If there is anything the COVID-19 crisis has shown healthcare leaders and case managers, it is the triple aim of focusing on improving population health, enhancing care experience, and reducing overall costs is not enough to improve value-based care.
A quintuple aim of also prioritizing health equity and workforce wellness/burnout is needed. Both became crises during the pandemic.
“As we use value-based strategies, it’s about how all these things fit together,” says Nicole Sunder, LCSW, director of health plan solution design at PointClickCare in Mississauga, Ontario.
Healthcare Burnout Becoming Priority
After a decade and a half of the triple aim, success is elusive. The problems with the healthcare continuum were made apparent during the pandemic.
“The pandemic accelerated what the gaps were and what our most severe gaps are as we drive toward value-based care,” Sunder explains. “We need to work to share necessary information with the right entity at the right time to help improve those population health outcomes and ensure the experience is positive and that it’s as cost-effective and efficient as possible.”
The Institute for Healthcare Improvement floated the idea of the quintuple aim, with conversation about health equity and inequity.1,2 One way to improve healthcare and health equity is to support populations that are marginalized, under-resourced, and historically oppressed, Sunder adds.
Although the idea of addressing the healthcare workforce and burnout was included as a priority before 2020, it has become even more important since the COVID-19 pandemic began. The pandemic has pushed many healthcare organizations to staffing crisis points as nurses and other healthcare professionals left the field during the past two years.
“We’ve seen that across North America and in different areas of healthcare, there have been capacity issues,” Sunder says. “It relates to hospitals, emergency departments, and others. We’ve seen it in the skilled nursing space.”
Meet the Quintuple Aim
A focus on workforce burnout and capacity is important for all levels of healthcare. The following are tactics for meeting the goals of the quintuple aim:
• Workforce wellness and burnout. “As we talk about workforce wellness, there’s a significant administrative burden that exists on many parts of the healthcare ecosystem today,” Sunder says.
For instance, healthcare organizations should align values with employees and make it easier for case managers, nurses, physicians, and others to provide person-centered, high-quality care.
“We need to make sure they have access to information that helps them most easily do their job,” Sunder explains. “One of the barriers to effective value-based care that we have found is the difficulty in collecting and reporting patient-level information.”
Health systems can do more to create infrastructure that makes care transitions smoother. When patients cannot be transitioned safely from hospital beds because of bottlenecks in the care continuum — something that worsened during the pandemic — healthcare professionals become distressed and burned out.
“A good example would be a hospital that often makes referrals to five nursing facilities,” Sunder says. “They need to ensure the facilities are able to accept the referrals and can give feedback to the hospital as quickly and as automated as possible.”
It is up to the health system to set up an infrastructure that is efficient, support patient experience, and help providers triage effectively. Employees experience less burnout and distress when administrative support is available.
“This is why people go into the field in the first place,” Sunder says. “They want patients to access the most appropriate care to support their needs.”
• Health equity. While increasing staffing levels can help reduce health inequity, this is more challenging because of the healthcare workforce’s burnout and capacity issues.
Healthcare organizations can address equity in other ways, including open-mindedness about solutions and understanding the needs they are addressing from a health equity perspective.
“A first step is to complete a health equity assessment of the population you’re serving and being thoughtful about where your services are rendered,” Sunder says. “Looking at what are the experiences in the community you serve is a good start.”
Once a health system assesses the community’s needs, it can collaborate with entities to help reduce inequities. This includes the health system and the health plan working together. Federally qualified health centers can work with health systems to address equity issues.
“Agree on the health inequities that exist in a community and bring together different entities to help solve the problem,” Sunder suggests.
• Improving population health. Healthcare organizations need to align their goals to improve population health. This includes value-based contracting, building data models, collaborating with payers, and aligning payment structures to help meet population health goals. One obstacle to improving population health is a breakdown in sharing health information.
“Sharing information is what helps drive the successes,” Sunder says. “A good example is the population of people who require medication reconciliation.”
It is imperative for each healthcare entity that sees the patient to receive an accurate and reconciled list of the patient’s medication. But if the various organizations do not share a common electronic health technology, or do not have checks and balances to ensure providers check patients’ medication from visits or stays at other facilities, problems can arise.
“How do they let the next entity know what the first entity knows?” Sunder asks. “We need to make sure medication reconciliation takes place so patients know what they need to do to have the best outcomes.”
In the future, collaboration will be crucial to improving population health. “It will be taken from a single-entity population healthcare strategy to a multiple-entity strategy in coming years,” Sunder says.
• Enhancing care experience. It is clear the future of improving the care experience involves prioritizing person-centered, individualized care.
“Think through the way you want to share information and make some effort in collecting and streamlining someone’s preferred language,” Sunder says. “Know the way they like to be communicated with and what health literacy means to them and their family members. Make it a person-first, person-forward approach to achieve outcomes specific to them.”
• Reducing overall costs. One way to reduce overall costs is for entities to share in financial risks.
“They can share in the risk for financial accountability for the total cost of care as a way to bridge some of the financial difficulties faced by the network,” Sunder explains.
For example, bring together hospitals and skilled nursing facilities with shared accountability and shared financial risk. The healthcare continuum can focus on patients’ general health, wellness, and individual experience, while reducing costs.
“By sharing the financial risk through value-based care contracts, make sure you’ve identified how you’re going to share the risk,” Sunder says. “Align the interventions and outcomes that you’re trying to execute.”
As the world emerges from the pandemic, healthcare organizations and medical professionals have become more aware of existing gaps in systemwide care quality.
“The pandemic is driving us toward prioritization in a different way,” Sunder says. “It makes us think through what this should or could look like and makes us focus — from a federal, state, and community perspective — on micro and macro levels of activity.”
Pushing system, workforce, and technological resources to unimagined limits has better prepared the care continuum for the future. Health systems know what they need to do next.
“We need to identify gaps, make changes, and build a healthier healthcare system for the decades to come,” Sunder says.
REFERENCES
- Nundy S, Cooper LA, Mate KS. The quintuple aim for health care improvement: A new imperative to advance health equity. JAMA 2022;327:521-522.
- Institute for Healthcare Improvement. The Quintuple Aim. March 16, 2022.
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