Q&A: Tackling the Triple Aim in a Region

By Sarah Klein

Shelby County, which has Memphis as its county seat, assembled a wide and influential group of leaders to address the region's most pressing problems, which include high rates of chronic disease and widespread racial and ethnic disparities in health outcomes. The participants in the Healthy Shelby initiative include four of the county's largest health care systems, its two federally qualified health centers, its two local mayors (county and city), the University of Memphis' school of public health, the University of Tennessee Health Science Center, some of the region's largest employers including FedEx and AutoZone, and local clergy, who already play a significant role in health promotion. (For a full list of participants, see Exhibit 1.)

The chair of Healthy Shelby's governing council is Kenneth S. Robinson, M.D., a former state health commissioner who is currently the public health policy advisor to Shelby County's mayor. Robinson is also the pastor and CEO of St. Andrew AME Church in Memphis Quality Matters asked Robinson how the partnership plans to tackle the health problems Shelby County faces.

Quality Matters: First I have to ask: how did you get all of these people to the table?

Robinson: It really started with three people: Robert Waller, M.D., the former CEO of Mayo Clinic who quote unquote retired to Memphis; Scott Morris, M.D., who is executive director of the Church Health Center, a faith-based clinic that relies on volunteer physicians, nurses, and dentists to supplement its staff; and Gary Shorb, the CEO of Methodist LeBonheur Healthcare, a nonprofit health care system. They thought Memphis would be an ideal place for the Triple Aim because the region has all these excellent health care systems with low standardized mortality rates and high consumer assessments, yet it still has such poor public health indicators and health outcomes. They were struck by the tremendous paradox. The three of them reached out to several of us who had worked on lots of projects, which led to Shelby County Mayor Mark Luttrell getting involved. He turned out to be a pivotal figure in drawing others including the employers and area hospitals to the table.

QM: What has the partnership decided to focus on?

Robinson: A few things stood out. Memphis has high heart disease rates, we are in the middle of the stroke belt, and our diabetes rates are well above state and national averages. The racial and ethnic disparities associated with these diseases make already dismal statistics even more devastating. As an example, our overall infant mortality rates are 12 per thousand. Yet, within that high rate, the rates among babies born to African-Americans are three times those of babies born to whites. I often say we have rates that rival Botswana. So these were obvious targets. To prioritize our goals, we followed IHI's advice, which was to look around to find where there is already energy and effort, but no evidence of improvement. With infant mortality there were 40 or 50 agencies with efforts to reduce these rates.  Each of the individual programs was successful, but as a public health person I can say they have not moved the needle in terms of our overall infant mortality rates.

QM: Why is that? 

Robinson: They are all separately funded and have different targets. Some are part of hospital systems. Others are standalone agencies. The eligibility for the programs is also different. It is just a classic example of what the Triple Aim tries to address by finding opportunities for collective action.

QM: So is that where you are starting?

Robinson: Actually there's a portfolio of three projects. So that's one. The second project in the portfolio addresses chronic disease management as it impacts patients' quality of life. You can look at diabetes and see clearly we have not mastered how we alter our lifestyles or diet, which lead downstream to very high nephropathy rates and people on dialysis, or to peripheral neuropathy and vasculopathy with disproportionately high amputation rates. Similarly if you look at heart disease, we have racial disparities and huge loci of poor outcomes. To start, we chose to look at the management of diabetes. We have since added the management of hypertension in certain population subsets. 

QM: And the third?

Robinson: That focuses on coordination of care, particularly care transitions at the end of life. Again there's a lot of activity already going on. The hospitals have been working on palliative care and end-of-life issues but again doing it individually and in some ways at the wrong point—very late—in a patient's predictable course. Advance care planning is a deeply personal issue and a discussion that ideally you have before someone is sick and in the hospital. That is clearly not the best time to engage emotionally involved folks who are uncertain about the outcome. This is a role the clergy can play earlier in the course of terminal illness. They have access at a very intimate individual and family level to convey messages about end-of-life care. On the issue of care transitions the Regional Medical Center has a different issue. This safety net hospital has patients who are often indigent and have nowhere to go after they are discharged from the ICU or the hospital. They just don't have the social support network and as a result they often bounce back to the hospital. This is something we have to figure out as a community: is it just that there is a paucity of extended care facilities? Is there a need within the social service community to provide services and resources to lower-income families or to intervene in other ways to create other social networks for frail elderly persons?

QM: How will the group tackle these problems, especially the chronic disease issue?

Robinson: We're going to take advantage of the faith community, for example. In Memphis, there are 3,000 or more churches and almost 100 percent of Memphis residents are attached to a congregation. Our goal is to have the churches integrate messages about appropriate preventive health and lifestyle measures. We think that will help decrease inappropriate use of the hospital, decrease cost of care, and improve quality of life for the congregants. The nice thing is there is an infrastructure to build on including Methodist LeBonheur's Congregational Health Network, which has been assisting 300 or so churches in helping parishioners navigate their way through the health care delivery system. The network's approach is to employ navigators who literally are liaisons between congregations and the hospital. They are facilitating not only health education, but hopefully also behavioral changes. There are other models as well. The Church Health Center has congregational health promoters. These are lay persons who are educated and variably trained to be peer mentors. You can imagine we use them for many reasons and we certainly can adapt that model to talk about some sensitive health issues—such as preparing for an anticipated end of life—and to implement community-based teaching programs, such as diabetes self-management, compliance with treatment regimens, and education about healthy eating and active living. 

QM: Not every region has such a strong religious community. If you were working in another city, where would you turn to find someone or a group that has that level of influence?

Robinson: Any community-based organization that has credibility and longevity in a community and can be seen as an authoritative voice. Perhaps academic institutions that have used their community for statistical research. There are also community development corporations. I'd look for anybody with boots on the ground, including barbers and beauticians, fraternal organizations, community elders, and affinity or peer groups. I would also say that even in the Northeast and out West, the percentage of the population that would be connected to a congregation is still significant. Whether the penetration is 30 percent or 100 percent, that is a big chunk of folks whose ear their clergy person has.

QM: How might the corporate community get involved?

Robinson: In Memphis, they have a great influence with respect to regional programs related to education, crime prevention, as well as economic and human capital development. When these corporate giants speak, people listen. We have tapped into their efforts by approaching Memphis Tomorrow, a group of CEOs of our largest local corporations that focuses on community and economic development. They had previously never focused on health. Now they are going to lend their visibility and their voices to this agenda, making our efforts a regional priority, and keeping us results-oriented. Employers that have wellness programs can also serve as mentors to other companies.

QM: Who's paying for all this?

Robinson: The four hospital systems and Shelby County Government are sharing the cost of first two years of initiative, which adds up to $500,000. The city mayor has also placed "Healthy Shelby" —as our regional Triple Aim initiative is now branded—in his budget. In addition, The Church Health Center participated in the initial engagement of IHI. We will also be depending on collaboration with research elements at the University of Memphis School of Public Health and the University of Tennessee Health Science Center, and with other providers of health and health care resources. 

QM: What advice would you give to others cities and counties considering this approach?

Robinson: I think working with a group like the IHI helps give the project some significant credibility—particularly with employers. I think it convinced Memphis Tomorrow and the corporate leadership that this would not all crash and burn and that this would not be about finding world peace or curing the ills of society. Another lesson is that you can't do this only with the usual players. You not only need health care providers, but also the people who are involved in the social determinants of health. And for this to work in a region you need to engage the whole community, including the employers and foundations whose funding may provide sustainable resources to accomplish these goals. I'd also suggest collaborating with their regional health and health care improvement organizations. We are building upon the Healthy Memphis Common Table's work on health promotion, health quality, and health equity to operationalize Healthy Shelby.