The Triple Aim: An interview with Dr. Donald M.Berwick
by Adriana C. Linares, MD, DrPH
March 5, 2019 -- Hello. This afternoon while precepting at my clinic I received an e-mail from the IHI (Institute for Healthcare Improvement). They were advertising a blog by Dr. Donald M. Berwick related to the Triple Aim.
I would like to encourage all of you who are interested in this topic to read this great interview. What I liked most was the end of the blog where they talked about what surprised doctor Berwick about the Triple Aim concept. He mentioned that social determinants of health need to be taken into consideration when trying to reach the Triple Aim in different organizations. He ends with the following quote:
“There are some good programs. Some countries have programs and approaches that we need to copy, but we are taking baby steps so far on the health of populations and giant progress is available if we want to go for it.”
From the editor -- I am a Colombian family physician who has worked in Washington state for the past five years. I moderate this blog as part of the transformation efforts of our team.
We are going to write about the four aims, or pillars, of health care. We would like feedback, comments, criticisms, and especially solutions to some of the topics we discuss. Please let us know what you think. Send your comments -- what would you like for us to cover? How can we improve our blog? - Adriana Linares
New name, continuing mission
Our new name
February 14, 2019 -- The Practice Transformation Support Hub Resource Portal (WA Portal) started life as part of the federal State Innovation Model (SIM) initiative. A collaborative effort led by the Washington State Department of Health’s Systems Transformation team and the University of Washington’s School of Medicine Primary Care Innovations Lab, WA Portal will continue as the SIM initiative sunsets. As we move into this next phase of WA Portal, we’ll do so with a new name:
Healthier Washington Collaboration Portal
Resources to support Washington State’s health and wellness community
We’re changing the formal name, but we’re continuing the same mission of providing a collaborative environment—or virtual workbench—to help our partners in the state’s health and wellness system share and connect with the resources needed to meet their innovation and transformation goals.
Why Healthier Washington?
Since Governor Inslee launched the Healthier Washington initiative in 2014, it’s been synonymous with work done as part of the SIM funding. But its triple aim of better health, better care and lower costs for Washington residents doesn’t end with SIM.
As the governor stated in 2014, “Our goal is to help Washington’s seven million residents lead healthier lives and access the best quality health care at the best price…”
That work continues under the Healthier Washington umbrella. Healthier Washington is an ongoing, multi-partner, multi-faceted effort to help improve the health of people in our state, and our state’s health and wellness system.
WA Portal’s new formal name reflects that broader meaning.
We’re still WA Portal
We may have changed our name to better describe our ongoing mission, but we’ll always be WA Portal.
We created WA Portal with and for Washington’s health and wellness community. And, as our new name suggests, we look forward to our continued collaboration.
Thanks to all of our partners! Your ongoing support makes WA Portal possible.
- The WA Portal team
The Children’s Behavioral Health Integration and Value Transformation Toolkit
February 2019 -- by Blake Edwards, MSMFT LMFT CMHS
Behavioral Health Director-Columbia Valley Community Health; Statewide Lead Behavioral Health Champion-Pediatric Transforming Clinical Practices Initiative, Washington Chapter of the American Academy of Pediatrics; Governing Board Member-North Central Accountable Community of Health
To the extent we as health care providers resign ourselves to treatment in a vacuum, we neglect person-centered care by perpetuating a system in which treatment revolves around silos rather than around the needs of a whole person. Collaboration is essential to effective health care, not elective.
We each naturally and necessarily engage in our work with people from differing areas of expertise. That being said, psychotherapists, psychologists, psychiatric prescribers, social service specialists, as well as primary care physicians—and, I should add, other health care specialists and education and community-based partners—best serve their clients and patients when they integrate efforts to provide care. Within the treatment fray, conscientious providers aim to treat the whole person, not just the part they are naturally apt to see at first assessment. A collaborative approach enhances communication of evaluative and ongoing therapeutic feedback, increases clinicians’ adherence to the treatment plan, and helps reduce risk, frequency of crises, and unnecessary emergency room visits and inpatient stays.
In the coming years, behavioral health agencies will be paid based on measurable health outcomes and demonstrable evidence of value, rather than strictly through fee-for-service or no-risk capitated payment arrangements. Value-based payment is shaping up along a continuum, with statewide efforts enabling providers to move along that continuum. This involves risk sharing and incentives to reward providers for achieving quality. So, how can behavioral health agencies make a positive impact on the quality and effectiveness of physical health care, on achievement of standardized population health measures, on improving client/patient experience, and on reducing unnecessary costs of care?
I developed the Children's Behavioral Health Integration & Value Transformation Toolkit to support children's behavioral health agencies in Washington State in taking practical steps toward integrated care and value transformation. It is not intended as a blueprint but, truly, as a "toolkit" from which to tailor vision and practical steps in a direction that may be right for a particular behavioral health agency. Those behavioral health practices enrolled in Pediatric TCPi will receive training, technical assistance, and coaching through the grant initiative, but the toolkit itself is being offered widely as a free resource.
We see more effective treatment outcomes when we share not only our perspective but also responsibility as we partner to provide optimal care. It is important for behavioral health providers to be well connected to and collaboratively engaged with multidisciplinary care teams to ensure that the most effective and integrated treatment that can occur does occur.
First step to obtain NCQA Recognition - Creation of a Team
December 2018, Adriana Linares -- We have all heard about the special recognition that some medical practices are applying for.
What is the importance of that recognition?
Health care in America is evolving. A lot of payers are switching from the fee-for-service model to a model that reimburses based on quality and metrics. Practices that want to be successful need to complete all the requirements to compete in this new environment.
What are benefits to medical practices?
The benefits are several. One of the most important is that practices provide better care to patients with less resources and with clear workflows that help each person in the team work at their highest level of competence. The PCMH model encourages the fulfillment of the Four Aims for Quality Medical Care: Patient satisfaction, Medical care, Low cost and Staff satisfaction.
I have a story to tell
In 2014 my clinic in Vancouver, WA decided to apply for NCQA recognition as part of the transformation to be a Patient Centered Medical Home. What was the first step for this clinic?
The stakeholders and the staff determined participants in creation of the different requirements to apply for NCQA recognition. After that, they created a list and started the learning process. A lot of research, internet searches, contact with different people who had gone through the transformation, etc.
How did they keep the information organized? How did all the people access the information?
The clinic created a work space in their shared drive to collect all the information obtained by different members of the team. The shared drive repository has been a life-saver for the clinic. The subsequent applications have gone smoothly since all the information related to NCQA and PCMH is located in one place.
Reviewing the WA Transformation Portal, I found something very similar: My Portal Teams. This feature allows practices to share problems, challenges, resources within the practice and with other practices that are going through the process. They have list-servers, repositories of data, virtual meetings. My Team is a great tool that all the participants can access at any time (at their convenience) where they can post comments, share resources, ask questions, write ideas to be shared with all the team members.
I invite all of you to review this resource. Please let me know what you think.
November 2018 -- By now, I think all of us involved in health care have heard this word. Burnout was defined by Christina Maslach and her colleagues at the University of San Francisco as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.”
When talking about the best way to optimize health system performance we think about the three aims: enhance patient experience, improve population health, and reduce cost. However, an article by Thomas Bodenheimer and Christine Sinsky describes a fourth aim: improve the work life of health care providers including clinicians and staff.
I attended the AAFP FMX in New Orleans this year. This meeting of several thousands of family medicine doctors had a specific path related to physician well-being. The AAFP also organized the first-ever meeting related to wellness this year: Family Physician Health and Well-being Conference. The next meeting is in Phoenix, AZ, June 5 to June 8, 2019. Something is going on.
What is going on?
Why are all the stakeholders, organizations, boards, residency programs and medical, nursing school and other entities concerned about this? How can we improve the way we deal with Burnout of staff and clinicians when working within the Patient-Centered Medical Home?
We have several resources available. Healthier Washington: The Practice Transformation Support Hub provides access to articles related to wellness, resilience, burnout and prevention of suicide. One resource that I found useful and pertinent is about the Washington State Medical Association's Physician Wellness website. This site provides information about ways to promote wellness programs at the local and national level.
1. Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine, November/December 2014 vol 12 no 6 573-576.
Please comment on this. I hope the information is useful for you.
The 4th Aim of Practice Transformation
We are going to write about the four aims, or pillars, of health care. We decided to start with the fourth aim.
To be able to excel on our work, we as health care workers need to be satisfied.
I attended the American Academy of Family Physicians FMX (Experience) meeting in San Antonio, and came back motivated and ready to continue my efforts for excellence in health care. You know what helped me? The American Academy of Family Physicians presented a new portal: Physician Health First. It provides great resources, strategies and evaluations to enhance physician wellbeing. The Academy has heard its members and is working on trying to alleviate some of the problems associated with health care in the United States that burden the practice of medicine in our country.
I invite all of you to review the resources available on the WA Portal related to well being. We have included also resources related to staff wellness and providers in different areas of medicine.
Clinical Data Repository (CDR) Application for Behavioral Health Providers
October 2018 -- Behavioral health providers contracted with Medicaid now have free access to OneHealthPort, Washington state’s Provider Data Service and Health Information Exchange (HIE) system, for a more comprehensive view of a client’s engagement in care.
As an HIE system, OneHealthPort houses the Clinical Data Repository (CDR) which allows users to view client/patient data for “the purposes of managing treatment, payment or business operations” (OneHealthPort, 2018). The CDR contains data for all Medicaid beneficiaries. The CDR allows for shared care planning as it contains claims, EHR data and utilization history for medical, dental and pharmacy lines of service.
Behavioral health providers can access the CDR at no cost to look up client utilization history and to view uploaded clinical summary documents. As an additional service, providers on the CDR may connect their EHR platforms so clinical information can be stored, accessed, and aggregated in one location. For example, a behavioral health provider can access the CDR to identify a client’s engagement in the healthcare delivery system to enhance coordination with other providers involved in client care.
Simply, the CDR is a population health tool to improve and coordinate whole-person care. Why not become a CDR user?
To learn more about the CDR and how it can benefit your practice contact Deb Hemler, Vice President of Development with OneHealthPort.
By: Pierce County ACH's Strategic Improvement Team
OneHealthPort. (2018, October). Use of CDR. Retrieved from OneHealthPort: http://www.onehealthport.com/cdr/use-cdr
Collaborative Care Model for Behavioral Health Integration
My clinical work includes working as a consulting psychiatrist in two ways in primary care clinics – one as a direct consultant using telehealth technology to see patients, and the other as an indirect consultant in a population based model of care called collaborative care. The Portal includes resources on both models of care. The Telepsychiatry Toolkit from the American Psychiatric Association provides background information on telepsychiatry, along with clinical training, reimbursement, and technical considerations. Telepsychiatry is one way to distribute specialist physician visits to areas with fewer specialists such as psychiatrists. Reimbursement for telehealth is expanding under MACRA, and 49 states cover telepsychiatry under Medicaid. Collaborative care is team based care involving the primary care clinician, a care manager, and a psychiatric consultant. Resources from the AIMS Center at the University of Washington are included in the Portal and are standard tools for clinics to use in deciding whether or how to implement collaborative care. One recent example is the Financial Modeling Workbook that can help organizations understand associated costs and revenues. Is your site working on new strategies for telehealth or on implementing a population based model of care such as collaborative care? Check out the Portal for resources.
Social determinants of health are central to health care
Early this week I had an encounter with a relatively new patient to me, which made me pause. She was desperately upset, saying she had been told by an ED physician that she “has lung cancer.” The physician had been evaluating her for possible pneumonia. I reviewed the discharge materials she had been given and found there was no mention of any sign of abnormalities in the range of imaging that was done. It turned out that this 50-year-old Washington native had dropped out of school early and was illiterate, which contributed to her misunderstanding the comments of the ED doc (probably related to them doing some smoking cessation counseling). Unsurprisingly, she and her family faced additional obstacles to health care involving lack of employment, housing, and insurance.
While sociologists, educators, and economists have pointed to the role of social factors in health and well being for decades it has only been in recent years there has been increasing awareness of the crucial role that social determinants of health (e.g., education and income), have on health throughout the lifecourse. As described in a recent article about screening for social determinants in primary care pediatrics, health care delivery sites can make a big difference in connecting patients to community services. These linkages improve the effectiveness of the health care delivery as well and lead to better health outcomes. The accountable communities of health (ACHs), throughout the state of Washington have made connection of community resources to the health care delivery systems a priority. WA Portal
Find out more about the opportunities to link community services to the work of care delivery sites by searching “social determinants” on the WA Portal resource library.