The Triple Aim:

The Simultaneous Pursuit of Population Health,

Enhanced Individual Care, and Controlled Costs for a Population

Drivers of a Low-Value Health System

Low Value

High Cost Low Quality

Supply-Driven

Demand

No mechanismto controlcost at the

population level

New drugsand

tech ≠outcomes

Over-Reliance

On Doctors

Under-valuing

“system”design

Insignificant role for

individuals and families

Three Dimensions of Value

PopulationHealth

Experienceof Care

Per CapitaCost

Design of a Triple Aim Enterprise

Define “Quality” fromthe perspective of an individual member

of a defined population

The “Triple Aim”

Health care Public healthSocial services

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PH

4

Design of a Triple Aim Enterprise

Define “Quality” fromthe perspective of an individual member

of a defined population

The “Triple Aim”

Health care Public healthSocial services

System-LevelMetrics

$E

PH

5

Potential Triple Aim Outcome Measures 9/25

Dimension MeasurePopulation

Health1. 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: summary of the 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

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

6

Design of a Triple Aim EnterpriseDefine “Quality” from

the perspective of an individual member of a defined population

The “Triple Aim”

Health care Public healthSocial services

Per capitacost reduction

Integration

System-LevelMetrics

$E

PH

Definition ofprimary care

7

Individuals andfamilies

Prevention and Health promotion

What Are We Trying To Accomplish ?

Aims: – Reduce health inequalities for cardio-vascular disease and improve life expectancy

for all residents in Bolton aged 45+.– Understand A&E utilisation and preferred care access models. – Work in partnership between public health, local authority and primary care to

improve health experience and wellbeing.

Outcomes:– 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. – Improve utilisation of A&E and development of unscheduled care facilities.

Bolton Primary Care Trust (NHS)

CARDIOVASCULAR SCREENING PROGRAMME PROGRESS

Farnworth:•59% screened (6121pts)•To test 6 health trainers to target open sessions•Priority to target businesses•Social marketing:

Early expansion to all Bolton:•65% screened (57,000 pts)•Priority to expand business links•Target lists•Social marketing

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?

Activities to Get Started

• Development of Infrastructure ( Executive Sponsor, Team Formation, etc.).

• Establish Aim, Population, and Measures. • Align current portfolio of projects with the

Triple Aim Initiative. • Work on Improving Primary Care.• Focus on Cost Control Project.

Triple Aim Prototyping Evolution

Phase I: Concept design and projects

Phase II: Phase I plus detail design of components, for example primary care

Phase III: Phase II plus total triple aim design for a sub population

Phase IV: Phase III plus total triple aim design for a region or community

Design Needs by Sub-populationSub population

Primary care Role of patients & families

Cost control

Prevention and health promotion

IntegrationMicro &Macro

Employed people <65

Focus on disability and workers comp trends

-Connection with company wellness programs-Safety and ergonomic advice

Employer & Health System integrated approach (e.g. Onsite clinical staff)

People>65 “Home is the hub”

End of life care

Support for staying in the home if desired

Multiple specialists

Socially complex

Strong mental health component

Strengthen family support mechanisms

Self help programs

Integration w/ public health& social services

Children and families

Transition to adult care

Support for parenting skills

Immunizations and well child care

Cooperation with schools

All cells are important for all sub populations. Blank means only minor differences in approach.

Sub population(Based on health, social support etc)

Primary care Role of patients & families

Cost control

Prevention and health promotion

IntegrationMicro &Macro

Low Need good system to identify patients as the move to different subpopulations(low medium high)

Identification of support system

1.Passion for life(Jonkoping program)

Medium Integrate strong geriatric practices into the care

Integrate family into the service. Access to medical information etc.

Define specific goals for the patient

Home safety survey

High 1.Intensive geriatric service including end of life services without handoffs2.Embedded Case Management for PC team

The service receiver is the patient and family/caregiver. No 1-1 appointments.

1.Execute to patient goals

2.Cooperation between LTC,HHA and hospital

Support for staying in the home if desired

1.Coordination of specialty care2. Coordination of roles of long term care, hospital,HHA and family

All cells are important for all sub populations. Blank means only minor differences in approach.

65+ Sub-populations

Risk Segmentation and Program Interventions

Problem

Inefficient, unreliableprevention and treatment for seriouschronic diseases

Care Partners Frail Elder Program (n=227)

Healthy, 17%

At Risk for Chronic Disease, 39%

End-stage Chronic Disease, 7%

Uncomplicated Chronic Disease, 29%

Complex Co-morbid Chronic Disease, 7%

Physician Chronic Disease P4P chart review programs (n=7,792)

Accessible exercise Program: Silver Sneakers

Palliative Care: Home Connections (n=231)

Health Coach Outreach (n=6,979)

Care Transitions for Readmissions

Chronic Disease Self-Management (n=231)

Risk Segments Program Interventions

Medicare Populationn = 55,718, doubled Since 2006

Triple Aim Prototyping Sites

1

1

35

3 23 1

North American Triple Aim Prototyping Sites

• Health PlansBlue Cross Blue Shield of Michigan (MI)CareOregon (OR)Essence Healthcare (MO)UPMC Health Plan (PA)Independent Health (NY)

• Integrated Delivery Systems (w/ Health Plans)HealthPartners (MN)Kaiser Permanente, Mid-Atlantic Region (MD)Martin’s Point Health Care (ME)Presbyterian Healthcare (NM)Southcentral Foundation and Alaska Native

Medical Center (AK)Vanguard Health SystemVeterans Health System:

VISN 10—Cincinnati VAMC (OH) VISN 20—Portland VAMC (OR) VISN 23—Nebraska, Western Iowa

VAMC (NE)Wellstar Health System

• Public Health DepartmentWashington DC Department of Health (DC)

• Social ServicesCommon Ground (NY)

• State InitiativeVermont Blueprint for Health (VT)

• Integrated Delivery Systems (w/o Health Plans)Allegiance Health (MI)Bellin Health (WI)Bon Secours - St. Francis Health System (SC)Cape Fear Valley (NC)Cascade Healthcare Community, Inc. (OR)Cincinnati Children’s Hospital Medical Center (OH)Erlanger Health System (TN)Fort Healthcare (WI)Genesys Health (MI) (Ascension)

• Safety NetColorado Access (CO)Contra Costa Health Services (CA)Health Improvement Partnership of Santa Cruz County (CA)Nassau Health Care Corporation (NY)North Colorado Health Alliance (CO)Primary Care Coalition Montgomery County (MD)Queens Health Network (NY)

• Employers/BusinessesQuadGraphics/QuadMed (WI)

• CanadianCentral East Local Health Integration NetworkSaskatchewan Ministry of Health British Columbia Team

Last Updated 12/1/09

International Triple Aim Prototyping Sites

• Jonkoping (Sweden)• National Healthcare Group (Singapore)• NHS Blackburn With Darwen PCT (NW

England)• NHS Bolton PCT (NW England)• NHS Bournemouth and Poole (SW England)• NHS East Lancashire Teaching PCT (NW

England)• NHS Eastern and Coastal Kent PCT (South

East Coast England)• NHS Forth Valley (Scotland)• NHS Hastings and Rother (South East Coast

England)• NHS Heywood, Middleton and Rochdale PCT

(NW England)• NHS North Lancashire Teaching PCT (NW

England)• NHS Medway (South East Coast England)• NHS Oldham PCT (NW England)

• NHS Salford PCT (NW England)• NHS Somerset PCT (SW England)• NHS Swindon PCT (SW England)• NHS Tayside (Scotland)• NHS Torbay Care Trust (SW England)• NHS Blackpool PCT (NW England) • NHS Central Lancashire PCT (NW England)• NHS Sefton PCT (NW England) • NHS Warrington PCT (NW England) • NHS Western Cheshire PCT (NW England)• NHS Wirral PCT (NW England)• State of South Australia, Ministry of Health

(Australia) • Western Health and Social Care Trust (Northern

Ireland)

Last Updated 11/1/09

TRIPLE AIM:TRIPLE AIM: Health-Experience-Health-Experience-AffordabilityAffordabilityHealthPartners ClinicsHealthPartners Clinics

0.9200

0.9300

0.9400

0.9500

0.9600

0.9700

0.9800

0.9900

1.0000

1.0100

4Q04 1Q05 4Q082Q05 4Q053Q05 1Q06 3Q083Q062Q06 4Q06 2Q071Q07 3Q07 4Q07 1Q08 2Q08

INCREASE % patients with Optimal Diabetes Control*

* controlled blood sugar, BP & cholesterol AND daily aspirin use

AND non-tobacco user

DECREASE Total Cost Index (compared to statewide average)

< 1 is better than network average

80%

90%

100%

INCREASE % patients “Would You Recommend”

HealthPartners Clinics

Tota

l C

ost

Index

0.9200

1.0005

1Q09

34%

9%

30%

32%

34%

24%

98%97%

10%

12%

14%16%

18%

20%

22%

26%

28%

32%

34%

Population Health: Admissions for Ambulatory Care Sensitive Conditions per 100k Member Months

Triple Aim Design Components

1. Individuals and families2. Redesign of “primary care” services and

structures3. Prevention and health promotion4. Cost control platform5. System integration

1. Individuals and Families

A. For medically and socially complex patients, establish partnerships among individuals, families and caregivers, including identifying a family member or friend who will be supported and developed to coordinate services among multiple providers of care.B. Jointly plan and customize care at the level of the individual. C. Actively learn from the patient and family to inform work for the population.D. Enable individuals and families to better manage their own health.

2. Redesign of “Primary Care” Services and Structures

a. Have a team for basic services that can deliver at least 70% of the necessary medical and health-related social services to the population.

b. Deliberately build an access platform for maximum flexibility to provide customized health care for the needs of patients, families, and providers.

c. Cooperate and coordinate with other specialties, hospitals, and community services related to health.

3. Prevention and Health Promotion

A. Work with the community to advocate and provide incentives for smoking prevention, healthy eating, exercise, and reduction of substance abuse.

B. Develop multi-sector partnerships, utilize key stakeholder resources (worksites, schools, etc.) and align policies to provide community-based support for all who wish to make health-related behavior change.

C. Integrate healthcare and publicly available community-level data utilizing GIS mapping to understand local context to determine where and for whom health-related strategic community-level prevention, health promotion and disease-management support interventions would be most useful.

4. Cost Control PlatformA Achieve < 3% inflation yearly for per capita cost by developing

cooperative relationships with physician groups and other health care organizations committed to reducing the waste of health care resources.

B. Achieve lowest decile performance in the Dartmouth Atlas measures by breaking or countering incentives for supply-driven care.

C. Reward health care providers, hospitals, and health care systems for their contribution to producing better health for the population and not just producing more health care.

D. Orient care over time - the “patient journey” - targeted to the best feasible outcomes.

5. System IntegrationA. Match capacity and demand for health care and social services across suppliers.B. Insure that strategic planning and execution with all suppliers including hospitals

and physician practices are informed by the needs of the population. C. Develop a system for ongoing learning and improvement.D. Institute a sustainable governance and financial structure for the Triple Aim systemE. Efficiently customize services based on appropriate segmentation of the population.

F. Use predictive models and health risk assessments that take into account situational

factors, medical history, and prior resource utilization to deploy resources to high-risk individuals.

G.Set and execute strategic initiatives related to reducing inequitable variation in outcomes or undesirable variation in clinical practice.