Publication Date: October 31, 2014
Trissa Torres, MD, MSPH, FACPM
Senior Vice President
Institute for Healthcare Improvement
Q: What was your path leading up to IHI?
I was always interested in exercise and fitness — health, in general — so I started my career in health promotion. I entered a Master’s program focused on behavioral changes to help people become healthier, more physically fit. This brought me to the Pentagon, where I led an exercise program. I taught aerobics at the Pentagon!
While interacting with people participating in the program, they’d say things like, “My doctor told me I probably shouldn’t exercise because of my high blood pressure.” So I started to see that doctors were not very well trained in nutrition, in promoting exercise and healthy behaviors. Their work wasn’t about promoting health; it was about taking care of people when they’re sick — treating disease.
But at the same time, I was hearing how much people look to their physicians as a primary source of health advice and information. This made me see that we need to change the way we practice medicine so doctors are more focused on health rather than just disease. The only way I could do that was to become a doctor myself – to become a spy, infiltrate the ranks and change the way medicine is practiced from the inside.
My route to medical school reflects two themes in my path toward IHI. One, from the very beginning I saw myself as a change agent. And two, it’s been clear to me for a long time that we don’t have a health care system; we have a sick care system and a sick care financing system. We pay to take care of people when they’re sick, and the sicker they are the more we pay.
Medical school taught me to practice medicine, but also reinforced the “sick care” approach to medicine. It was frustrating. Then, for my residency, I found the perfect specialty area: preventive medicine. A lot of my colleagues had never heard of preventive medicine. But when I explained the field to non-physicians, people would say, “That’s exactly what we need.” So, what’s the disconnect? That’s what I was trying to influence, and why I think I’m a good fit with IHI, where facilitating change is at the center.
My residency also exposed me to public health, so this was when I started to broaden my view to look at whole populations and consider how to impact population health. I wondered, how do we bring the public health and medical worlds, which are a chasm apart, closer together?
From there I went to Genesys Health System in Flint, Michigan. It was right around the time [President] Clinton was coming into office and health care reform and universal coverage were in the spotlight. On top of the uncertainties of anticipating major reform, Genesys was already feeling strong financial pressure. Leadership realized that focusing on prevention was strategic — keeping patients healthy means you don’t have to care for them when they’re sick. So they hired me, a preventive medicine physician.
I started developing new models of care that could integrate traditional “sick care” with prevention. We knew the primary care doctor-patient relationship is crucial to helping patients adopt healthy behaviors and manage chronic disease. But we also knew doctors often don’t have time to engage patients in the depth of conversation needed to support behavior change.
We developed a new approach that we called Health Navigators, individuals who serve as extensions of the primary care practice team and work to support patients in healthy behaviors and their own self-management. For patients with diabetes, heart disease, or high blood pressure, the team could help patients overcome barriers to adopting the behaviors we know help manage these conditions: eat healthy, exercise, and don’t smoke.
People have barriers regardless of where they are, but that doesn’t mean they aren’t motivated to become active in their own health. It’s all about how you approach a topic. For example, saying, “You need to lose weight” rarely works. Maybe you say, “What are you worried about? What’s important to you?” A patient with high blood pressure and a family history of diabetes might say, “I want to make sure I’m around for my kids. I’m really worried I’m going to end up like my mom — she lost her eyesight in her 40s.”
The physician or health navigator might then talk about healthy eating and exercise, asking, “Where are your opportunities in those areas?” And she might say, “I can start walking a little bit every day. That’s something I can do.” So, we support her in making that change. She’s now motivated to reach her goal because she has clear reasons to succeed. And she does succeed — her blood pressure comes down, she feels better, which then motivates her to find other ways to improve her life.
At Genesys, we had many success stories and were able to demonstrate that people really can change their behaviors and improve their health outcomes. In turn, we were able to demonstrate reduced use of high-cost services including ER visits and hospitalizations. Over time, we replicated these successes with different subsets of our population.
Through a partnership with the Genesee Health Plan, we focused on the underserved population, a group that struggles with employment, housing, discrimination, and daily barriers to health and care. People became engaged. Empowering them to exert control in some area of their lives motivated many to make changes that can have a positive impact.
Around this time Genesys got involved in the first IHI Triple Aim prototyping phase. It was a natural fit since we were already working on those three things — improving care for individuals, focusing on population health, and reducing health care costs. Bringing them together in a systematic approach made perfect sense. For me, it was especially gratifying because it tied back to why I got involved in this field to begin with: to help people stay healthy.
When Genesys became a Pioneer Accountable Care Organization [ACO], we had the opportunity to align our finances so we’d be able to deliver the care model we had been testing for years. I was excited to be part of the transition to the ACO during the first 10 months, as my own focus on population health and prevention went from being a small piece of the organization to being in the spotlight. But, as the champion became the CEO, it was time to pass the torch to the next person to carry the journey forward.
Around the same time, I learned about the opportunity at IHI. What really excited me was IHI’s mission to improve health and health care worldwide. I couldn’t pass up the opportunity; it aligns so well with my personal journey as a change agent.
Q: What are you focusing on in your work at IHI?
From the perspective of IHI’s overall strategy, our two broad organizational goals are to accelerate the pace of improvement in health care delivery, and to innovate and partner with organizations and communities to improve health. Everything I do and support at IHI contributes to these goals.
My regional focus is North America, where a big part of my work involves the “improving health care” piece: supporting IHI’s strong base of customers who are inside health care: hospitals, physician organizations, and health systems. They’re all dealing with financial pressures and responding to health care reform changes. IHI is committed to guiding them through major industry transition: from the fee-for-service, acute care, fragmented care delivery and payment systems of today to an approach focused on prevention, chronic disease, and improving the health of populations.
Central to IHI’s focus and my work are supporting health systems and providers in learning their way through managing populations to achieve the Triple Aim. IHI first developed the Triple Aim framework in 2007 [and first published in 2008 in Health Affairs]. Today, the language around the Triple Aim is very recognizable. A version of it was built into US federal regulations, as part of the ACA [the Affordable Care Act]; it’s the guiding framework and approach of the law.
Hospitals and health systems now often speak of pursuing the Triple Aim because the lessons resonate in today’s health care landscape. For example, if you’re an ACO responsible for a discrete population of 14,000 patients and you need to optimize their care, the Triple Aim has proven to be a really useful path to transforming your system to achieve the goals and patient outcomes you seek. [Read Dr. Torres’ article, ACOs: A Step in the Right Direction.] Transitioning to population management is difficult and will require new approaches and new levels of partnership and collaboration across the continuum of health care delivery, as well as with communities.
Health care providers are not the only ones struggling through this transition. I’m also helping IHI support other sectors, including US states, which face greater demands than ever in providing and paying for health care. On top of resource constraints, states have new responsibilities around delivering expanded Medicaid services. For some states, that population has increased dramatically. IHI is looking at how we can help states reach more people while also keeping costs down, improving the care they deliver, and ultimately improving the health of the population in their state.
I lead similar efforts in Canada, supporting provinces in meeting their health care responsibilities, also focused on controlling costs while improving care.
That’s the part of my work centered on improving health care. I’m also helping to lead IHI’s strategy around creating health. It’s a major focus for IHI because even when we optimize care — improve safety and quality, improve patient experience — the health of patients, individuals, and communities is impacted by myriad factors outside the health care system. Social determinants play a huge role in a person’s health: education, jobs, income level, social care services, the environment, whether neighborhoods are safe and walkable, whether affordable healthy food is available, and so on.
How are we going to do it? In a variety of ways, in part building on IHI’s strength as a convener and our decades-long relationships with health care organizations. We’re also reaching out to community networks and social care organizations to find synergy in bringing our respective efforts together, and expanding on what we’ve learned through IHI’s Triple Aim initiative. Another asset IHI brings is a method for improvement that uses rapid cycle testing and planning for scale to learn quickly and share broadly.
Part of my focus is helping IHI find new organizations and partners committed to the Triple Aim, leveraging their assets and working side by side across industries to make a real difference. No one organization has all the answers, but there can be real power in learning together and learning from each other.
We hope to support and accompany these teams in their transformational journey, help them innovate, co-create new models and methods that achieve measurable results — again, working toward the goals of accelerating the pace of improvement in health care and improving the health of individuals and communities.
Q: What are some of the challenges you see, for IHI and more broadly?
One of the biggest challenges for health care professionals is recognizing the need for a shift in power. Historically, we as providers — and I’m trained as a physician, so I come from this perspective — did things to people or for people. You came to me with a concern or problem and it was my job to diagnose you, choose a treatment plan, and prescribe it. There are some cases where that is still absolutely necessary; if you’ve been in a car accident and you’re incapacitated, for example, you need the doctor to do things to you and for you.
But as we turn our energies to chronic care and prevention, we have to understand that you, the patient, are the one who ultimately has the power and the desire to improve your health. So, my job as the health care provider is to support you; not to do things to you or for you.
It’s a very different mindset, and a challenging transition, but when you start to see the results patients can achieve, with you supporting them, it’s really gratifying.
Another new cultural challenge for physicians is the shift toward being responsible for groups of patients over the long term. Traditionally the physician was responsible for you during an episode of care, for whatever the associated time period — when you were in the hospital, for example, from admission to discharge, or in an office practice, during a single visit.
That model of care is evolving. Physicians and practices are increasingly responsible for a group of patients or a discrete population over time, across care settings. Now my job as a physician is to help ensure your overall health, to keep you well and out of the hospital — thinking about your health and life in the hours and days when you’re not right in front of me.
Financing continues to be a challenge — how to make the money flow. It can be a struggle getting funding for this new approach, even when we’re all moving in the same direction — working in teams, being responsible for a group of patients longitudinally, putting patients’ needs in the center, coaching patients to be in charge of their own health, and so on. There is progress in the payment and policy areas, but it’s slow. And sometimes that in-between phase, the transition, can be especially challenging. In the midst of so much change, I see IHI’s job as helping to support organizations throughout this journey.
Another challenge is health equity. We know inequities exist within health care delivery — that certain groups get access to care more easily than others — and in health outcomes, in part the result of health care system flaws but also driven by socioeconomic determinants. IHI is constantly looking for and developing opportunities to directly address health equity, and we know we need to do more. As we expand our Triple Aim work, with both discrete patient populations and broad communities, we will be working to ensure equity is always a goal.
Q: What are you most excited about?
The commitment to transformation that we’ve seen from people across the US, across Canada, as well as around the world. People within health care delivery are certainly struggling, but they know we need to change and they’re ready to take action to move us ahead. We’re seeing a new level of awareness and commitment: “We want to provide better care, safer care; we want to achieve better health outcomes for the patients we serve and for our communities; and we want to find a way to finance this and redistribute the resources in a way that’s equitable and sustainable.”
I’m also excited by opportunities we’re seeing to convene groups of people who want to come together to share and learn from each other, people inside and outside of health care. We’re already learning side-by-side with them. It’s exciting to be part of this journey.