Triple Aim, Healthcare Reform, Primary Care to Save the System?!?, Serving New Populations and What Matters! Karen Boudreau, MD, FAAFP Chief Medical Officer Boston Medical Center HealthNet Plan IHI s 24 th Annual National Forum on Quality Improvement in Healthcare Minicourse M24 Enhancing Primary Care Value at Lower Cost to the Community 1 Three things to take from this part Social complexity impacts health, experience of care and costs The Triple Aim framework encourages consideration of all three (health, experience and costs) through a portfolio of projects We can engage communities in designing care systems that address social complexity 2 1
Origins of the Triple Aim Defining The Triple Aim Work to improve site-specific care for individuals should expand and thrive. In our view, however, the United States will not achieve highvalue health care unless improvement initiatives pursue a broader system of linked goals. In the aggregate, we call those goals the Triple Aim : improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations. Berwick, Nolan and Whittington, The Triple Aim: Care, Health and Cost Health Affairs 27, no. 3 (2008): 759 769; 10.1377/hlthaff.27.3.759populations. 3 The 2008 view A health system capable of continual improvement on all three aims, under whatever constraints policy creates, looks quite different from one designed for the first aim only. The balanced pursuit of the Triple Aim is not congruent with the current business models of any but a tiny number of U.S. health care organizations. For most, only one, or possibly two, of the dimensions is strategic, but not all three. Thus, we face a paradox with respect to pursuit of the Triple Aim. From the viewpoint of the United States as a whole, it is essential; yet from the viewpoint of individual actors responding to current market forces, pursuing the three aims at once is not in their immediate self-interest. Berwick, Nolan and Whittington, The Triple Aim: Care, Health and Cost Health Affairs 27, no. 3 (2008): 759 769;10.1377/hlthaff.27.3.759populations. 4 2
What has changed since 2008? Plus ACA Robust exploration of different payment models Medical homes taking off ACOs are launching Myriad of initiatives nationally Continued challenges CBO findings on Care Management and Valuebased pilots hard to demonstrate ROI Business models lag Requires investment Measurement of cost and health Still learning how to do this! 5 What are we learning? 6 3
7 http://www.ihi.org/offerings/initiatives/tripleaim/pages/approach.aspx Achieving Triple Aim Results for a Population Purpose Measurement/intelligence Portfolio of projects and investments Integration and governance 8 4
Successful Triple Aim Sites Culture of improvement and learning Application of learning Alignment of System Levers and Drivers for the population not always to the benefit of an organization Cultural shift for society and providers in the rational use of resources Focus on Existing Expenditure, Quality, Productivity and Efficiency Regional Focus Collective Power 9 The Improvement Guide, 2 nd Edition, Langley, Moen,Nolan, et.al., Jossey-Bass 2009 5
Building a TA Portfolio Projects Improved Population Health Achieving the Triple Aim for a Defined Population Enhanced Experience of Care Reduced Per Capita Cost 11 A Portfolio of Projects and Investments (All 3 aims-collective Action-Cost-Triple Aim focus areas) Initiative Typical projects Typical investments -Regional intelligence Accessing and analyzing locally available data, e.g. from ambulances, EDs, Ins co., QIOs, vital records -Primary care -Longitudinal experience of care Access for low income residents Population mgt. of chronic disease Outcomes for patients with mental illness Experience and cost for the socially complex Transitions/Readmissions End of life Capability building -Payment and cost control -Population health Lowering cost for employees Alternative payment mechanisms Transparent outcomes and cost Unintentional harm, e.g. falls Healthy behaviors Health of children -1 to 5 12 6
Potential Triple Aim Population Outcome Measures (6/2011) Dimension Population Health Experience of Care Per Capita Cost Measure 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: composite health risk appraisal (HRA) score 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) 1. Total cost per member of the population per month 2. Hospital and ED utilization rate CareOregon s Triple Aim Learning System METRIC METRIC Learning Global Rating of Health Care (0-10) Avg % meeting HEDIS effectiveness of care index target Learning Global Health Status (SF-1) Avg Total HRA score Avg EQ5D score (HRQOL) METRIC Total PMPM ED PMPM Hospital PMPM Primary PMPM Specialty PMPM 14 14 7
15 One Young Man s Story 16 8
Whose job is it? In your current system, who gathers and shares information about social context and complexity? We tend to look for things we can fix these problems often appear un-fixable 17 Many lessons learned Even with the best of intentions, complex situations often come with unforeseen obstacles that slow/impede getting to a positive resolution Wishful thinking cannot replace methodical process and barrier removal; may even require less than optimal interim steps Organizations, government, families, providers, members must work together to solve complex problems 18 9
Care Coordination Model Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011. (Available on www.ihi.org) 19 COMMUNITY & PROGRAM CCC s Recuperative Care Program Portland OR Pathways to Housing Philadelphia PA BronxWorks Homeless Outreach Team Bronx NY & INTEGRATOR ORIENTATION MEDICAL HOME Integrated Team: Lead case mgr = SW/EMT, plus MD, housing, logistics & FT volunteer * SW or EMT Multi-disciplinary Assertive Community Treatment (ACT) * RN Hospital Homeless Coordinator * LMSW Old Town Clinic FQHC On-site physician from TJU Locating FQHCs in community HOUSING ~30-day respite w/connection to Permanent Supportive Housing (PSH) Permanent Supportive Housing Transitional & PSH PROGRAM FUNDING Local Hospitals, CareOregon & City of Portland Housing Bureau ACT: Medicaid MD: Grant Local Department of Homeless Services Hospital to Community-Based Integrated Link to New York State Home Care Manager care team transitional & Department of * Community PSH Health grant New York NY health worker or BSW 20 * Denotes background of person in the Integrator role: identifying goals and coordinating care 10
John McKnight Northwestern: Asset based Community Design the principal history of the twentieth century relationships between systems and associations is the ascent of the system and the decline of the community of associations http://www.abcdinstitute.org/docs/twentyfirstcentury.pdf 21 Community Assets Systems-based society Based on addressing needs Power is defined by size, products, number of clients and consumption Growth depends on expanding needs and client base think healthcare system Raw material for systems is the deficiency, inadequacy, brokenness or disease of people Associational community Based on utilizing gifts and talents of citizens Power is defined by what the community can accomplish, how they care for each other, the decisions they make Growth depends on cooperation Raw materials for association are the capacities, abilities, skills and gifts of people http://www.abcdinstitute.org/docs/twentyfirstcentury.pdf 22 11
Community Integration Build on community assets (relationships, churches and other civic/social organizations, community benefit funds) Engage the community around issues that matter locally Activated community can define new needs to help shape the delivery system 23 IHI Triple Aim Design Concepts for High Value Care: A Regional Perspective 1. Primary Care: Redefined, Higher Capacity 2. Decrease Dependence on Highest Cost Care 3. Reclaim Wasted Hospital Capacity 4. Pursue Individual Patient Goals at Lowest Total Cost 5. Focus on the High Cost, Socially or Medically Complex Patients 6. Integrate Regional Resources 24 24 12
Guiding Themes How do we address these? Human connections emotional, personal Healing connections well before people get into the healthcare system. Schools, neighborhoods, churches Isolation as a burden in all areas. Retirement. Homeless. Young mothers. Workplace. How do we keep people engaged? Health Care System financing encourages the marginalization, isolation of practitioners. How do you pay a in way to get practitioners connected to the community? Do we really have scarcity, or is it about how we reallocate resources? Complexity no silver bullet. If we value community, we need to deal with the complexity. Reciprocity? 25 If we started with what matters How might communities design their associations and systems? What would be the balance between needs and gifts? Caring and servicing? Could the healthcare system be smaller (or better serve the needs of a larger community)? 26 13
IHI National Forum Minicourse M28 December 4, 2011 Access (41) To coordinated care To quick care the way I want it To providers and resources Trust (20) Healing caring relationship, continuity, belonging safe, secure (17) Expert team for what I need (13) Health resources in the community (12) Emotional intelligence (9) Respect me as an expert (9) People and resources to help me achieve goals (9) High value (9) Access to quick care the way I want it (8) Cultural relevance, sensitivity (7) Emotional intelligence (7) Care is local (7) Quality (6) Innovative (6) Access to providers and resources (4) Resources based on value (4) Identify family needs (3) Include preventive care (3) Transparency (3) Involvement- collaborate (2) Health Care Management and Policy Seminar Harvard School of Public Health, February 6, 2012 Palliative care Prevention Non-pharmacologic approaches Quality perceived by me, convenient, upto-date, safe Affordability to me Health service should not make me choose between care and food Access e-care, convenient, timely, family Respect me as the decision-maker Equity in what s offered Caregiver support Information is available and accurate Continuity building established relationships Awareness, Education, Cultural drive re: Eating well Exercising Not smoking Evidence-based care Affordable support (gym etc) Violence prevention Legal policies to improve health, e.g. cigarettes Health and Mental Health Policy Seminar Heller School, Brandeis, February 27, 2012 Access when you want and need, own info, coverage/insurance Trust, respect, integrity Accountability Hear me, see me Follow-up Dialogue Up-to-date: knowledge, facilities, technology Time! Prevention and treatment Relationships with family and friends Organized practice Social support for healthy behaviors, outside health care Systems coordinated across the continuum Food Exercise Sleep Choice Connect with others with similar interests, including gaming Healthful environment Context for my problems being responsive to my symptoms Self-management support Be vital, have fun Holistic approach, open to alternative/complementary treatments Access to good information Pets Education in the community (good schools etc) 27 Massachusetts Capitated Financial Alignment Demonstration (CFAD) Massachusetts Demonstration to Integrate Care and Align Financing for Dually Eligible Beneficiaries, Kaiser Family Foundation, Commission on Medicaid and the Uninsured Policy Brief #8291-02 http://www.kff.org/medicaid/8291.cfm 28 14
Massachusetts CFAD Massachusetts Demonstration to Integrate Care and Align Financing for Dually Eligible Beneficiaries, Kaiser Family Foundation, Commission on Medicaid and the Uninsured Policy Brief #8291-02 http://www.kff.org/medicaid/8291.cfm 29 Massachusetts Demonstration to Integrate Care and Align Financing for Dually Eligible Beneficiaries, Kaiser Family Foundation, Commission on Medicaid and the Uninsured Policy Brief #8291-02 http://www.kff.org/medicaid/8291.cfm 15
http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/prev-meetings/120409-data-presentation.pdf http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/prev-meetings/120409-data-presentation.pdf 32 16
http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/prev-meetings/120409-data-presentation.pdf 33 http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/prev-meetings/120409-data-presentation.pdf 34 17
http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/prev-meetings/120409-data-presentation.pdf 35 http://www.mass.gov/eohhs/docs/eohhs/healthcare-reform/prev-meetings/120409-data-presentation.pdf 36 18
ICT Foundation of the Model of Care 37 Key Features of the Model of Care Integrated Care Team Face-to-face assessment of all members on enrollment and with material changes Broad engagement with community based organizations and supports Based on member-centered goal-setting, independence and recovery Focus is much broader than traditional medical model 38 19
Focus Groups - What matters? Maintain relationships important to me Speak my language, listen to my needs I am not just an assemblage of data points Care team driven by me, help empower me not fix me Support the expansion of community based organizations and peer support options My needs may evolve over time Stick with me even if I fail or don t go in the direction you want me to go Help me maintain the fragile set of supports I ve worked hard to establish, including Independent Living Centers and Recovery Learning Centers Involve us in the design 39 Some Potential Risks (there are sure to be more) Will we be able to find and connect with members? Strong disability culture, civil rights-basis - understandable fear of disruption COORDINATING THE COORDINATION! PCP Practice readiness PCMH development, change fatigue LEARNING TO LISTEN AND MANAGE IN NEW WAYS 40 20
Start with what matters Building on what matters to members, Identifying and achieving their goals Face-to-face assessment, engagement of member-chosen natural and community supports, strong plan integration with behavioral health 41 21