Clinical Integration across Yale New Haven Health System: the “Triple Aim” in Action

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Primary Author:</td>
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Carmela Valentino, MPH, CHES, CPHQ</td>
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Co-Principal Investigators/Collaborators:</td>
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Frank Loria, MD, Robert McLean, MD, Amanda Skinner, MSN, MBA</td>
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Organization:</td>
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Yale New Haven Health System</td>
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Abstract</h2>
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Purpose</h3>
<p>Establish a formalized structure of collaborative committees and workgroups charged with the task of achieving the Institute for Healthcare Improvement's (IHI)“Triple Aim” for patients cared within the Yale New Haven Health System (YNHHS). </p>
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Background</h3>
<p>The “Triple Aim” includes: better care for individual, better health for populations, and lower growth in expenditures Clinical Integration is (CI) a network of physicians and practices that deliver evidence based care to ultimately improve the quality, efficiency, and coordination of health care services. A well-developed Clinical Integration program identifies evolving quality targets and metrics, and uses this data to improve patient care. Foundational goals of the CI initiative include: Improve patient health, quality of care and experience of care. Do so in a way that creates value, reduces costs and uses resources wisely. Create a more seamless system of care for both patients and physicians. Ensure physician leadership and influence in transforming the system. Ensure aligned incentives for achieving the above.</p>
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Materials & Methods</h3>
<p>Health System leadership chartered the CI Steering Committee in December 2012 Strategic constituents and key stakeholders from Northeast Medical Group (NEMG), Yale Medical Group (YMG) and New Haven Community Medical Group (NHCMG) participates in the work, bringing to the table: Physician partners, Epic analysts, Performance improvement specialists, and Care coordinators. Team members agreed to a physician-led committee structure that meets monthly. Four main workgroups were launched and Sub-groups emerged to tackle task-focused challenges including patient engagement, primary care physician (PCP) communication, discharge summary completion, medication reconciliation, and patient education.</p>
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Results</h3>
<p>Eighteen months post launch of the CI Steering Committee, robust clinical improvement work takes place across an array of task-focused workgroups and subgroups to the workgroups. Each workgroup has approved metrics and are working on multiple interventions aimed at working on the “Triple Aim”.  There are seventy six committee members across organizations that are working together on the ten CI workgroups and Steering Committee. Accomplishments of Diabetes Workgroup include: Approved initial set of metrics; Utilize registry data in Epic – launched in 2014 and is used for improvement in diabetes patient's care; and Patient engagement workgroup launched; For Heart Disease Workgroup: Approved initial set of metrics for CAD; Development of registries in Epic underway – CAD, CHF, HTN; Patient engagement: Shared Medical Visits for HTN; Cardiac Rehab referral process; Ejection fraction documentation workflow for easier data capture; ForFor Care Transitions. Accomplishments include: Approved initial set of metrics; 2 sub working groups: Optimizing the Discharge Summary & PCP Identification and Communication; SAP reports developed for discharge summary and PCP identification; Increased representation from community physicians; Gained representation on other existing workgroups to ensure cross-pollination and to prevent redundant efforts; and conducted a PCP satisfaction survey assessing satisfaction with Communication and Discharge Summary Information; and for the results of the Geriatric Workgroup: approved initial set of metrics; Implemented templates for documentation of cognitive assessment; Created a workflow for insuring patients receive influenza vaccination and documenting vaccination to insure electronic capture; Developed report for influenza compliance (previously data was manually extracted) and Improved influenza vaccination rates.</p>
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Conclusion</h3>
<p>The YNHHS includes a diverse array of delivery networks, clinics, providers, and programs. Engagement of key stakeholders is fundamental to the success of any large scope initiative such as this one. NHCMG and YMG both reside outside of the System “financial umbrella”, yet play an integral role as partners in the clinical integration work as these providers manage patients admitted to the hospital delivery networks and seen at system urgent care facilities. As a system initiative present at every delivery network and covering a myriad of affiliated clinical settings, all sites can benefit from lessons learned. Clinical structure and process change can be spread at a pace and scope not seen before by the Health System. As initiative metrics become increasingly automated through maximization of Epic capabilities and increased software capacity, clinical performance and patient outcome data will become increasing available. The Health System has begun its journey and will continue toward achieving the “Triple Aim”.</p>
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Bibliography</h3>
<ul>
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Berwick, D. (2012). Institute for Healthcare Improvement. Retrieved from http://www.ihi.org.</li>
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Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012.</li>
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<p>© Improvement Science Research Network, 2012</p>
<p>The ISRN published this as received and with permission from the author(s).</p>