triple aim is it achievable?
DESCRIPTION
TRIPLE AIM Is it achievable?. The Triple Aim. Healthcare Dollar Spend. Healthcare Dollar Spend National Health Expenditures, 2010. Source: http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx. HealthCare Partners (HCP) Population Management. - PowerPoint PPT PresentationTRANSCRIPT
TRIPLE AIM Is it achievable?
The Triple Aim
Better care for
Individuals
Better health for Population
s
Lower Cost
Healthcare Dollar Spend
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Healthcare Dollar Spend
National Health Expenditures, 2010
Source: http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx
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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”
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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
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• 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
HCP Inpatient Strategy
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
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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
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
HCP Comprehensive Care Programs
Comprehensive Care Programs provide:
• Medication management• Advance care planning• Disease education• Access to additional community resources• 24-hour on-call telephone access to a high risk program
provider• Interdisciplinary care plan• Coordination of treatment plans across multiple providers or
locations Teams document in EMR to facilitate care coordinationKeep the patient’s PCP abreast of the patient’s care plan
HealthCare Partners (HCP)Care Model
ACM/Disease Management•CHF / COPD / DM / CKD
Comprehensive Care Clinic
ESRD/Dialysis
Palliative Medicine Consults
House Calls
Urgent Care
Hospitalist/SNF Programs
Patient
Family
Primary Physician/Specia
lists
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HealthCare Partners Transitional Care
Management
F/U Appointments Red Flags
How to get
HELP!
Medication reconciliation
HCP CCC OutcomesCalifornia 2010-2012
Pre In Post
Patients 4887 3370
Admits Per Thousand
1575 1028 (34.%) 913
Days Per Thousand
7510 5199 (30.8%) 4960
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HCP House Calls Outcomes
California 2008-2012
Pre In Post
Patients 5488 3021
Admits Per Thousand
1418 960 (32.2%) 701
Days Per Thousand
9076 5644 (37.8%) 4090
ER/1000 645 581(9.9%) 527
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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
HCP ESRD Outcomes California 2008-2012
Pre In
Patients 523
Admits Per Thousand
1377 984 (28.5%)
Days Per Thousand 5940 3737 (37%)
ER/1000 385 486 (26%)
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HCP High Risk Program Impact
HCP Outcomes
and Benefits
• Reduction in Hospital Admits and Days• Reduction in ER Utilization• Reduction in Deaths in Hospital and ICU• Improved Advance Care Planning and
Documentation• Improved Patient Satisfaction and Quality of
Life• Improved Treatment Adherence
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Team Approach
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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
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QUESTIONS