WebEx Quick Reference 1 Welcome to todays call! Please chat - - PowerPoint PPT Presentation

WebEx Quick Reference

1

Welcome to today’s call! Please chat questions to “All Participants” For technology issues only, please Chat to “Host” WebEx Technical Support: 866-569-3239 Dial-in Info: Communicate / Join Teleconference (in menu) Select Chat recipient Enter Text

Using the IHI Triple Aim to Manage Populations

Objectives

Gain an overall understanding of general principles for working with populations around the Triple Aim Learn more about populations, purpose and governance as it relates to the Triple Aim We want you to think about our work together as building a system to care for populations and not simply as a “project”

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.

Setup for Population Management

1.Choose a relevant Population for improved health, care and lowered cost 1.Identify and develop the Leadership and Governance for a Triple Aim effort 1.Articulate a Purpose that will hold your stakeholders together 4.Develop a Portfolio (group) of projects that will yield Triple Aim results

Delivery of Services at Scale

Community, Family and Individual Resources

Managing Services for a Population

Feedback Loops

Needs Assessment for Segment Service Design

Coordination Goals

Integrator

Population Segmentation Population Outcomes

Feedback Loops

Learning System for Population Management

1.

System level measures

2.

Explicit theory or rationale for system changes

3.

Segmentation of the population

4.

Learn by testing: PDSA cycles, sequential testing of changes, Shewhart time series charts

5.

Use informative cases: “Act for the individual learn for the population”

6.

Learning during scale-up and spread with a production plan to go to scale

7.

People to manage and oversee the learning system with periodic review

Activities of a Population Management Learning System

8

Choose a relevant Population for improved health, care and lowered cost

Triple Aim Participant 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

“Defined” Population Examples

Employees Members of a health plan All the individuals who use a particular FQHC All the uninsured who use a hospitals ER ACO Other?

Observations About Defined Population

Some heath care workers tend to pick a population by focusing on a disease, i.e. heart failure patients If you use a disease to pick your population remember that for the those patients you are going to manage the Triple Aim and not just a disease, i.e. this is not just a heart failure “project”

Do you have a clear reason for choosing your defined population?

How will working with this population work in your present business model? What business skills do you hope to gain by working with this population? What are your future growth plans for this population? (Example: Working with employees will give us skills to manage an ACO population in the future)

Geographic Region Population Examples

A City: Memphis, TN Primary Care Trust, England Everyone who lives within a certain zip code/postal code 14 County region in Michigan

*The key idea is that your population is everyone within the geographic boundary

Do you have a clear reason for choosing your geographic population?

• 1. How will you work on the multiple determinants of

health for this population?

• 2. Can health care also play a significant role in improving

the health of this population?

• 3. Is the population of interest defined by geographic

boundaries - anyone living within the boundary is in the population whether or not they are currently engaged with the health care system?

• 4. How will you address health equity issues?

POPULATION SEGMENTATION

Population Segmentation Examples

“Bridges to Health Model”

– Splits populations into 8 segments

1.

Healthy

2.

Maternal-infant health

3.

Acutely ill, likely to return to health

4.

Chronic conditions with normal daily function

5.

Serious relatively stable disability

6.

Short decline to death

7.

Repeated exacerbations, organ system failure

8.

Multi-factor frailty, with or without dementia

Lynn, Joanne, Straube, Barry M., Bell, Karen M., Jencks, Stephen F. and Kambic, Robert T., Using Population Segmentation to Provide Better Health Care for All: The 'Bridges to Health' Model. Milbank Quarterly, Vol. 85, No. 2, pp. 185-208, June 2007.

Population/Cost Segments

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % Population % Cost

Long, dwindling course Organ system failure Short period of decline near death Stable, significant disability Chronic condition, normal function Acutely ill mostly curable Maternal & infant Healthy

Source: Lynn J, Straube BM, Bell K, Jencks SF, Kambic RT in Milbank Quarterly, Vol 85 No. 2, 2007 (pp. 185-208)

Population Segments

600,000 Population Employers Children Seniors Low Income

Triple Aim Population: High risk and high cost population Segments:

Older tri-morbid adults Frail older adults Young adults with addictions and mental health concerns Child-bearing women High needs children Complex infants and toddlers These clusters total approximately 4623 in Edmonton Eastwood

Alberta Health Services

Care Delivery Needs Differ Across The Population

21 Source: Yvonne Zhou

*Nominal Range of Frail Elders in a Population of 500,000 Number over 65yrs of age =

– 500,000 x % over 65 years of age =

500,000 x 13.1% = 65500

Number of frail elderly =

–

65500 x (5% - 10%) = 3275 - 6550

* An example of subdividing the population further

A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions).

An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system…

Note: The size of the rectangles is meant to be indicative of population size, not cost.

A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. A sub-population, high cost and or high utilization people from the larger population. People who have “fallen through the cracks” of our “rescue-care” system. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Note: The size of the rectangles is meant to be indicative of population size, not cost.

An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system…

A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. A sub-population, high cost and or high utilization people from the larger population. Sub-groups, people from the high cost high utilization sub- population that can be stratified based upon relatively similar needs. People who have “fallen through the cracks” of our “rescue-care” system. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Sub-groups based more on needs and less

• n conditions.

Note: The size of the rectangles is meant to be indicative of population size, not cost.

An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system…

A population, for which claims data exists and achieving Triple Aim results will not result in perverse economic loss. A sub-population, high cost and or high utilization people from the larger population. Sub-groups, people from the high cost high utilization sub- population that can be stratified based upon relatively similar needs. People who have “fallen through the cracks” of our “rescue-care” system. Interventions intended to address the needs of high cost high utilization sub- groups, Plan Do Study Act cycles. Cannot be defined by a clinical condition (Diabetes) or issue (readmissions). Sub-groups based more on needs and less

• n conditions.

Some interventions will work and some will not. All should result in learning and start on the smallest practical scale. Note: The size of the rectangles is meant to be indicative of population size, not cost.

An approach to achieving the IHI’s The Triple Aim for a given population - from the perspective of a consumer health plan-less, FFS based, Medicare participating, not for profit, hospital->health system…

Alberta Health Services

Overall Population:

– The Eastwood area of Edmonton (health service area

Z4.2C),in the inner north east of the city, with a population of 68,813 in 2011.

Subpopulations:

– People of all ages from this area with repeat

presentations to Emergency Departments of Royal Alexandra Hospital or North East Health Centre

SCHS

Overall Population:

–

All members of the Central Oregon Coordinated Care Organization (Oregon Health Plan)

Subpopulations: Complex Patients

–

Hospital costs data for that reflects patients with the top 5%

–

SCFC PCMH patients:

– EHR utilization review – Identification by healthcare team – Truven analysis risk score at or above 7 – Chart based risk stratification score at or above 5

–

ED patients with the following qualifiers:

– 6+ ED visits in 6 months, 2 in past 2 months – 2-3 ED visits in 6 months and one non-OB hospital admission

–

2 non-OB hospital admissions in 6 months

– In-patient referrals must be assigned to SCFC

QUESTIONS?

29

Exercise: Prework Population

Identify and describe your Triple Aim Population: Identify the subpopulation(s) that will be the focus of your initial projects: If you know these type them in. Otherwise keep thinking about it

30

Triple Aim “Watch Outs”

Population Choosing a populations which doesn’t make sense for the Triple Aim. Another way to say this is that you haven’t created a business model that can support the Triple Aim in all three dimensions

Understanding Your Governance and Leadership Structures

Some questions to think about…

Is the Triple Aim strategic or just one of many “projects”? How important is population management to your strategy?

Shape Culture Engage Across Boundaries Create Vision & Build Will Deliver Results Develop Capability

Driven by Persons & Community

High-Impact Leadership Framework

http://www.ihi.org/resources/Pages/IHIWhitePapers/HighImpactLeadership.aspx

Creating the Vision & Building will

Is there alarm in the system or region about a particular population segment or issue (cost, access, quality, big social problem, economy, etc.)? Who has a sense of urgency and why? Is the urgency broad based?

Deliver Results

Creation or refinement of a business model that can support the Triple Aim for at least part of the population that they care for Willingness to allocate sufficient resources to this work Participation in portfolio development

Capability

Teach basic Improvement Invest in needed infrastructure Integrate improvement into daily work at all levels

Leadership 101

Is it clear to you who is the executive sponsor/governance structure for this work? And have the other team assignments been made: portfolio manager, project manager, content experts , improvement advisor and data analyst?

Example: Teams and Projects Aligned

IHI Triple Aim Improvement Community Project Team Contact Worksheet

Sonoma County Committee for Healthcare Improvement (CHI) August 31, 2012 Project Project Team Role Contact Name Educate and empower patients and their loved ones to make informed choices during the last years of life Day-to-Day Project Manager Trayce Beards Content/Clinical Expertise Antara Aiama Bo Greaves Patty Jellison-LaVine Susan Keller Mary Maddux-González Jack Neureuter Additional Improvement Expertise Lynn Silver Chalfin Measurement Lead Jenny Mercado Align care with patient choices during the last years of life Day-to-Day Project Manager Trayce Beards Content/Clinical Expertise Kathy Ficco Robin Hagenstad Gary Johanson Karen Leider Pat Riley Brad Stuart Additional Improvement Expertise Lynn Silver Chalfin Measurement Lead Jenny Mercado

Prerequisites of Governance When Working in a Region or Community

Understanding the stakeholders History of the region regarding health system reform Familiarity with dynamics of health system related politics Knowledge of community leadership Assessment of strength and weaknesses of governance structure(s) of existing organization(s) (if any)

Some Governance Observations

Rely on existing governance structures within your organization

• r community, and if not, understand you’ll need time to build

infrastructure The pursuit of outside grant money may be more of a distraction than a help. Internal organization or community based funding for this work that has the potential to be sustained would be better. It’s in the telling of “war stories” that builds the will and confidence across sectors, not always in “best practice” Honor your partners but don't seek consensus: If a region waits for all stakeholders (esp. health systems) to cooperate they will never start. “Leave the door open.” What can you do to make Governance more robust and sustainable?

– Policy change: Oregon CCO, Vermont Blueprint, NC Medicaid – Connection with ongoing structure in the community: local government,

business community

– ?

Practical tips

Discuss and observe who is at the “table”, who is not and should be? And who is optional for this work?

– “Decisions are made by those who show up”

Who is committed to making it work? Who is neutral? Who is skeptical? Who wants it to fail? Is there a commitment to transparent regional measurement for all aspect of the Triple Aim?

Getting Projects Done

You need two levels for your governance structure:

1.

Overall steering committee of high level leadership- this could be your organization or coalition’s senior leadership team

2.

A working committee of folks who understand project management and have people skills to work across the

• rganization or community

You need to think ahead about resources And how will you make decisions

Exercise: Prework Leadership

Complete your leadership and contact worksheet

44

Triple Aim “Watch Outs”

Governance and organization

• 1. The Triple Aim is not strategic, just one of many

“projects”. Population management is just a sideshow for the organization

• 2. No governance structure in place to manage the Triple

Aim that includes the top leaders and key stakeholders. The leadership team can’t move very fast to make progress.

Purpose: Strategic Direction for the Triple Aim

Challenges for Working with a Defined Population

Good understanding for treating disease not managing populations Financial model supports the care of disease and not populations Even for defined populations there is a need to work on the upstream determinants of health which is new for health care

Challenges for Working in a Region

Cooperating among competitors without violating anti-trust regulations Establishing regional governance structures that are sustainable Integrating health care with public health and social services Involving businesses and unions in the effort Developing business models and transition strategies

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? Or something else?

49

Purpose Statement: Pueblo Triple Aim Coalition (PTAC)

Ever-rising healthcare spending weakens Pueblo’s local economy, threatens jobs, and has failed to deliver improved health of Pueblo County citizens. This combination of increased costs and poor results threatens Pueblo’s future by diverting resources from investment in education and growth. The Pueblo Triple Aim Coalition (PTAC) formed to respond to these issues. PTAC’s goals are to improve health, reduce the per capita cost of care and improve the experience of care in Pueblo County, otherwise known as the “Triple Aim”.

50

Key Points

Statements should be clear, compelling, and include what, why, and when If this work is strategic this statement should outline why it is strategic for the organization All Triple Aim activities should be connected to the purpose Once the Purpose Statement is formed, it should be communicated to all leaders in the

• rganization/coalition, such that all can clearly

articulate it.

51

QUESTIONS?

52

Exercise: Prework Purpose

Using the Worksheet, draft a purpose statement Be sure to include the “why”

53

Triple Aim “Watch Outs”

Purpose Not creating a clear “why” statement- something that can hold a group together during challenging times

Next Steps

Infrastructure Call #2: August 20 11:00-12:30 Focus on measures and establishing a learning system Prework worksheets due August 31st Send to Meghan mhassinger@ihi.org Collaborative Kick-Off Call: Tuesday 9/9/14 11:00-1:00 ET No question is too small-contact: Catherine Mather cmather@ihi.org Meghan Hassinger mhassinger@ihi.org Cory Sevin csevin@ihi.org

55