TRIPLE AIM Is it achievable?

The Triple Aim

Better care for

Individuals

Better health for Population

s

Lower Cost

Healthcare Dollar Spend

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Healthcare Dollar Spend

National Health Expenditures, 2010

Source: http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx

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HealthCare Partners (HCP) Population

Management• Top 2-5% of patients at risk • Target the right patient population for

high risk needs – Early identification

• Provider education to Identify Patients • Care Management – Locally focused

Population Health identifying Patients with MD offices

• Ensure high patient satisfaction– Expectation-≥50% “completely satisfied”

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HCP Population Management

• Predictive Modeling Tools– Proprietary – “Opportunity List” – Claims

data• Hospital, SNF, ER• PCP visits • Number of chronic conditions• Number of medications

• Intensive outreach efforts to identify patients• Create coordinated path to care• Inter-disciplinary Care Meetings

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• Does not own Hospitals/Skilled Nursing Facilities (SNFs)– Partner with Facilities– Focus on collaboration, care and service– On site Hospitalists and Care Managers

• Long term Hospital/SNF Partnerships > 10 years

HCP Inpatient Strategy

HCP Hospitalist/SNFist Program

• Model – MD and Care Manager• Established over 30 years ago• About 100 employed hospitalists and several

dozen contracted• Diverse training backgrounds

• In California – Continuous coverage 24/7– Approximately 30 contracted hospitals (network)– Dozens of contracted skilled nursing facilities (SNF’s)

• Out of Area (OOA) Unit for non-network coverage and repatriation of patient

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HCP Outpatient

• Primary Care– Group Model– Independent Physicians - IPA

• Ambulatory Care Management (ACM)/Disease Management

• Urgent Care Centers– Operated by HCP employed staff

• Comprehensive Care Programs

HCP Integrated Comprehensive Care Programs

• Comprehensive Care Clinic• House Calls• Palliative Medicine consults• ESRD• Contracted home-based palliative care

services• Close relationships with community

hospices

HCP Comprehensive Care Programs

Comprehensive Care Programs provide:

• Medication management• Advance care planning• Disease education• Access to additional community resources• 24-hour on-call telephone access to a high risk program

provider• Interdisciplinary care plan• Coordination of treatment plans across multiple providers or

locations Teams document in EMR to facilitate care coordinationKeep the patient’s PCP abreast of the patient’s care plan

HealthCare Partners (HCP)Care Model

ACM/Disease Management•CHF / COPD / DM / CKD

Comprehensive Care Clinic

ESRD/Dialysis

Palliative Medicine Consults

House Calls

Urgent Care

Hospitalist/SNF Programs

Patient

Family

Primary Physician/Specia

lists

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HealthCare Partners Transitional Care

Management

F/U Appointments Red Flags

How to get

HELP!

Medication reconciliation

HCP CCC OutcomesCalifornia 2010-2012

Pre In Post

Patients 4887 3370

Admits Per Thousand

1575 1028 (34.%) 913

Days Per Thousand

7510 5199 (30.8%) 4960

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HCP House Calls Outcomes

California 2008-2012

Pre In Post

Patients 5488 3021

Admits Per Thousand

1418 960 (32.2%) 701

Days Per Thousand

9076 5644 (37.8%) 4090

ER/1000 645 581(9.9%) 527

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HCP ESRD Program

Management of Pre ESRD and ESRD Patients• Reduction of avoidable Hospitalization

and unnecessary utilization – Emergency vascular interventions– Catheter related infections– Early access

• Palliative Care and Advanced Care Planning

HCP ESRD Outcomes California 2008-2012

Pre In

Patients 523

Admits Per Thousand

1377 984 (28.5%)

Days Per Thousand 5940 3737 (37%)

ER/1000 385 486 (26%)

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HCP High Risk Program Impact

HCP Outcomes

and Benefits

• Reduction in Hospital Admits and Days• Reduction in ER Utilization• Reduction in Deaths in Hospital and ICU• Improved Advance Care Planning and

Documentation• Improved Patient Satisfaction and Quality of

Life• Improved Treatment Adherence

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Team Approach

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Opportunities for the Comprehensive Care

Program• Increase capacity • See all patients who their MD would “not

be surprised if they died in the next year”• 24/7 in home assessment when

appropriate• Enhance the adoption of a common care

plan – All involved clinicians, especially specialists– Rooted in patient/family values and goals

• Ensure we are measuring the right things

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QUESTIONS