1. Healthcare to Health - A
future worth creating
• Health, the ultimate team sport
6-1

2. Population Health –
Three Sub-Aims
• Health determinants
• Health promotion and primary prevention
• Environmental “adjustments”
• Individual health risk
• Behavioral risk
• Physiological risk
• Resilience
• Illness and disease burden
• Tertiary prevention – reducing the impact of chronic illness
• Improved pathways of care for common conditions (eg PTSD
and Depression)
Success – We will empty our hospitals
6-2

3. Defining Population Health
Behavioral
Risk Factors
Genetic
Endowment
Health and
Medical Care
Function
Prevention and
Disparities
Health Physiological Disease and
Promotion Well-Being
Risk Factors Injury
Socioeconomic
Factors
Death
Physical
Environment
Resilience
Determinants/ Individual Intermediate States of
Quality of Life
Factors Risk Factors Outcomes Health
Source: Dr. Matt Stiefl , Institute for Healthcare Improvement 6-3

4. Delivering the Quadruple Aim
1) To whom and where do we deliver the Quadruple Aim?
2) Where can we deliver the Triple Aim?
3) Where is it feasible to Job
deliver “only” health care Specific
Skills,
Attitudes,
Knowledge
Genetic Behavioral Ready
Endowment Risk Factors Medical
Force
Medical Health
Prevention Care
Disparities
and Health and
Function Medically
Promotion
Physiological Well-Being Ready
Risk Factors Disease Force
Socioeconomic and
Factors Injury
Death Readiness
Physical of Families
Environment
Resilience
Determinants/ Individual Intermediate States of Quality of Readiness
6-4
Factors Risk Outcomes Health Life
Factors

5. The Challenge
• Build the measures
• Change our mindset
• Change incentives
• Change beneficiary behaviors
6-5

6. The “Total Package”: MTHA  PPP
“HRA Plus Process”
(Taken from Final Rule released week of 12/12/11)
• HRA completed – not effective by itself –
needs the following – called health risk
assessment plus
• Feedback received
• Shared decision Making to develop goals and
prevention plan
• Referrals provided
• Progress monitored
• Follow-up Regularly
6-6
6

7. KP Colorado Pilot Flow- Start-Date: Jan. 3, 2012
In Clinic
Provider reviews HRA
Prior to office visit results and PPP letter-
Contact with member to plan for office content can be amended
visit, and discuss completion of HRA if indicated
Collaboration and
Communication:
Provider hands member
the printed PPP letter;
Prior to office visit Health support team
HRA responses reviewed and PPP In Clinic addresses ongoing
letter created and pended in Staff in clinic aware that HRA wellness issues from
Electronic Medical Record completed and PPP letter in EMR positive findings
waiting to be printed
Proactive encounter work 6-7
7
Confidential and Proprietary- Kaiser Permanente
7

8. 6-8

9. Support for Population Health
Initiative: DoD’s Focus
Tobacco and Alcohol
Infant Mortality
Low Birth Weight
Very Low Birth
Weight
Cancer Screening
Obesity
Mental Health Screening 6-9

10. Delivering the Quadruple Aim
1) To whom and where do we deliver the Quadruple Aim?
2) Where can we deliver the Triple Aim?
3) Where is it feasible to Job
deliver “only” health care Specific
Skills,
Attitudes,
Knowledge
Genetic Behavioral Ready
Endowment Risk Factors Medical
Force
Medical Health
Prevention Care
Disparities
and Health and
Function Medically
Promotion
Physiological Well-Being Ready
Risk Factors Disease Force
Socioeconomic and
Factors Injury
Death Readiness
Physical of Families
Environment
Resilience
Determinants/ Individual Intermediate States of Quality of Readiness
6-10
Factors Risk Outcomes Health Life
Factors