1. Using the IHI Triple Aim to Manage Populations
Trissa Torres MD
April 11th 2014

2. 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.
The NZ Triple Aim:
Improved quality, safety and experience of care
Improved health and equity for all populations
Best value from public health system resources
Alan Merry, Chair, Health Quality and Safety Commission

3. Determinants of Health and Their Contribution to Premature Death
Proportional 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.

4. Potential Triple Aim Population Outcome Measures (6/2011)
Dimension
Measure
Population Health
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: composite health risk appraisal (HRA) score
Experience of Care
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
A useful system of measurement which operationally defines each dimension of the Triple Aim is essential to this work. Although no single organization or region has yet achieved an ideal, comprehensive measurement system for the Triple Aim, good examples and data sources are now available to illustrate how a good set of population outcome measures can fuel a learning system to enable simultaneous improvement of population health, experience of care, and per capita cost of health care.
The health outcomes of mortality, health and functional status, and their combination —
healthy life expectancy — are ultimate outcome measures for population health. Measures of
disease burden and behavioral and physiological factors are included, as they are contributors to
health outcomes. Sites might use these measures initially if data are more readily available.
For measuring the experience of care, two perspectives are considered: first, the perspective of the
individual as he or she interacts with the health care system (i.e., patient experience surveys) and
second, the perspective of the health care system focused on designing a high-quality experience
for patients as defined by the Institute of Medicine’s (IOM) six aims for improvement.
Total cost per member of the population per month is the desirable measure for per capita cost;
sites can also use high-cost services (e.g., inpatient utilization/costs) that account for a substantial
share of health care expenditures.

5. Triple Aim Populations
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
Triple Aim Results
Defined Populations
Community-Wide Populations

6. Which population do you hold yourself accountable for the Triple Aim?
With a show of hands…
Which population do you hold yourself accountable for the Triple Aim?
Kevin
Facilitate Q&A depending on time left.

7. Global Triple Aim Participants
Over the past five years, this initiative has included more than 100 sites from around the world, spanning a wide
range of entities, from health plans to integrated health systems, social service entities, and regional coalitions, in the US, Canada, UK, Sweden, Denmark, Spain, Australia, New Zealand, and Singapore.

8. Setup for Population Management
Choose a relevant Population for improved health, care and lowered cost
Identify and develop the Leadership and Governance for a Triple Aim effort
Articulate a Purpose that will hold your stakeholders together
Develop a Portfolio (group) of projects that will yield Triple Aim results 8

9. Managing Services for a Population
Community, Family and Individual Resources
Goals
Coordination
Needs Assessment for Segment
Delivery of Services at Scale
Service Design
Population Segmentation
Population Outcomes
Kevin
Integrator
Feedback
Loops
Feedback
Loops

10. Population Change Packages
Assess and segment the population
Activate the population
Care for the population
Address macrosystem factors that will support the population 10

11. Learning System for Population Management
System level measures
Explicit theory or rationale for system changes
Segmentation of the population
Learn by testing: PDSA cycles, sequential testing of changes
Use informative cases: “Act for the individual learn for the population”
Learning during scale-up and spread with a production plan to go to scale
People to manage and oversee the learning system with periodic review 11

12. Activities of a Population Management Learning System

13. 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?

14. CareOregon’s Triple Aim Learning System
METRICS
Population Health
Global Health Status (SF-1)
Avg Total HRA score
Avg EQ5D score (HRQOL)
"Triple Aim"
Global Rating of Health Care (0-10)
Avg % meeting HEDIS effectiveness of care index target
METRICS
METRICS
Total PMPM
ED PMPM
Hospital PMPM
Experience of Care
Cost per Capita 14

15. CareOregon: Cost Measures (goals) Drive Projects
Population Metrics
Projects
Project Metrics
Predictive modeling (PM) for case finding
% enrolled via PM
Total PMPM cost
PAM scores (patient activation)
Transitional care follow-up
Readmission/ACSH rates
Hosp cost/rates
PAM scores
#days from discharge to f/u appt with PCP
ED outreach
ED cost/rates
Third-next available appt or % same day access
Clinic specific ED rates
Case Management
Primary Care Transformation 15

16. CareOregon Population Segments
Members who are also receiving regular mental health services from a community mental health agency
Members who have experienced 3+ hospitalizations and/or 10+ ED visits in the past 12 months
Members who receive primary care from one of five safety-net clinics engaged in the implementation of PCPCH
Members who meet a complexity threshold as defined by their predicted risk of future medical cost
CareOregon Member Population

17. CareOregon Population Segments: Shared Community Accountability
Members who are also receiving regular mental health services from a community mental health agency
Community Mental Health Agency
Various Social Services Agencies (housing, CD tx centers, disability case managers)
Members who have experienced 3+ hospitalizations and/or 10+ ED visits in the past 12 months
CareOregon Member Population
Members who receive primary care from one of five safety-net clinics engaged in the implementation of PCPCH
Members who meet a complexity threshold as defined by their predicted risk of future medical cost
Primary Care Practices
Combinations of all of the above

18. STRATEGIC AIM: Better Health/Better Value (Jeff/Karen)
Secondary Drivers
Strategic Aim
Develop data analytics tools and models to identify and stratify high risk populations; measure results
Map and connect data through the HIE to manage the care continuum
Manage Populations around the Triple Aim
Primary Drivers
Integrated Data Support
Promote effective utilization of services
Access to care
Develop and implement prevention strategies
Implement evidence-based models to manage high risk / high cost populations
Strengthen the health system’s global risk infrastructure
Primary Care Medical Home
Metrics
Defined Populations
Achieve a 2% reduction in per capita medical expenditure trend from July 2013-July 2015
Improve moderate and high health risk scores by 2% by year end 2014
Improve Top box patient satisfaction scores by 10% by year end 2014
Decrease inpatient utilization of populations by 1% by year end 2014
Decrease ED visits of populations by 5% by year end 2014
Development of standardized measurement to decrease obesity rates at the community level across EHR platforms for the following population segments:
year olds with A1c<9.0% for Diabetes 1 and 2
year olds with BP<140/90
year olds with BMI above 30.0
Care Coordination for populations
Develop models to facilitate complex care and effective disease management
Manage transitions across the care continuum
Develop and utilize patient and family advisory groups
Partnership with Providers
Promote integration to achieve changes in provider culture, redesign payment methods and incentives and meet demands of health care reform
Build relationships with public health and human services – behavioral health payment models
Identify social determinants of health to support Regional Health Improvement Plans
Expand Healthy Lives wellness program to Central Oregon employer community
Partnership with Community

19. Why is the Triple Aim Strategic for You?
Do you need to start understanding population management because of new payment models like the ACO?
Can it help you organize work that you are already doing?
Is there a significant health issue in your community that you have been unable to move?
Are businesses collapsing or leaving or not coming because of health care cost?

20. Building will
Is there alarm in the system or 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?

22. Bolton Primary Care Trust
Population 261,037 budget of £369,000,000
Bolton residents have shorter life expectancy than the national average, with significant disparities in the Borough.
Biggest contributors to death: Heart disease and stroke, and cancer.

23. What are we trying to accomplish?
The Aims:
Reduce health inequalities for Cardio-Vascular Disease and improve life expectancy for all residents in Bolton aged 45+
Work in Partnership between Public Health, Local Authority and Primary Care to improve health experience and wellbeing
Strategies:
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.

24. What worked at scale Decreased Clinical Variation
Involved Community Health Workers
Involved the local press 24

25. Before

26. After!

27. Outcomes – MI Admissions
BBHC commences

28. Outcomes - Mortality

29. Changes in Life Expectancy
Compared with England:
In 2004: 2.3 year gap compared with England
In 2009: 1.8 year gap compared with England
Within the Borough
In 2004: 15 year gap
In 2009: 11.9 year gap