The Primary Care Coalition (PCC) in Montgomery County, Maryland, has been pursuing the Triple Aim since 2007 as one of the original IHI Triple Aim prototype communities. Even with, or perhaps because of, their years of experience, they continue to gain new insights about how to approach their efforts to improve population health. In this blog post, Leslie Graham, PCC Chief Executive Officer, and Barbara Eldridge, Manager of Quality Improvement and Outcomes, describe some of their lessons learned.
Leslie Graham (left) and Barbara Eldridge (right)
During our years working with IHI, we’ve learned how to do rapid testing and scale up at the local level. We’ve also consistently set aims, developed measures, collected data from the beginning of our projects, and used data to drive where we’re going with our projects and programs. It’s safe to say we’re very familiar with the most important basics IHI teaches about improvement. At the same time, we are keenly aware of the importance of being open to continuous learning. We hope our lessons learned will be useful to others on their population health journey.
Every project does not need to focus on all three dimensions of the Triple Aim (but your portfolio of projects does).
Even as Triple Aim “veterans,” we had a crucial a-ha moment earlier this year while taking part in IHI’s program, Kick-Start the Triple Aim
: every program and every project does not need to focus on or measure all three dimensions of the Triple Aim
. Until this year, we tried to include a measure for population health, patient experience, and cost reduction for every project we had. Previously, we thought a Triple Aim portfolio was a collection of projects each of which
should achieve all three aims simultaneously. We now understand that our portfolio of projects
needs to achieve all three aims.
It’s like a financial portfolio. You should expect your portfolio to contain some investments that are riskier with higher reward and possibly more likely to fail. Some are going to give you short-term wins and have a higher likelihood of success. Some things are harder to predict; they're long-term investments. You're going to hunker down and keep working on them for the long term. If someone asks, “Why is this taking so long to show any returns?” you can remind them that we expected it to take longer.
After completing the Kick-Start the Triple Aim program, we reviewed our projects to realistically redefine project objectives. A project may be intended to achieve aims in one or two Triple Aim dimensions, but not necessarily all three. By doing this, we realized that sometimes we were going after an aim that was probably not realistic. This is also important for morale and culture because it is difficult to maintain enthusiasm, both for individual projects and for the Triple Aim as a framework, when it feels like every project has an element that is unachievable. This review helped us reenergize the enthusiasm of our organization and our county for using the Triple Aim as our framework.
- Be clear on the definition and identification of your population.
Another lesson we learned from Kick-Start the Triple Aim was about the formal structure underlying the Triple Aim. First and foremost is to be clear on how we define and identify our population. For an organization like ours, that can get a little messy. Having complete clarity, however, drives how we operate going forward.
We now understand that when we’re confused or find ourselves wandering down a path that doesn’t work, it may be because we aren’t clear about our population. Those are the times we step back and revisit who is in our target population and how we identify them because everything else flows from that. We’ve learned to ask specific questions at the outset: Is it an enrolled population or a geographic population? What type of governance are we going to have? What projects should be included in our portfolio?
- Never underestimate the value of learning from patients.
The Triple Aim prototyping work we did with IHI focused on emergency department (ED) utilization and contributed to the success of our efforts to link ED patients to primary care (as described in a study published in Health Affairs in May 2015). During the prototyping, IHI promoted the concept of studying an “n of 1” [with “n” denoting sample size] and pushed us to see how much we could learn from talking to a single patient who went to the ED. We started small and ended up doing a number of interviews.
We developed a template for interviewing patients from all five hospitals in our county at the time. From this, we started to identify why people chose to go to the ED instead of primary care. We then developed interventions to address those reasons, whether it was lack of awareness about primary care clinics, inconvenient clinic hours, or other reasons.
Patients have also taught us about the importance of asking "What matters to you?" instead of “What’s the matter?” The story of a patient who was part of our patient-centered medical home project helps illustrate this. One of our clinic care managers visited him when he was in the hospital with complications of diabetes. This gentleman did not want to acknowledge that he had diabetes, but once he did, he expressed hopelessness that there was anything he could do about it. His A1C levels were very high. As the care manager learned more about his history, she discovered he had a number of other serious illnesses, including a cardiac condition that required a pacemaker defibrillator. However, because his diabetes was so poorly controlled, two cardiac surgeons declined his referrals because they considered him too high risk.
The care manager, who developed a relationship with him over several months, learned he had a grandson living in South Asia who was seriously ill. While our clinical team wanted to manage the patient’s A1C levels so he could have the pacemaker defibrillator implanted, he was clear that all he wanted was to see his grandson. Finding out what he cared about most helped us change our approach to helping him. By making medication adjustments, using motivational interviewing, and helping him develop the skills, confidence, and optimism to make lifestyle changes, his A1C became better controlled. The team referred him again to cardiology and they cleared him to get the defibrillator pacemaker.
The main goal of the clinical team had been to help the patient manage his diabetes well enough to get a pacemaker. They never anticipated he would also get to see his grandson, but both the cardiologist and the primary care physician gave him clearance to travel. The patient flew home to see his family and he called both his social worker and nurse care manager. His first words to each of them were, “I have achieved my final goal.” His story demonstrates how important it is to work outside the hospital walls and see our patients as people with hopes and dreams.
Looking back over the past eight years, it’s interesting how IHI and the Primary Care Coalition have evolved in our work on the Triple Aim. IHI started with a strong focus on hospitals and we started with a strong focus on ambulatory care, particularly primary care. Now PCC is working with hospitals and IHI is working more in the community.
Can we move hospitals from a purely medical model to an approach that helps people reach their most cherished goals? We believe we’re moving in the right direction. If we take a long-term view and stick with it across a portfolio of projects, we’ll improve population health and the patient experience while also reducing the total costs of care.