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

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

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.

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.

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

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.

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.

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

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

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

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

Activities of a Population Management Learning System

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?

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

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

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

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

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: - 18-75 year olds with A1c<9.0% for Diabetes 1 and 2 - 18-84 year olds with BP<140/90 - 18-75 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

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?

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?

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.

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.

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

Before

After!

Outcomes – MI Admissions BBHC commences

Outcomes - Mortality

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