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Pursuing the IHI Triple Aim: The Canadian Experience

By Kimberly Mitchell | Tuesday, September 9, 2014

The Canadian Foundation for Healthcare Improvement (CFHI) has partnered with IHI since September 2013 to support Canadian organizations’ participation in the Triple Aim Improvement Community. The CFHI recently announced a new cohort of Canadian teams participating in Better Health and Lower Costs for Patients with Complex Needs, a new IHI Triple Aim Collaborative that launched in July 2014. Over 12 months, teams participating in the Collaborative will seek to transform how their organizations care for patients living with complex health needs so patients experience better care and improved health, all at a lower cost.

In this blog post, Kathryn Brooks, IHI Project Manager for the Triple Aim Improvement Community, interviews Jennifer Verma, Senior Director of Collaboration for Innovation and Improvement at CFHI, to discuss the progress and challenges Jenn has observed in the Canadian teams over the past year, and what the work looks like in the year ahead. 


Kathryn Brooks (left), Jennifer Verma (right)


KB: What excites you about working with organizations that are pursuing the IHI Triple Aim?

JV: First and foremost, we are very excited to be working with IHI. The idea of the Triple Aim in and of itself is exciting, too. It has a real potency as a concept because it defines what everyone in health care wants to achieve — a better care experience for patients and families now, investment in better health of their populations for the future, and doing both at a lower cost. That focus is especially enticing at a time when patients are reporting inconsistent and unsatisfactory health care experiences; many populations are aging and living with more chronic, complex health needs; and health care is highly reliant on facility-based care with high variation in the quality and cost of care. So, the Triple Aim really hits the nail on the head for those system-level issues.

What encourages me most about working with organizations pursuing the Triple Aim is that they are truly motivated to make the changes required to create a new health care narrative. They come together to share their experiences and work toward a different kind of health care that is dignified for patients, while leading to healthier populations and with better financial accountability. I love seeing the change in perspective that takes place among the organizations participating in the IHI Community, and it seems to have a ripple effect — improvement has a way of leading to more improvement.

LEARN MORE: Leading Population Health Transformation, Feb. 22-24, 2017, in San Diego, California

KB: Is there a site whose journey stands out as showing the potential of the Triple Aim approach?

JV: No one journey is exactly like another, and I’m enjoying learning vicariously through all the teams, but I can give an example that exemplifies the potential of the Triple Aim approach. Alberta Health Services (AHS) Edmonton Zone set out to deliver more equitable care for those who need it most in the Eastwood area, which has a population of 75,000 people. The Triple Aim framework allowed them to focus on the people who are accessing the most health care services — 4,600 people — and begin to understand who they are, their needs, and whether AHS-Edmonton is delivering optimal health services to meet these needs. What they found is incredible, and I think it’s very likely to be what others will find elsewhere — this population of 4,600 comprises frail elderly; people living with mental health and substance abuse issues, as well as chronic diseases; women (e.g., those with reproductive issues); children living with acute developmental issues; and infants and toddlers with complex needs. They also found that many in this population had common denominators at play — poverty, low literacy, homelessness, and struggling in a system that prioritizes facility-based care and undervalues continuity of primary health care. AHS-Edmonton is already starting to see results due to shifting care to assess and address patients’ priorities; listening to and responding to the suffering — not just treating the symptoms, but increasing patients’ confidence and self-efficacy to self-manage; and increasing routine primary care while decreasing the need for episodic care in this population. One result they observed is that the mental health and home care teams were able to lower costs for both acute care emergency services and home care from close to $8,000 per person to $3,100 per person in just 11 months.

KB: What struggles have AHS-Edmonton or other organizations faced as they set out on this Triple Aim journey?

JV: The AHS-Edmonton team had difficulty in getting timely population-level data that covers each of the quality domains — health status, experience of care, and per capita cost of care — and they struggled with project-level data, too. The team had this concern from the get-go, but didn’t keep it to themselves, which so many do. They didn’t worry alone, which took courage. They reached out early and often to IHI faculty and to CFHI, and their perseverance is a big reason why they are now seeing results.

And what AHS did to overcome this data challenge was really creative. They started with what data they did have, balanced that with the frontline knowledge of the project teams, and they are building better data as they go. Their project lead, Crispin Kontz, told me that through this work they have formed stronger relationships with others in the organization — people in Data Integration, Finance, and Population Health — who are helping more as time goes on, both with access and interpretation of data. So, much of their Triple Aim journey was about building that capability of the system so they could take the next steps toward improvement.

KB: What other setbacks have Canadian teams encountered as their work on the Triple Aim continues? 

JV: CFHI recently connected with Triple Aim Improvement Community project leads and, by and large, they report overwhelming success. One setback identified is needing active senior-level support. It’s one thing to have leaders who are engaged and have freed up the time of teams to participate, but you also need active leaders who are invested in the same types of results that teams are seeking to achieve. That becomes a challenge when there’s turnover or changes in direction, which invariably happens once you start to look at the data and it indicates what’s working and what’s not; you are going to make adjustments to that change process.

Improvement and change are difficult, non-linear and messy, so managing that change process was also challenging. But what really benefitted teams was starting to focus on the patient perspective and asking, “What can we do that would matter to the patient?” Asking that question made it start to come together for teams, along with the nature of the IHI Community itself — sharing ideas, sharing struggles, learning as you go, not worrying alone — these were all really helpful for teams as they encountered setbacks. With the IHI Community, they had a place they could talk about their challenges and seek guidance to overcome them.

KB: How does the Canadian health care improvement experience expand what we know about the IHI Triple Aim?

JV: There’s a lot that can be learned from Canadian teams around integrated health and social services and community coalitions. For example, in Quebec, there’s legislation around “la responsabilité populationnelle” (literally, “population-based responsibility”), which requires those working in integrated health and services to think about determinants of health and population health alongside providing the best possible clinical care. That kind of provincial policy context creates a fertile ground for the Triple Aim to take root. In Ontario, community “Health Links” is similarly creating a rich environment for Triple Aim improvement by bringing together health care providers in a community to better and more efficiently coordinate care for patients with the most complex needs. 

I expect we are going to learn a lot in the coming year from the Canadian teams participating in the new IHI Better Health and Lower Costs Collaborative, such as the distinction between “frequent users” and “long-term users” and the different types of patients in the top “5%” category who are living with complex and chronic conditions.

KB: IHI is excited to keep learning from the experience of the Canadian teams as our work together continues in the new Collaborative. Are there any final thoughts you’d like to share?

JV: I would echo what one of my mentors, Professor Jean-Louis Denis [Canada Research Chair on Governance and Transformation of Health Organizations and Systems at École nationale d'administration publique in Montreal], says all the time because it proves to be true once again. He says, “Don’t underestimate the importance of doing things differently.” Change is messy and it takes time to realize improvements, but in the process of getting there, don’t lose sight of how important it is to learn a new approach, apply it and start to invest in a new kind of health care. 

The Canadian Foundation for Healthcare Improvement is a not-for-profit organization dedicated to accelerating health care improvement by working with provinces, territories, and other health care partners to promote efficient health care that delivers better outcomes. CFHI is funded through an agreement with the Government of Canada.

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