Caring for the 5% and Paying it Forward: Can a Triple Aim Approach Deliver?

by Nadine Morris | Mar 30, 2015






By Jennifer Verma, Crispin Kontz & Elina Farmanova

A small proportion of patients living with complex needs often accounts for as much as two-thirds of health care use and costs. But what if we could reduce health care spending by focusing on the highest risk and highest need patients and then redirect that money to work in the community on other issues that impact the health of the population?

We know that caring for very sick people, not surprisingly, is often very costly. Ideally, we should help those who make frequent use of health services so they either need less care or receive more appropriate services. In addition to probably being more to patients’ liking, this could also lead to modest improvements in cost-effectiveness and free up resources. The challenge is how to benefit those organizations and people who affect the health care savings rather than penalize them by giving their ‘dividend’ to some other sector. 

The Institute for Healthcare Improvement’s (IHI) Triple Aim– improved care experience, at optimized cost, while bettering the health of the population – is helping us to tackle this question in Alberta Health Services (AHS) Edmonton Zone.

AHS-Edmonton is one of 19 Canadian health care delivery organizations participating in the IHI Triple Aim learning collaborative, Better Health and Lower Costs for Patients with Complex Needs, with support from the Canadian Foundation for Healthcare Improvement (CFHI). In Alberta, 5% of the population accounts for 66% of healthcare use and cost (a higher share than has been reported elsewhere in the U.S. and Canada), so we are relying on a Triple Aim approach to transform services for high-risk, high-needs patients.

At AHS-Edmonton, which serves 1.2 million people, a total of 4,600 patients in the Eastwood area accounted for more than $169-million[1] in healthcare use and costs in 2009-10. An examination of root causes among the individuals with high emergency department (ED) visits revealed the determinants of health to be an obvious factor – the Eastwood area has the lowest socio-economic status, highest health risks and highest prevalence of homelessness in the city.

Health care providers often work in silos, rendering health services fragmented, complex and frustrating to patients who report feeling disrespected and lacking close, trusting relationships with their care providers. Rather than helping some of those who make frequent use of the health care ‘system’ use fewer services, the health care ‘system’ tends to aggravate and even intensify the health care use. That’s because in Canada, publicly funded healthcare favours acute, episodic, hospital-based care (which comprises 30% of total health spending in the country based on recent national health care expenditures); whereas what many patients in the 5% category need are longer-term, community-, primary-health and home-based supports.

The 1,750 older adults with addictions, mental health issues, and chronic disease are one of AHS-Edmonton’s patient population clusters. The average annual per capita health spending in Alberta is $6,783; however, for older adults in this patient cluster, their annual $35,000 average per capita health care bill results in total annual spending of more than $60,000,000. By talking to patients and asking “What matters to you?” (a far more progressive question than the standard, “What’s the matter with you?”) service providers learned to re-prioritize their efforts:

  1. Build trusting relationships with patients/clients and families;
  2. Address the basic necessities of life (e.g., managing addictions, housing, personal care, medication management, acute medical needs);
  3. Communicate and coordinate a care plan based on the person’s priorities among all service partners, inside and outside of the health system; and
  4. Provide emotional support (peer, family, social network)

By doing so, AHS-Edmonton is learning it’s possible to reduce overall per capita cost of care and shift away from a reliance on acute-based care to a more community-based model. Although this success at AHS-Edmonton is limited to a small group of patients and has not yet led to material savings, it shows promise. Firstly, it’s possible to reduce reliance on costly facility-based care, while increasing reliance on (in this case) less costly community-based care for the highest risk/highest need patients. Secondly, while the hospital dividends are not yet flowing to community care nor to other sectors (e.g., housing), the AHS-Edmonton example shows it’s possible for health care providers to work outside the boundaries of the traditional health care system in collaboration with other sectors and community partners toward a shared Triple Aim vision.

For example, given that most of the people the AHS-Edmonton team identified with complex high health needs are homeless or have unstable housing, the team worked with community partners who coordinate housing and shelters and supply affordable housing spaces with flexible rules and regulations to ensure provision of comprehensive ‘wrap-around’ services. The team is also learning that outreach workers and non-traditional health care workers are crucial members of the team for supporting better integration of services.

It’s a step toward transformation, where we can envision dollars that are saved or freed up from health care can be repurposed or reinvested in other areas of social services (including housing, education, social services, public infrastructure, etc.) to help improve population health.

Where do we in healthcare go from here? Share your examples of providing more appropriate services to high-risk, high-cost populations and let’s take the next step.

Learn more about the AHS-Edmonton Triple Aim work >>

[1] The costing data were compiled from several different sources, including the Alberta Health Care Plan Insurance Plan Registry, the physician claims database, the inpatient discharge-admission abstract (DAD) database, the national ambulatory care reporting system (NACRS) database, and census data by various groups in Data Integration, Measurement and Reporting and Population and Public Health.