The Triple Aim and Rural Health:

So What’s New?

David A. V. Reynolds, DrPH

My Business Card

Intentionally Blank

Presentation Outline

• Why the Triple Aim?

• Triple Aim: What is It?

• Triple Aim: New to Rural Health?

• Triple Aim: Can Telehealth Advance It?

Why the Triple Aim? Life Expectancy & Health Care Spending

AUS

AUT

BEL

BRA

CAN

CHL

CHN

CZE

DNK

EST

FIN

FRA

DEUGRC

HUN

ISL

IND

IDN

IRL

ISR ITA

JPN

KORLUX

MEX

NLDNZL NOR

POL

PRT

RUS

SVK

SVN

ESPSUE

SWZ

TUR

GBR

USA

64

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72

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80

84

$0 $2,000 $4,000 $6,000 $8,000

Health Care Spending/Person

Life

Exp

ecta

ncy

in Y

ear

s

OECD Health Statistics, 2013

Why the Triple Aim?

Why the Triple Aim?

Triple Aim: What is It?

A Framework developed by the Institute for Health Care Improvement that seeks to optimize health system performance by simultaneously pursuing three dimension:

• Improving the patient experience (including quality & satisfaction);

• Improving the health of populations; and

• Reducing the per capita cost of health care

Triple Aim: What is It?

Outcome Accountable Care

Coordinated Seamless Healthcare System 2.0

• Patient/person centered

• Transparent cost and quality performance

• Accountable provider networks designed around the patient

• Shared financial risk

• HIT integrated

• Focus on care management

and preventive care

Community Integrated Healthcare

● Healthy population centered

● Population health focused strategies

● Integrated networks linked to community resources capable of addressing psycho social/economic needs

● Population-based reimbursement

● Learning organization: capable of rapid

deployment of best practices

● Community health integrated

● E-health and telehealth capable

• Episodic health care

• Lack integrated care networks

• Lack quality & cost performance

transparency

• Poorly coordinated chronic care management

Acute Care System 1.0

Triple Aim: What is It?

Community Integrated Healthcare System 3.0

Health Delivery System Transformation Critical Path

Episodic Non-Integrated Care

Triple Aim: What is It?

IHI components of a system that would fulfill the Triple Aim:

Focus on Individuals & Families

Emphasis on Primary Care Services

Management of Population Health

Cost Control

System Integration

Triple Aim: New to Rural Health?

The Evolution of Northern Counties Health Care

• 1976: Northeast Kingdom of Vermont Lowest per capita income in state

All three counties federally-designated as medically underserved

Yet, a community vision of what could be

Triple Aim: New to Rural Health?

The Evolution of Northern Counties Health Care

By 2007, an integrated system: 6 Federally Qualified Health Centers

2 Dental Centers

a Medicare-certified Home Health & Hospice

serving 2 out of 3 residents in its service areas with a 300-member staff

EHR system before Fletcher Allen Health Care

1st NCQA-certified medical homes in Vermont

1st Blueprint for Health community

Triple Aim: New to Rural Health?

Vermont’s Blueprint for Health (2006)

Codified in State statute as a “program for integrating a system of health care for patients, improving the health of the overall population, and improving control over health care costs by promoting health maintenance, prevention, and care coordination & management.”

Triple Aim: New to Rural Health?

Vermont’s Blueprint for Health

• NCQA-certified patient-centered medical homes (121 PCMHs serving 82% of Vermonters)

• Multi-disciplinary Community Health Teams

• All-insurer (public & private) payment reform & CHT support

• Health information technology for population management

• Evidence-based self-management programs

Triple Aim: New to Rural Health?

Vermont’s Blueprint for Health

Results in 2012 (N = 240,000) (Blueprint Annual Report: 2013)

Lower Hospital Discharges

Increase in Primary Care Visits

Breast Cancer Screening

Cervical Cancer Screening

Emergency Room Use

Triple Aim: New to Rural Health?

Vermont’s Blueprint for Health

Savings vs. Investment in 2012 (N = 240,000) (Blueprint Annual Report: 2013)

Total Saved vs. Comparison Group

Total Invested Ratio of Gain to Investment

Commercial Insurance

$93.2 M $5.9 M 15.8

Medicaid w/out Special Services

$23.6 M $2.9 M 8.2

Medicaid with Special Services

$6.4 M $2.9 M 2.2

Triple Aim: Is It Enough?

Vermont Health Care Reform Goals: Quadruple Aim!

Assure that all Vermonters have

access to and coverage for high

quality care

Improve the health of

Vermont’s population

Assure greater fairness and

equity in how we pay for health

care

Reduce health care costs and

cost growth

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Triple Aim: Can Telehealth Advance It?

Duh!

• Integrating Primary & Specialty Care

• Linking Rural & Urban Health Care

• Overcoming Professional Isolation

• Monitoring & Engaging the Active Patient

• Avoiding Duplication & Reducing Cost

• Advancing Payment Reform

. . . And finally, but most importantly,

Triple Aim: Can Telehealth Advance It?

Telehealth is a Two-way Street.