Pursuing the Triple Aim: The First 7 Years.

UNLABELLED: 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.

Clinical complexity and the effectiveness of an intervention for depressed diabetes patients.

OBJECTIVES: In a trial completed in 2010, US patients with diabetes and depression were randomized to usual care or telephone cognitive behavioural therapy that emphasized physical activity. Twelve-month intervention effects were observed for blood pressure, depression, and pedometer-measured step-counts. This study examined variation in intervention effects across patient subgroups defined by a measure of clinical complexity. METHODS: Three groups of patients were identified at baseline using the Vector Model of Complexity that recognizes socioeconomic, biological, behavioural, and other determinants of treatment response. Complexity-by-intervention interactions were examined using regression models. RESULTS: Intervention effects for blood pressure, depression, and step-counts differed across complexity levels (each p < 0.01). Effects on Beck Depression Inventory scores were greater in the low-complexity group (-8.8) than in the medium- (-3.2) or high-complexity groups (-2.7). Physical activity effects also were greatest in the low-complexity group (increase of 1498 steps per day). In contrast, systolic blood pressure effects were greater among intervention patients with high complexity (-8.5 mmHg). CONCLUSIONS: This intervention had varying impacts on physical and mental health depending on patients' clinical complexity. Physical activity and depressive symptom gains may be more likely among less complex patients, although more complex patients may achieve cardiovascular benefits through decreased blood pressures.

A randomized trial of telephonic counseling plus walking for depressed diabetes patients.

BACKGROUND: Patients with diabetes and depression often have self-management needs that require between-visit support. This study evaluated the impact of telephone-delivered cognitive behavioral therapy (CBT) targeting patients' management of depressive symptoms, physical activity levels, and diabetes-related outcomes. METHODS: Two hundred ninety-one patients with type 2 diabetes and significant depressive symptoms (Beck Depression Inventory scores ≥ 14) were recruited from a community-based, university-based, and Veterans Affairs health care systems. A manualized telephone CBT program was delivered weekly by nurses for 12 weeks, followed by 9 monthly booster sessions. Sessions initially focused exclusively on patients' depression management and then added a pedometer-based walking program. The primary outcome was hemoglobin A1c levels measured at 12 months. Blood pressure was a secondary outcome; levels of physical activity were determined by pedometer readings; depression, coping, and health-related quality of life were measured using standardized scales. RESULTS: Baseline A1c levels were relatively good and there was no difference in A1c at follow-up. Intervention patients experienced a 4.26 mm Hg decrease in systolic blood pressure relative to controls (P=0.05). Intervention patients had significantly greater increases in step counts (mean difference, 1131 steps/d; P=0.0002) and greater reductions in depressive symptoms (58% remitted at 12 mo vs. 39%; P=0.002). Intervention patients also experienced relative improvements in coping and health-related quality of life. CONCLUSIONS: This program of telephone-delivered CBT combined with a pedometer-based walking program did not improve A1c values, but significantly decreased patients' blood pressure, increased physical activity, and decreased depressive symptoms. The intervention also improved patients' functioning and quality of life.

Nurse consultation support to primary care practices to increase delivery of health behavior services.

Tobacco use, lack of physical activity, poor diet, and alcohol use are the key preventable causes of death in the United States. This study tested the use of nurses as consultants to primary care practices to assist practice clinicians and staff in identifying and carrying out plans to help their adult patients improve these health behaviors. A pre-post chart audit was conducted, and 17 of 20 practices (85%, p = <.01) increased documentation of health behavior delivery a mean absolute increase of 5.5% after the intervention. Nurse consultation may be an effective strategy to increase health behavior delivery to patients in primary care.

The community health educator referral liaison (CHERL): a primary care practice role for promoting healthy behaviors.

BACKGROUND: Tobacco use, unhealthy diet, physical inactivity, and risky alcohol use are leading causes of preventable death. As there are many barriers that prevent primary care clinicians from effectively assisting patients with these behaviors, connecting patients with health behavior resources may reduce these unhealthy behaviors. METHODS: A new adjunct role in primary care practice, the community health educator referral liaison (CHERL), was tested in 15 practices in three Michigan communities. All practices were advised how to access this liaison, and nine practices were randomly selected to receive support to develop a systematic referral process. Adult patients needing improvement in at least one of the four unhealthy behaviors were eligible for referral. The CHERL contacted referred patients by telephone; assessed health risks; provided health behavior-change counseling, referral to other resources, or both; and sent patient progress reports to referring clinicians. Data were collected from February 2006 through July 2007. RESULTS: The CHERLs received 797 referrals over 8 months, a referral rate of 0%-2% per practice. Among referred patients, 55% enrolled, and 61% of those participated in multiple-session telephone counseling; 85% were referred to additional resources. Among patients enrolling, improvements (p<0.001) were reported at 6 months for BMI, dietary patterns, alcohol use, tobacco use, health status, and days of limited activity in the past month. CONCLUSIONS: The results of this study suggest that through relationships with practices, patients, and community resources, these liaisons successfully facilitated patients' behavior change. The CHERL role may fill a gap in promoting healthy behaviors in primary care practices and merits further exploration.

Nurses as practice change facilitators for healthy behaviors.

This study used nurses as practice change consultants to help primary care medical practices improve their delivery of health behavior services to patients. Nurse consultants worked with 20 practices from 2 healthcare systems. In each practice, the nurses helped clinicians and staff to develop a practice-specific protocol so that they could identify and intervene with the health behavior of their patients. As a result of the nurse consultant intervention, health behavior delivery was improved. This article describes the specific methods and the lessons learned through this study. We encourage practices to use nurse consultants as one way of improving quality of care.