Why It Matters
How can you achieve the Triple Aim without also pursuing health equity?
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What’s the Relationship Between Health Equity and the Triple Aim?

By Ronald Wyatt | Thursday, February 11, 2016

Understanding the relationship between health equity and the Triple Aim starts with this basic question

Understanding the relationship between health equity and the Triple Aim starts with this basic question: How can you improve my experience of care if I don’t trust you?

The Triple Aim is improving health of a population, reducing costs, and improving patient experience. But how can you improve my experience if you don’t listen to me or show any effort when I try to talk to you?

Culture Is Everywhere

I’m from Alabama, and there are people from Alabama who aren’t understood because of the way they speak. Language differences don’t only apply when a patient speaks Spanish or Polish or Russian; it could just be that I’m from Alabama. It could be that I speak differently or use a different dialect in south Alabama versus north Alabama. So, how can you improve my experience if you don’t even try to understand my culture, my language, or what I’m trying to say to you?

So, we have to start there. But there’s more, of course.

The Health of Populations

When I think about patient experience in the Triple Aim, it means treating me like a whole person. It’s treating me like you care about me — not just what’s happening to me now, but what’s going to happen to me when I go back to my community. That’s where the population health comes in. Sadly, too often for people of color, they are just put back in their community. Then, two weeks later, guess what? You see that person again.

I’ll give you an example: I went to visit a big organization in the upper Midwest. They looked at their readmissions and started to wonder who was driving their readmissions, because it was a cost. When they looked at their most common readmissions, they saw two groups: African-Americans who had kidney failure and Hmong women. “Hmm,” someone at the organization said, “that’s odd. We see mostly female Hmong being readmitted. We need to understand that better.”

Now, originally, they were looking at the cost to the organization. But what they got out of it was this important piece of learning about the patient experience: when Hmong woman were discharged, they realized, the provider gave them discharge instructions with information about what medicines to take when. But they didn’t always talk to her husband or the paternal person in the family. In Hmong culture, not allowing the man to make health care decisions is generally considered disrespectful. And not including other family members in that conversation means that the patient is less likely to adhere to the management plan and more likely to be readmitted.

In other words, it’s critical for an organization to know the answer to the question: Who is our population? 

A Focus on Health, Not Revenue

Population health management, in my view, has sometimes become a business enterprise. That’s not what it was intended to be. It was to say, “Let’s improve the lives of people where they are, where they live.” As Don Berwick said years ago, “The safest hospital bed is the empty one.” Health care organizations need to be in the community trying to understand what’s happening at that community level, with community people involved, to get better outcomes for generations of people. That’s population health — not “How can I make sure my revenue margins are better next year?”

Understanding populations then links back to the patient experience and all those scary questions patients have when they enter an organization: Do I trust you? Do you listen to me? Are you concerned about me? Do you talk to me? Do you speak my language? Do I have a place to go when I’m discharged? Do they know I’m coming? Do they know anything about me? Do they have my discharge summary? Do they know where I live? Do they know that I work two jobs, and sometimes I’m not able to make my appointment?

Then, with that knowledge, you start to attack inequity and disparity, as we call it, where it lives — in communities with real people.

Read the first in this series (Is It Time for a National Goal to Improve Health Equity?) and register on ihi.org to receive our weekly e-newsletter with the last installment of Dr. Wyatt’s three-part series on health equity.

You may also be interested in:

Improving Population Health and Health Equity Are Not One and the Same

The Challenge and Opportunity of Health Equity

Dimensions of Culture: Cross-Cultural Communications for Healthcare Professionals – “Providing Healthcare to Hmong Patients and Families”

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