Pursuing the Triple Aim: The First 7 Years

Abstract

POLICY POINTS: In 2008, researchers at the Institute for Healthcare Improvement (IHI) proposed the Triple Aim, strategic organizing principles for health care organizations and geographic communities that seek, simultaneously, to improve the individual experience of care and the health of populations and to reduce the per capita costs of care for populations. In 2010, the Triple Aim became part of the US national strategy for tackling health care issues, especially in the implementation of the Patient Protection and Affordable Care Act (ACA) of 2010. Since that time, IHI and others have worked together to determine how the implementation of the Triple Aim has progressed. Drawing on our 7 years of experience, we describe 3 major principles that guided the organizations and communities working on this endeavor: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time.

Context: In 2008, researchers at the Institute for Healthcare Improvement (IHI) described the Triple Aim as simultaneously "improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations." IHI and its close colleagues had determined that both individual and societal changes were needed.

Methods: In 2007, IHI began recruiting organizations from around the world to participate in a collaborative to implement what became known as the Triple Aim. The 141 participating organizations included health care systems, hospitals, health care insurance companies, and others closely tied to health care. In addition, key groups outside the health care system were represented, such as public health agencies, social services groups, and community coalitions. This collaborative provided a structure for observational research. By noting the contrasts between the contexts and structures of those sites in the collaborative that progressed and those that did not, we were able to develop an ex post theory of what is needed for an organization or community to successfully pursue the Triple Aim.

Findings: Drawing on our 7 years of experience, we describe the 3 major principles that guided the organizations and communities working on the Triple Aim: creating the right foundation for population management, managing services at scale for the population, and establishing a learning system to drive and sustain the work over time.

Conclusions: The concept of the Triple Aim is now widely used, because of IHI's work with many organizations and also because of the adoption of the Triple Aim as part of the national strategy for US health care, developed during the implementation of the Patient Protection and Affordable Care Act of 2010. Even those organizations working on the Triple Aim before IHI coined the term found our concept to be useful because it helped them think about all 3 dimensions at once and organize their work around them.

Keywords: Triple Aim; population management; populations.

Figure 1

Population Management Driver Diagram: St. Charles Health System (Bend, Oregon) Reprinted with permission from St. Charles Health System.

Figure 2

Average HRA Score for Employees and Spouses: Bellin Health (Green Bay, Wisconsin)

Figure 3

Percentage of Employees and Spouses With a Low (0-50) HRA Score: Bellin Health (Green Bay, Wisconsin)

Figure 4

Percentage of Wellness Certificates Completed: Bellin Health (Green Bay, Wisconsin)

Figure 5

Percent Increase in Cost per Employee Plan per Year (PEPY): Bellin Health (Green Bay, Wisconsin)

Figure 6

Patient Survey: “Usually My Health Is Good,” Chinle Service Unit Ambulatory Care Patients, July 2012 to June 2014 (Adjusted for Age and Sex)

Figure 7

Incidence of Diabetes per 1,000 User Population^a by Quarter, Chinle Service Unit, January 2010 to March 2014 ^aUser population: any patient residing in Chinle Service Unit communities with at least 1 visit in the 3 years before the end of the reporting period, regardless of the clinic type.

Figure 8

Diabetes Outcome Bundle: Hemoglobin A1c, Blood Pressure, and LDL in Control, Chinle Primary Care Active Diabetic Patients,^a December 2012 to March 2014 ^aActive diabetic patients are active clinical patients diagnosed with diabetes before the reporting period, with at least 2 visits during the reporting period and 2 diabetes-related visits in total.

Figure 9

Urgent Care Utilization: Urgent Care Visits per 100 User Population, Chinle Service Unit, January 2010 to March 2014

Figure 10

Hospital Bed Days per 1,000 User Population: Years by Month, Chinle Service Unit Active Clinical Population,^a January 2011 to April 2014 ^aActive clinical population refers to any patient residing in Chinle Service Unit communities with 2 visits in the 3 years before the end of the reporting period and at least 1 visit to a primary or urgent care clinic.