based health improvement

• Dedicated department created

Next Steps:2011-• Community Wellness

Campaign• Overarching

Population Health Metric

• Integration with CIN/JCMR

Progress:

2006-2010

•Governance-level board committee

•Re-visioning with a broader focus on community

•HIO Coordinating Council

•Community Action Plan launch

•Invited to join IHI ‘Triple Aim’initiative

•2010 AHA Foster McGaw Award Recipient

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Governance Structure/Strategic Plan

Allegiance Health Board of

Trustees

Health Improvement (HIO) Board Committee

HIO Coordinating

Council

Strategy:Partner with individuals and our

community as “co-creators” of health improvement

MissionWe lead our community to better health and well-being at every stage of life

Pillar: Personal and Community Health

Aligned CommunityHealth Goals

County

Strategic

Planning

United WayCommunitySolutionsTeam

AllegianceHealth

HIOCC

•Active Living•Nutrition•Smoke-Free Lifestyle•Emotional Health

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Revisioning Process

•New HIO Vision Statement

The HIO will create a culture of continuous health improvement in our community

•HIO Principles

Progress on meeting the HIO vision can only be accomplished through enacting the following principles:

• We Focus on Prevention

• We Put the Community First

• We Build Community Capacity

• We Take an Integrated Approach

• We Target Efforts on Identified Problems

Measures

• Goals

─ Increase awareness of health guidelines

─Reduce exposure to cigarette smoke

─Reduce obesity rate

�Increase adherence to guidelines around fruit and

vegetable consumption and physical activity

─ Increase recognition of signs/symptoms of stress/depression and healthy coping mechanisms

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A Community Approach for a Population Health Project

• Adaptive Leadership- “honest broker”

• Community Assessment of ongoing work

and resource

• Infrastructure to support the project work:

project management, quality improvement,

data analytics and logistical support

• Common Working Knowledge- QI Training


• High Level Measures- with multiple

agencies it is important to be focused on

the big outcome

• Funders -Get funders involved in a unified

way that will support the overall aims

• Communication- across agencies and

within the community

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• Design issues -high risk population

segment, self management issues, care

coordination issues , economic or social

factors and patient and family involvement

including self management issues

• Helpful Reference: Collective Impact By

John Kania & Mark Kramer Stanford

Social Innovation Review Winter 2011

Questions?

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Action Step 6

• At your table pick one population health

project

• Using the check sheet work through the 8

step process

Wrapping Up

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Our Aim Today

• Motivation to pursue the Triple Aim within

your region

• An opportunity to address who, where,

what, why, when, and how for your

regional population

• An understanding of community-based

approaches to achieving the Triple Aim

• Practice in getting started

Our Structure Today

• Develop a shared vocabulary

• Have a clear understanding of opportunities and threats to local leaders

• Do a community assessment

• Identify governance

• Develop clear purpose

• Understand high level measures

• Begin work on a portfolio of projects.

• Work on a Project that Requires Collective Action

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Questions?

• Ninon Lewis [email protected]

m11: the ihi triple aim in a region - eventpilot...

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