Noted ecologist Wendell Berry, in an essay entitled “Solving for Pattern,” observed that “Good solutions recognize that they are part of a larger whole. They solve more than one problem and don't create new problems.” Berry was thinking mainly about environmental issues. But his mandate applies equally to the health system, where some of the most effective leaders routinely strive to achieve the “Triple Aim” of better health, better care, and lower cost for all.
One such endeavor is unfolding in Pueblo, Colorado (population 160,000), located about two hours south of Denver, where scores of stakeholders are now committed to the Triple Aim. According to the Institute for Healthcare Improvement, Pueblo is one of a few sites formally working at a county-wide scale. Pueblo is also an early adopter of the Collective Impact strategy, popularized by the nonprofit consulting firm FSG, and one of the first pilot sites in the ReThink Health Dynamics project. Together, these influences have shaped their approach to system-wide planning and action (see figure below).
- IHI’s Triple Aim defines basic goals and an ethic of iterative improvement;
- FSG’s Collective Impact emphasizes shared governance and solid infrastructure; and
- ReThink Health equips leaders to engage with one another, examine data, play out scenarios, weigh trade-offs, and strengthen their capacity for high-leverage action.
Building on these elements, the Pueblo Triple Aim Coalition (PTAC) devised a distinctive stewardship strategy that they are now poised to enact. Here is a brief summary of its features.
Recognizing & Responding to a Crisis
With health care premiums rising three times faster than wages, and County Health Rankings placing Pueblo 54th out of 59 Colorado counties on health outcomes, many stakeholders see a “burning platform” that compels them to act. In a brief statement written to engage fellow leaders, PTAC members explain that “ever-rising healthcare spending weakens our local economy, threatens jobs, and has failed to deliver improved health.”
They also identify a potentially abundant source of money, estimating that a modest decrease in health care spending (on the order of 7.5% per capita) could yield more than $75 million in annual savings, even apart from the potential boost to economic productivity. Thinking about the work ahead, they conclude that “progress in Pueblo has been badly hampered by the absence of an overarching strategy and a coordinating institution.” Pueblo’s Triple Aim Coalition aspires to fill precisely that gap in a way that individual actors working separately could never do.
Crafting a Stewardship Strategy
After its launch in November 2010, the PTAC grew to encompass dozens of constituents including the health department, community health center, hospitals, mental health center, Kaiser Permanente, schools, business leaders, elected officials, philanthropies, and more. Aligning such diverse groups is time-consuming, but there are rewards for laying a strong initial foundation. About a year into the process, over 35 senior leaders from across Pueblo’s organizational landscape voted unanimously to join the effort. Colleagues from IHI and ReThink Health support the PTAC team, but it remains a local endeavor, animated by passionate leaders who devote their time, talent, and resources to the work, with Kaiser Permanente generously paying IHI dues and the salary of a half-time coordinator.
More fundamentally, those involved maintain an unswerving commitment to go beyond fragmented, short-sighted action. Donald Moore, CEO of the Pueblo Community Health Center, explains their rationale for this critical stance: “Most Triple Aim projects start with a project and build up from there. Instead, we have been thinking big picture and haven't selected specific projects yet. We are building governance, structure, and strategy first because we believe our work will be more successful and sustainable with this approach.”
Using the ReThink Health Dynamics model, calibrated with Pueblo’s own data, team members studied scores of scenarios and eventually identified a compelling suite of initiatives that could significantly strengthen most aspects of their health system. The PTAC plan now centers on a mix of cost-saving initiatives, like care coordination and post-discharge planning, along with support for self-care, greater safety net capacity, and investments in upstream social, economic, and behavioral initiatives. Just as importantly, PTAC planners determined that it may be possible to sustain all of these activities over decades by capturing and reinvesting a portion of health care cost savings. This financing strategy is similar to one that Sanne Magnan and colleagues have proposed in their essay on Accountable Health Communities.
Christine Nevin-Woods, Executive Director of the Pueblo City-County Health Department, says that, “ReThink Health modeling opened our eyes. It offered perspectives on big impact changes that might not pay off right away.” In addition, other supporters also see great potential in Pueblo’s disciplined strategy. Just last week, for example, senior staff from the Colorado Health Foundation met with PTAC members and ReThink Health allies to consider next steps, such as establishing a backbone organization, a shared measurement system, and other elements needed for collective impact. PTAC representatives will discuss their strategy and accomplishments at the Public Health in the Rockies Conference on September 19th.
Looking beyond Pueblo, there are hundreds of organizations actively pursuing the Triple Aim, expanding its reach, and pressing toward wider, population impact. At the same time, members of the ReThink Health alliance are creating new tools and working with innovators to strengthen their capacity for stewardship, sharpen their understanding of health system dynamics, and organize more effective action. As this work goes forward, we may all learn what it takes to solve for the vital pattern of better health, better care, and lower cost for all.
Beyond The Triple Aim: Integrating The Nonmedical Sectors (by David Kindig, May 19, 2008)
Can Healthcare Organizations Lead in Population Health Improvement? (by David Kindig and John Whittington, September 28, 2010)
Unpacking the Triple Aim (by David Kindig, January 11, 2011)
Triple Aim: Accelerating and Sustaining Collective Regional Action (by David Kindig and John Whittington, January 16, 2011)
Modeling Long Run Population Health Costs and Outcomes (by David Kindig, July 27, 2011)