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MAY/JUNE 2011 :: 72(3)
New Models of Care

The policy forum of this issue reviews new models of health care payment and delivery. North Carolina is a national leader in some of the new models envisioned under the Affordable Care Act, and this forum features authoritative commentaries about 6 types of models in the state: entrepreneur-driven activities, management of innovations, applications of technology, changes in financing, market approaches, and structures involving changes in how health care professionals work. Also in this issue, original articles describe overweight and obese employees’ perceptions about lifestyle-associated changes in health benefits, career transitions among physicians dually trained in internal medicine and pediatrics, and hospitals’ use of data to identify disparities in the care of minority patients.


Use of the Triple Aim to Improve Population Health

Jerome F. Levine, Betty Herbert, Jan Mathews, Andrea Serra, Valinda Rutledge

N C Med J. 2011;72(3):201-204.PDF | TABLE OF CONTENTS

CaroMont Health has embraced the Triple Aim initiative to implement its core vision and competencies of delivering health care, promoting individual wellness, and creating vibrant communities. An imperative to achieve success has been aligning the corporate goals with the processes and outcomes that foster the Triple Aim.

The country needs and, unless I mistake its temper, the country demands bold, persistent experimentation. It is common sense to take a method and try it: if it fails, admit it frankly and try another. But above all, try something.

Franklin D. Roosevelt [1]

The passage of the Affordable Care Act (ACA), in March 2010, began a new era in the efforts to improve the health of Americans and to reform the US health care system. The need to control the ever-increasing spiral of health care costs, to reduce the fragmentation of the delivery of care in this country, to focus on prevention and wellness, and to improve the quality of care a certainly not a new concept and has been discussed in detail in a previous issue of the NCMJ [2]. However, the ACA has ushered in the opportunity to achieve these goals by using new models of delivery, such as accountable care organizations, bundled payments for acute care episodes, chronic disease management, and patient-centered medical homes. The Triple Aim concept was propelled onto the health care community by Berwick and colleagues [3] in 2008. The Triple Aim focuses on simultaneous, integrated work over time to improve the patient’s experience with care, improve the health of a defined population, and contain the per capita cost of health care.

CaroMont Health is a not-for-profit, multisite, community-based health care system located in Gastonia, North Carolina. Our vision is to be a nationally recognized leader and a valued partner in promoting individual health and vibrant communities. We have embraced the Triple Aim framework, building on past quality initiatives that originally focused on improving care and reducing harm in the hospital and moving these initiatives into the community. By improving the health of our population, enhancing the patient’s experience of care, and reducing or, at minimum, controlling the costs of care, major benefits will be realized by our patients, our patients’ families, and our employees. At CaroMont Health, we are focused on moving from a volume-based business model to one that is value based. To achieve this transformation, we must examine our organizational structure and processes and focus on 3 core competencies: a redesign of the care system, with enhanced coordination; clinical integration with health care professionals; and an understanding of the community needs as they relate to population health. The primary drivers of success must include the following activities: institute transparent measurements; foster public health interventions by collaborating with community groups that can influence change in a defined population; design and coordinate care at the patient level, including clear identification of the provider; execute a shared treatment plan; and incorporate the family and the patient in care planning. Our journey started with our own employees as the defined population.

CaroMont Health’s commitment to enhancing the health of its employees was initially demonstrated in early 2010, when the board of trustees revised the corporate vision to read, “We are a nationally recognized leader and valued partner in promoting individual health and vibrant communities.” This commitment generated the motivation to pursue the Triple Aim for CaroMont Health’s employee population. CaroMont Health’s wellness strategy included incorporating employee-wellness goals into corporate goals for fiscal year 2011, establishing incentives for healthy behaviors, redesigning the health benefit structure, offering clinical health risk assessments (CHRAs) to employees, and changing the philosophy of food service management from one of sales to one of health. To further align these goals on an enterprise level, the 2011 corporate goals included increasing the number of employees who completed the CHRA by 10% and decreasing the proportion of employees who never exercised by 2%.

The organizational infrastructure to support a wellness focus included the creation of 2 positions: a vice president of research and wellness development, as well as a wellness director. The employee health department offerings were enhanced and structurally aligned with the cardiac health and fitness center in the wellness arena. An employee-focused, on-site integrative medicine practice recently opened. To understand the needs of our population, we reviewed year 2009 claims. CaroMont Health’s top 4 conditions associated with episodes of care included coronary artery disease, hypertension, and diabetes. The completion of a CHRA is required for employees to remain in the least-expensive health plan. On the basis of claims data and CHRA results, we placed a focus on slowing the continual increase in the incidence of chronic disease among employees by means of nutrition, exercise/activity, smoking cessation, and stress reduction initiatives.

From a nutritional standpoint, Weight Watchers @ Work is conveniently available to employees at CaroMont Health. Weight Watchers recipes are used in retail meal preparation; nutritional values are conveniently provided for all items sold in The Terrace Cafe, an on-site dining facility at CaroMont Health; and a color-coded system is used to easily identify the healthiness of meals. Ovens have replaced deep fryers in The Terrace Cafe, and all items that were typically fried are now baked. The price of healthy food has decreased, and the price of unhealthy food has increased. There has been a decrease in the unhealthy food offerings. Farmers’ markets are held in The Terrace Cafe, and each item for sale includes a healthy recipe. A chef and a dietician are available during the market, and they engage staff in conversation about healthy eating and teach healthy cooking techniques. All food catered by CaroMont Health is healthy, and 60% of items in vending machines are healthy options.

On the exercise and activity front, the employee health and fitness center has been enhanced to include cardiovascular training, strength training, and 30 group exercise classes per week. Clinical monitoring is provided before, during, and after exercise, as needed. Access to the center is free to employees and is offered for a nominal fee to families; it is also open to community members. Smoking-cessation initiatives include smoke-free buildings, smoke-free campuses, and smoking-cessation support for staff. Stress-reduction efforts include yoga classes, guided walks during breaks, and free stress-management workshops.

Other wellness and health plan incentives include the metabolic and circulatory disorder self-management programs, tobacco-cessation and tobacco-free incentives, nutrition and exercise consultations, and exercise and body mass index incentives. The accomplishment of corporate and Triple Aim goals during the past year can be seen in Table 1. The goals for 2011-2012 are currently under discussion.

Gaston County ranks 75th in health status among the 100 counties in North Carolina [4]. Development of a collaborative commitment from other Gaston County organizations is crucial to addressing this major health problem. The Gaston County Health Coalition has recently been formed, and it comprises a robust variety of community groups (Table 2). The mission of the coalition is to use employer-based strategies to spread the success we have achieved with our own employees into the community. Our Voice of the Community initiative enables us to reach out to Gaston County residents and let them tell us what health care looks like from their perspective. On the basis of essay submissions, local residents will be selected for the CaroMont Healthcare Leadership Forum. This forum will meet regularly to discuss and make suggestions about a host of important issues, including how to improve processes and support underserved communities.

By engaging the community on a regular basis, we can enhance the patient experience in accordance with Triple Aim goals. The valuable anecdotal data we gather from the CaroMont Healthcare Leadership Forum meetings will also let us know how internal innovations and community outreach efforts are being perceived. Since perception influences adoption, we will know whether there are mitigating factors that could potentially impact efforts to improve health outcomes and control costs.

We have clearly recognized the important role that primary care physicians play in the new models of health care delivery. They will be responsible—and ultimately accountable—for the integration of care to their patients. This accountability will include the areas of quality, efficiency, and costs. The foundations for this transition have been put into place at CaroMont Health. Physician-led councils have been developed that cross the boundaries of the classic hospital-centric service lines. The councils are multidisciplinary teams that are chaired by physicians and charged with developing strategies to coordinate and improve care while understanding the importance of bending the health care cost curve. Every month, they review multiple metrics that include a variety of quality performance indicators, market share data, costs, and other information. To address the apparent need for physician education, we have partnered with Sg2 to provide on-site classes that cover the full array of tools that will be needed as health care reform moves forward. These sessions have been extremely well received by the medical staff.

As approximately half of the physicians on staff are employed by CaroMont Health, a new governance structure is currently under development. The new model places the physicians at the lead in making decisions about the care of the population. The physicians work closely with the chief executive officer and senior leadership of CaroMont Health to transition effective and high-quality health care from the hospital to the community. Other current initiatives include implementation of a robust electronic medical record system in all of the employed primary care physicians’ practices. This will provide the foundation for data gathering and communication among providers. The patient-centered medical home (PCMH) is another crucial arm of our clinical integration. All of our primary care clinics that have an electronic medical record have received National Committee for Quality Assurance Level III designation as a PCMH [5]. We anticipate that all of the clinics will receive level III approval by December 2011. Again, the physicians have had a major voice in the development and organization of the patient-centered medical home.

As we have traveled on our journey to implementing the Triple Aim goals, it has become clear that achieving those goals will set the stage for us to be successful in the next decade. As hospitals move from a volume-based, competitive model to a value-based model, different competencies are needed to be successful. The ability to collaborate with various stakeholders, such as primary care physicians, public health departments, and federal qualified health departments, will be key for the future. To be able to bend the cost curve, we must redesign the entire continuum of care, beginning with prevention and ending with return to health. To efficiently deliver care and move our communities to optimum health, we need to work in tandem with our community partners. This will facilitate the discovery of new ways to provide care together, rather than in silos and with potential duplication of expensive services. Use of the Triple Aim as the framework for this change provides a structure for all health care leaders in a community to lead this transformation to optimum health, thereby bending the cost curve on a permanent basis.

Potential conflicts of interest. All authors have no relevant conflicts of interest.

1. Roosevelt FD. Oglethorpe University Commencement Address. Atlanta, GA: May 22, 1932. Accessed June 8, 2011.

2. Shore S, Griggs GK. Health care reform: a perspective from primary care. N C Med J. 2010;71(5):421-423.

3. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759-769.

4. Health outcomes map. 2011: North Carolina. County Health Rankings Web site. Accessed June 28, 2011.

5. National Committee for Quality Assurance (NCQA). Standards and Guidelines for Physician Practice Connections—Patient-Centered Medical Home (PPC-PCMH). Washington, DC: NCQA; 2008. Accessed June 28, 2011.

Jerome F. Levine, MD, MBA executive vice president and chief medical officer, CaroMont Health, Gastonia, North Carolina.
Betty Herbert, BA director, managed care, CaroMont Health, Gastonia, North Carolina.
Jan Mathews, RN, MPHA, CPHQ, NEA BC associate vice president, quality management, CaroMont Health, Gastonia, North Carolina.
Andrea Serra, BS, MHA vice president, research and wellness development, CaroMont Health, Gastonia, North Carolina.
Valinda Rutledge, MBA president and chief executive officer, CaroMont Health, Gastonia, North Carolina.

Address correspondence to Dr. Jerome F. Levine, CaroMont Health, 2525 Court Dr, Gastonia, NC 28054 (