Meeting the health needs of vulnerable populations means addressing more complex needs and challenges as well

Oct. 24, 2016

A ground-breaking collaboration called the IMPACT 5/65 project is providing funding and expertise to improve the health of Alberta’s vulnerable populations. This unique collaboration–involving Alberta Health Services (AHS), Alberta Innovates – Health Solutions (AIHS), and Merck Canada–is pioneering an innovative approach to better understand complex, high-needs patients and using that information to make a real difference to their wellbeing.

Conventional health care delivery models have often proven ineffective for people with physical and mental health issues that are complicated by alcohol and drug dependency, homelessness and poverty. For example, take the case of an Edmonton patient who has diabetes. His doctor wants to know if he is taking insulin with meals, but this patient is homeless. Not only does he not have regular meals, he has no way to keep his insulin cold.

In this situation, a positive medical outcome (better control of diabetes) is best achieved via a social intervention (finding housing and the necessary social supports). In other words, making sure these kinds of patients receive better health care means helping them address other needs at the same time.

In 2012, AHS began implementing the Triple Aim framework to do just that.

Seven Triple Aim projects are now ongoing in Edmonton’s Eastwood community, a neighbourhood that has a high proportion of residents with lower incomes and who live with high health risks and poor health status. Early indications are that the projects are successful – the data shows that there is a decrease of about $5000.00 per patient per month in health care costs. But to be able to implement these kinds of projects on a bigger scale, more data is needed.

“Triple Aim is a quality improvement initiative and the foundation of quality improvement is to be able to measure success in various groups of patients,” says Stephanie Donaldson, director, Primary Care & Chronic Disease Management, AHS.

“Right now, Alberta is good at collecting measures across the general population. We collect a lot of system-wide data such as hospital admissions, immunization rates, and the like. But we don’t do as well at the individual level. For people in the Eastwood community who have complex, chronic or long-term health needs, the system does not collect the measures that providers feel are important to evaluate how their clients are doing.”

This is where the IMPACT 5/65 project comes in.

“Through the IMPACT 5/65 project, we’re building a data evaluation capability within AHS,” adds Donaldson. “Our people will gather and assess information across the goals of Triple Aim. Once the data start rolling in from IMPACT 5/65, we’ll have hard evidence to tell us what is working and what isn’t. Looking ahead, we’re very interested in building a sustainable measurement system province-wide. This is an important first step.”

When discussions to conceptualize IMPACT 5/65 began about three years ago, Merck Canada was one of the first organizations at the table. “We saw the potential of the project to support health system sustainability and efficiency,” says Norma Sebestyen, ‎director of Policy and External Affairs, Merck Canada. “IMPACT 5/65 will analyze the data and help us understand how we can best support improved health outcomes for patients.”

Also at the table was Alberta Innovates – Health Solutions (AIHS), who helped broker the partnership and provided support and expertise.

“While AIHS is often thought of as a grant funding organization to academic institutions, we’ve evolved over the years and have been the catalyst for a number of partnerships with the private sector, in line with provincial initiatives,” says Reg Joseph, vice president, Initiatives & Innovations, AIHS. “To date, these collaborations have been mainly research focused. IMPACT 5/65, with its focus on quality improvement in the health system, is a new area for us and it’s very exciting.”

“Having the right kind of data is essential to assessing impact,” adds Joseph. “IMPACT 5/65 is looking at patient groups in their actual care settings. When you run analytics on this kind of data, you can very quickly figure out where the pain points are. Not only are we improving health outcomes, we’re making the system more efficient, which frees up dollars for other areas. It’s no surprise that health systems around the world are diving into data as much as they can.”

Read more about the Impact 5/65 project and partners:

A view from the front line

Funding and expertise from the private sector – Merck

Innovation through partnerships – AIHS

Protecting people and their health information – AIHS

Merck 5/65 – A closer look at the project

IMPACT 5/65 & Edmonton: A view from the front line

Far from being abstract statistics, the complex high-needs patients addressed by the IMPACT 5/65 project are very real to the staff of the Boyle McCauley Health Centre. They are their clients. The centre has been serving Edmonton’s inner-city communities for more than 30 years. It offers accessible, comprehensive, culturally sensitive primary care that respects the uniqueness and complexity of the people who live in the inner city.

“Our clients require a greater degree of support and a greater amount of time,” says Program Manager Karin Frederiksen. “Alongside their medical issues, they often have barriers to health including mental illness, addictions, poverty, chronic homelessness, and social isolation. We focus on care for the whole person and provide a wide range of services including medical, dental, social work, outreach and housing needs.”

When AHS introduced Triple Aim in 2012, staff at the Boyle McCauley Health Centre immediately recognized that they had already implemented many of the Triple Aim principles in their daily practice. Triple Aim added a new focus on clients with the highest of high needs. For example, the Boyle McCauley Health Centre team zeroed in on connecting wound care patients with the centre. Their analysis showed that the approach resulted in a marked reduction in emergency visits for these patients.

IMPACT 5/65 adds a broad and rigourous evaluation component to Triple Aim. “We’ve done some small-scale evaluation and we’ve gathered a lot of anecdotal information to assess our impact,” notes Frederiksen.

“IMPACT 5/65 goes far beyond what we’ve been doing. It involves crunching the numbers and collecting information from patients and providers. With these more rigorous evaluations, we hope to clearly demonstrate a positive difference in health outcomes.”

IMPACT 5/65 & Merck: Funding and expertise from the private sector

The Impact 5/65 project is about assessing the effectiveness of social interventions designed to improve the health outcomes of complex high needs patients. “This project in Alberta fits well with Merck’s global priorities,” says Sebestyen. “Merck is a significant investor in bringing research to the world and is celebrating 125 years of contributing to innovation in health care. When you look at our business this way, participating in IMPACT 5/65 makes a great deal of sense.”

Merck is also contributing expertise on data collection and analysis. The company’s Center for Observational and Real-world Evidence (CORE) links together a wide range of experts including epidemiologists, health economists, outcomes researchers and data specialists. Newell McElwee, executive director of Merck’s U.S. Outcomes Research and a world-leading quality improvement specialist, is a member of the IMPACT 5/65 steering committee.

“Accurate data is the foundation of a robust and cost-effective model for serving people with complex health needs,” says Sebestyen. “Much of the focus in Phase 1 of IMPACT 5/65 is on using data to segment the complex high-needs population in a meaningful way. This way, a tailored program can be developed to support achievement of short-term and long-term goals that impact patients and the health system. Ultimately, we envision this approach as having widespread application in all patient populations.”

IMPACT 5/65 & AIHS: Innovation through partnerships

Known internationally as a funder of high quality health research and innovation, Alberta Innovates – Health Solutions (AIHS) has been building strength in a new area for the past five years. “We’ve brokered a number of research partnerships involving industry, where AIHS manages the money and frequently adds more funds to the project,” explains Reg Joseph, vice president, Initiatives & Innovations, AIHS. “Combining resources from the public and private sectors to work on important health issues is a powerful approach. AIHS is moving toward being an investor, broker, enabler, and developer of partnerships of value.”

The IMPACT 5/65 project is an example of one of these partnerships and represents a milestone in the evolution of AIHS because it moves the organization beyond its traditional role in health research into social interventions in the health system. Because AIHS is an agency acting on behalf of government, it can develop relationships with industry that government departments typically cannot. AIHS is also administering the project, including an ethics review, and will take a comprehensive approach to impact assessment through its Performance Management and Evaluation team.

“IMPACT 5/65 is using a collaborative, innovative approach to increase the capacity of the provincial health system to collect and analyze data and put the findings to immediate use in the community,” explains Joseph. “Typically in the past, this expertise has resided in academia. What we’re aiming for in IMPACT 5/65 is to build additional capacity within AHS. This way, AHS teams can use that data to make real-time decisions in Edmonton Eastwood to impact health outcomes and make a difference in the community.”

“We’re capitalizing on a huge opportunity in Alberta by leveraging expertise and resources from the private sector to supplement provincial resources and build capacity. At AIHS, we’re gaining important experience with managing these types of partnerships. There’s great potential in expanding this approach across the province.”

Protecting people and their health information

Although medical research projects must undergo formal ethics reviews before proceeding, there’s no similar policy or legislative requirement for non-research projects like IMPACT 5/65. And yet, these types of projects can also have ethical risks because they deal with people and their information. To help with this, there is ARECCI, an AIHS-led initiative which offers supports to provide ethical oversight for non-research projects.

“When conducting projects, it’s important that people and their information are respected and protected,” says Don Flaming, ARECCI manager. “ARECCI’s goal is to prevent ethical risk from becoming ethical harm. We help project leaders assess and mitigate any risks.”

Practitioners, agencies and organizations involved in non-research projects (e.g., quality improvement, program evaluation, needs assessment, knowledge translation) can use ARECCI’s online screening tools for practical decision-support assistance in areas of perceived ethical issues. For more complex projects like IMPACT 5/65, a Second Opinion Review process probes more deeply into ethical issues. Second opinion reviewers meet with project leaders to ensure they have done due diligence to protect people and their health information.

IMPACT 5/65: A closer look at the project

For many complex high-needs patients, medical interventions from a hospital do not always solve their health problems. That’s because health and social issues are intertwined and better solutions, safe housing for example, can often be found through community agencies. IMPACT 5/65 targets this disconnect between acute care and community care in Edmonton’s Eastwood community. The multi-year project is divided into three phases:

  1. Phase 1: data measurement, evaluation and analysis to understand how the Triple Aim framework can improve broad service delivery in a more cost-effective manner.
  2. Phase 2: development and implementation of interventions.
  3. Phase 3: effective measurement of the outcomes of the interventions.

Results from each phase will be evaluated before proceeding to the next. Phase 1 is underway with the development of a measurement plan. By consulting widely with a range of health care providers—including nurses, home care workers, exercise therapists and physicians—the project team has developed a core set of measurements across the complex high-needs population. Providers can use these measures to track both health outcomes and experience of care.

“We didn’t want lengthy 50-question surveys, but rather four or five questions that providers can ask clients monthly or quarterly to see whether they are heading in the right direction,” explains Eric Van Spronsen, manager, Primary Care & Chronic Disease Management, Alberta Health Services. “From a case study perspective, it’s so powerful to be able to actually measure the progress your clients are making.”

“Another important aspect of the measurement system is that it will give us the ability to look into an area where we had made improvements in the past but aren’t focussing on currently. This way we’re not only looking for successes but also using surveys to identify where we may be having trouble and need to increase our focus again.”

Providers began using the surveys on June 1. Databases have been developed and are ready to receive data. A visualization program that updates tables and figures automatically will be running by the fall.

Van Spronsen notes that measurement has always been top of mind for the teams involved with the Triple Aim approach. Front-line workers have been reporting successes with their clients, but these successes are generally not reflected in system-wide data. “We know from talking to our providers and our team leads that being involved in Triple Aim has had an impact on client care,” says Van Spronsen. “From a health perspective and experience of care perspective, I can’t emphasize enough the importance of IMPACT 5/65 in helping us capture the data we need.”

Back to AIHS e-newsletter, Vol. 2, Iss.9
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“5/65” refers to the five per cent of the Alberta population that accounts for an average 65 per cent of health care use and costs.

IMPACT stands for Improving Measurement – Partnership to Access and sCale the Triple Aim in complex care high-needs patients

IMPACT 5/65 is supporting all the Triple Aim projects by measuring and evaluating the variety of interventions these teams are using to make sure that the interventions truly reflect the needs of the residents of Eastwood.