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The Triple Aim for the Medicaid Population: Surprising Lessons from St. Charles Health System, Oregon

Author: IHI Open School, 12/4/2014 11:50:00 AM


With a growing Medicaid population, St. Charles Health System in Bend, Oregon, began using the Triple Aim framework to develop strategies to both identify and then better meet the needs of this often high-risk, high-cost patient population. As part of its Strategic Partnership with IHI, the system is pursuing the Triple Aim as a core focus of its work. “Our work on the Triple Aim means addressing the total patient experience,” says Emily Salmon, “and approaching patients from the perspective of ‘How can we make it better together?’” Ms. Salmon, Program Manager at St. Charles, describes some of the surprising lessons the health system is learning in this interview with IHI Communications Specialist, Jo Ann Endo.

Q:  Why is St. Charles focusing its Triple Aim work on the Medicaid population, and what have you’ve learned so far?
The primary impetus for focusing on the Medicaid population was that we jumped into the “risk arena” in Central Oregon with our Coordinated Care Organization. Also, with the Affordable Care Act (ACA), our Medicaid enrollment doubled, so we now have a population that is far larger and far different than in the past. We realized there was a lot we could learn by focusing first on Medicaid patients.  

We’ve been working with IHI on strategies to find the high-risk, high-cost patients who are new to our primary care clinics. What we’ve learned as a result of our tests is that these patients are not easy to locate for a variety of reasons.

Q: Is it like trying to figure out how to know who you don’t know?
Right, exactly. Our Medicaid patient enrollments doubled. We assumed that about 10 percent of our pre-ACA Medicaid expansion population were medically complex, high-risk, high-cost patients. We then estimated that all of our new post-ACA expansion enrollees represented another 10 percent – which would mean we had a lot more high-risk, high-cost patients to find.

We started doing some tests around claims data, and doing some outreach using the SF-1 question by mail survey. The SF-1 question, which is part of the Short Form 36 questionnaire centered on well-being and functional health status, asks patients to rate their own health status as either, “Excellent, Very Good, Good, Fair, or Poor.” What our team has learned, through the IHI Improvement Advisor training and the Triple Aim seminar, is that many believe that how patients rate their own health status is one of the best predictive indicators for risk and cost.

However, we weren’t finding anybody in the high-risk, high-cost group. Thanks to this information, we are rethinking our assumptions about our Medicaid population and realizing that the new enrollees are actually healthier than we had predicted.

Q: Based on what you’ve learned from that initial testing, what is your thinking now about identifying your Medicaid patients?
Essentially, the new prediction we’re testing is that maybe the newly enrolled population represents more of the working poor, or those that aren’t chronically ill. Maybe some of these newer Medicaid recipients represent a different segment of the population. The ACA eligibility changed, and the ceiling rose on the amount of money a recipient could make, so it’s possible some of these Medicaid enrollees are, for example, educated college graduates who can’t find a job or low-wage workers whose employers don’t provide health coverage. They don’t necessarily have some of the chronic disease conditions that someone who has been really struggling and living long-term without resources or insurance might have.

Q: How is what you’ve learned so far guiding what you’re doing next?
In addition to contributing to what we know or think we know about this population, it’s driving how we engage with our patients. To be more specific, it’s driving how we find them. Historically, Medicaid patients have been hard to reach by phone or by mail. We’re finding that may not necessarily be the case anymore, so that changes the way we approach reaching out to patients.

What we’re learning also helps challenge some of our assumptions, which is good because it’s pushed us to redesign our tests. There were things we took for granted, and having some of our expectations disproved has forced us to go back to the drawing board.

Q: What has surprised you as you’ve done this work?
One of the biggest surprises was the response we received to the mailed surveys. First of all, we had a good response rate, which no one expected. We assumed many of the recipients wouldn’t get their mail, and we didn’t think they’d return the survey if they did receive it. Our prediction was we were only going to hear back from the really sick patients because they would take the opportunity to alert us to their needs in the hopes of receiving expedited medical care. We were completely wrong. Two-thirds of the survey recipients said, “I’m in good health, I’m not on any medications, and I don’t have any conditions.” The other third of recipients said, “Yes, I could be in better health.” 

We expected to get responses from sicker people, who we’d call and set up appointments for them in the clinic. Instead, we heard back from people who weren’t very sick, so we had to ask, “What do we do now?” It was a good way for us to really engage our community health workers. From a medical standpoint, these patients aren’t reporting that they have any issues, but we need our community health workers to call them because it’s possible they could use help with some other issues that they don’t see as part of their medical care. 

Identifying mostly healthy patients pushed our team to test new workflows with the community health workers. Instead of connecting community health workers with patients as a reaction to needs identified in the course of medical care, we are working on ways they can be proactive and find out if there are any needs we can address now so they don’t turn into problems later. It’s better, when possible, to start a relationship with the patient proactively. That way, if a patient does someday have a medical issue, instead of walking into the emergency department because they don’t have a relationship with any health care provider, they call our clinic because they know the community health worker. As one of our community health workers said recently, “We can learn more in one visit to a patient’s home than we can in a year’s worth of appointments.” It’s so true. A patient’s life is so much more dynamic than how they present in an exam room.

Q: While there seems to be growing interest in addressing all three components of the Triple Aim simultaneously, no one is required to do so. How would you describe the importance of pursuing all aspects of the Triple Aim?
First and foremost is the fact that our current national health care situation is not sustainable. To address the patient experience, the health of the population, and costs at the same time, we must start to understand that patients are more multifaceted than perhaps we have acknowledged in the past. It makes us look at what we do in all aspects of caring for a patient, and really get down to what works and what doesn’t.

It’s also been a good thing to bring physicians and groups of clinicians together because it helps us understand the interconnection between community, mental health, and medical services. The medical community doesn’t have to do this all on its own. We need to understand how we can do it better together.

Q: Is there a patient who comes to mind when you think about the importance of St. Charles pursuing the Triple Aim?
One of our RN care coordinators shared a story with me, and I think it’s a good example of why we’re doing the work we’re doing. She told me about a middle-aged male who was in the hospital with an injury. During his hospital stay, they discovered he’s severely diabetic. He was very sick. At around the same time, he lost his job and his health insurance.

After his discharge from the hospital, he came to one of our clinics, and was pretty unpleasant to everybody. Our RN care coordinator met with him and said, “We’ve got to do something about your diabetes. I know you’re upset about your job, but we need to work through this.” She asked whether he was interested in attending education classes to learn diabetic self-management tips. He said something gruff like, “I don’t know. I’m going to have to check my schedule.” Because of the relationship the care coordinator had developed with the patient, she felt comfortable joking with him about his less than busy schedule. And he laughed. His wife was there, and said, “That’s the first time he’s laughed in a month.”

Using humor broke the ice. The patient went to the education classes. He lost weight. He got his sugars under control. He got a new job. The RN care coordinator helped him get patient assistance for his medications. He was able to turn his life around with the help of the resources in the clinic, medical and otherwise, because the patient was engaged in his own care, and was willing to partner with the RN care coordinator and the clinic.

And why is this a Triple Aim story? I think our work on the Triple Aim means addressing the total patient experience. The key is having clinic staff who don’t approach the patient with a “What’s wrong with you?” perspective, but instead ask, “How can we make it better together?”