Use of the Triple Aim to Improve Population Health
Jerome F. Levine, Betty Herbert, Jan Mathews, Andrea Serra, Valinda Rutledge
Via -N C Med Journal
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,
Franklin D. Roosevelt 
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 . 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  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
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
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 . 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 . 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
1. Roosevelt FD. Oglethorpe University Commencement Address. Atlanta, GA:
May 22, 1932. http://newdeal.feri.org/speeches/1932d.htm. 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. http://www.countyhealthrankings.org/north-carolina. 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. http://www.bethesda.med.navy.mil/medicalhome%5Cdocuments%5Cmeasuressuccess%5Cmedical%20home(ncqa%20stnds%20and%20guidelines).pdf. 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 (firstname.lastname@example.org).