TRIPLE AIM Is it achievable The Triple Aim

TRIPLE AIM Is it achievable?

The Triple Aim Better care for Individuals Better health for Populations Lower Cost

Healthcare Dollar Spend 3

Healthcare Dollar Spend National Health Expenditures, 2010 Source: http: //www. kaiseredu. org/Issue-Modules/US-Health-Care. Costs/Background-Brief. aspx

Health. Care Partners (HCP) Population Management 5

HCP Population Management 6

HCP Inpatient Strategy 7

HCP Hospitalist/SNFist Program

HCP Outpatient 9

HCP Integrated Comprehensive Care Programs

HCP 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 coordination Keep the patient’s PCP abreast of the patient’s care plan

Health. Care Partners (HCP) Care Model ACM/Disease Management • CHF / COPD / DM / CKD Hospitalist/SNF Programs Comprehensive Care Clinic Patient Primary Physician/ Specialists Family Urgent Care ESRD/Dialysis House Calls Palliative Medicine Consults

Health. Care Partners Transitional Care Management F/U Appointments Red Flags How to get HELP! Medication reconciliation 13

HCP CCC Outcomes California 2010 -2012 Pre Patients In Post 4887 3370 Admits Per Thousand 1575 1028 (34. %) 913 Days Per Thousand 7510 5199 (30. 8%) 4960 14

HCP House Calls Outcomes California 2008 -2012 Pre Patients In Post 5488 3021 Admits Per Thousand 1418 960 Days Per Thousand 9076 5644 ER/1000 645 (32. 2%) (37. 8%) 581(9. 9%) 701 4090 527 15

HCP ESRD Program 16

HCP ESRD Outcomes California 2008 -2012 Pre Patients In 523 Admits Per Thousand 1377 984 (28. 5%) Days Per Thousand 5940 3737 (37%) ER/1000 385 486 (26%) 17

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

Team Approach 19

Opportunities for the Comprehensive Care Program 20

QUESTIONS 21