Some in this category have competing personal agendas and choose not to work on their condition at this time. “Non-compliance” is a set of discoverable opportunities for intervention. Lists can also be run to identify people with worsening clinical conditions.Ĭlaims and clinical data are only part of the more complex reality of our patients. A care management team can run monthly reports from our dashboards identifying individuals with chronic conditions who have no PCP visit in 6 months or no physician visit at all in 12 months. Outreach to loosely or un-engaged individualsīeing responsible for a population means reaching out to loosely or un-engaged people with complex chronic conditions. health coach, care manager, case manager) reviews the chart with the PCP, reaches out to the individual, tailors interventions to support that person’s needs. Care management teams can use this data to identify high risk patient groups andĪ cadre of care management staff (a.k.a. The “hot-spotter” strategy identifies people with extraordinary risk (high illness burden + high ER/hospital admission use). Narrowing down to a patient segment – “population of focus” This begs the questions: who do we engage first? A number of groups start with a patient engagement strategy. This not a complete list of all potential interventions and is not meant to be exclusive of other interventions.Įventually we may be able to support all the needs of all patient segments, but as we get started it makes sense to begin with very high risk individuals and expand as our capacity allows. Below are segmentation and intervention strategies that meet these criteria. Interventions that simultaneously improve outcomes, experience of care and cost are more likely to achieve the Triple Aim than interventions addressing only one or two of the axes. Claims data provide a window into the people and activity beyond the practice.Ī segmentation strategy focused on the entire population rather than a specific diagnosis provides a pool of opportunity more likely to achieve the Triple Aim. It is important to know about patients who fail to come to our offices but show up in multiple emergency departments, who bounce from specialist to specialist, and who have chronic conditions but are receiving no care. Improving population outcomes means more than just aggregating our medical record data on those patients we see in our practices: our responsibilities extend to the population attributed to the practice and their health system interactions beyond our four walls. We must do more if the Triple Aim is our goal. Closing gaps in evidence-based care through the use of clinical registries is necessary but insufficient. The outcomes of tight blood sugar control in diabetes (fewer heart attacks, amputations, strokes) show up nine years later. Preventive care – while essential – is not likely to achieve near-term cost savings. This prioritization challenges deeply held beliefs regarding delivery system change. The list of potential improvement strategies is far longer than the capacity to make near-term change, so it is logical and appropriate to consider those strategies most likely to achieve the goals at the top of a priority list. The Triple Aim defines success as simultaneous improvement in population health and outcomes, patient experience of care, and cost trends.īecause of the immense pressures to reduce per capita medical expenditure in the near-term, Triple Aim strategies must also succeed in the near-term. The Triple Aim is a construct developed to move past the trade-offs typical in health care improvement: improved quality at the expense of increased costs, decreased costs at the expense of quality or access, improved guideline adherence at the expense of patient experience of care, etc. The Logistics of Population Health Under the IHI Triple Aim
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