I need this by monday

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Vila Health ® Activity

Triple Aim Outcomes

Introduction

Challenge Details

Your Of�ce

Triple Aim Interviews

Email Response

Conclusion

Introduction
Hospitals and other health care providers
increasingly are measuring quality through a set
of standards called the Triple Aim. To achieve the
Triple Aim, health care organizations are tasked
with (1) improving the patient experience of care,
(2) improving the health of populations, and (3)
reducing the per capita cost of health care.

Effective care coordination is an important part of achieving

the Triple Aim, as care coordinators are involved in all three

Triple Aim standards. Therefore, when health care

organizations seek to make the quality improvements

necessary to achieve the Triple Aim, the care coordination

process at the organization may need to be updated.

After completing the activity, you will be prepared to:

Develop strategies for modifying a hospital’s care

coordination process in order to achieve the Triple Aim.

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Analyze population data in order to develop strategies for

achieving the Triple Aim.

Interview stakeholders in order to develop strategies for

achieving the Triple Aim.

Challenge Details
You have just been hired as a case manager at Sacred Heart

Hospital (SHH), a 21-bed rural hospital located in Valley City,

North Dakota. SHH was recently acquired by Vila Health, a

large health care system that operates hospitals and clinics in

several Midwestern states.

Vila Health is committed to improving the quality of its regional

hospitals, and one of the primary standards they use to

measure quality is the Triple Aim. As part of the effort to help

the hospital achieve Triple Aim outcomes, you will be asked to

investigate ways that the care coordination process can or

must be updated.

Your Of�ce
It looks like you have email from Karen Dellington, Admissions

and Discharge Director. Read the message, then review the

Barnes County Regional Health Pro�le document.

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Email
From: Karen Dellington, Admissions and Discharge Director

Subject: Triple Aim Outcomes

We’re so glad to have you here at Sacred Heart! Please let me

know if you have any questions as you get settled in.

As you know, we’re going to be updating our care coordination

processes here at Sacred Heart so that we can achieve Triple

Aim Outcomes. I’m sure you’re familiar with Triple Aim, but if

you’re not, that’s a set of standards that refers to (1) improving

the patient experience of care, (2) improving the health of

populations, and (3) reducing the per capita cost of health care.

In summary–Triple Aim is care, health, and cost.

We’re going to be meeting with representatives from Vila

Health next week to discuss Triple Aim. I know that’s not much

time! What I need you to do is put together a PowerPoint

presentation with speci�c suggestions for how we can improve

our care coordination process to achieve Triple Aim outcomes.

That’s a tall order, but I know you’re up for the challenge! To do

that, I’d like for you to complete the following tasks:

1. I’m going to be sending you a detailed Barnes County

Community Pro�le. This document will give you a great

deal of information about the community and its health

needs. As you read through this document, think carefully

about what is needed to achieve Triple Aim outcomes for

this community, and how an effective care coordination

process might facilitate this strategy. You will be including

this information in your PowerPoint presentation.

2. I’d like for you to interview people at the hospital and in the

community. You’ll be asking them questions about care,

health, and cost, and you will include this information in

your presentation. You have limited time for these

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interviews, so choose wisely—and try to get the right

combination of people to get the information you need.

Good Luck!

Thanks,

–Karen

Barnes County
Community Health
Pro�le
Barnes County, North Dakota Community Health Pro�le by Age

Group, 2000 Census

Age Group: 0-9

Barnes County:

1288

10.9%

North Dakota:

82,382

12.8%

Age Group: 10-19

Barnes County:

1811

15.4%

North Dakota:

101,082

15.7%

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Age Group: 20-29

Barnes County:

1371

11.6%

North Dakota:

89,295

13.9%

Age Group: 30-39

Barnes County:

1303

11.1%

North Dakota:

85,086

13.2%

Age Group: 40-49

Barnes County:

1803

15.3%

North Dakota:

98,449

15.3%

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Age Group: 50-59

Barnes County:

1327

11.3%

North Dakota:

66,921

10.4%

Age Group: 60-69

Barnes County:

1057

9.0%

North Dakota:

47,649

7.4%

Age Group: 70-79

Barnes County:

998

8.5%

North Dakota:

29,492

4.6%

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Age Group: 80+

Barnes County:

817

6.9%

North Dakota:

29,492

4.6%

Total

Barnes County:

11,775

100%

North Dakota:

642,200

100%

Age Group: 0-17

Barnes County:

2624

22.3%

North Dakota:

160,849

25.0%

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Age Group: 65+

Barnes County:

2332

19.8%

North Dakota:

94,478

14.7%

Triple Aim Interviews

Choose four individuals from the hospital staff and the

community to interview. These individuals will give you more

information to help you develop a strategy to achieve Triple

Aim Outcomes.

Todd Chester: Director of Quality Assurance, Sacred Heart

Hospital

Courtney Donovan: Emergency Room Doctor

Sarah Kealey: Nurse Practitioner, Southwest Medical Clinic

Floyd Knutson: Mayor Of Valley City

Mary Loudsinger: Social Worker, Sacred Heart Hospital

Bob Van Ness: Home Care Liaison

Ned Walsh: Barnes Community Health Department

Director

Trish Walstrom: Care Coordination Manager

Todd Chester
Director of Quality Assurance, Sacred
Heart Hospital

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1. What are some of the major cost concerns
for SHH?

Like many rural hospitals, we have some serious �nancial

concerns. For one thing, we are incurring way too many costs

in relation to readmission rates. I can’t emphasize enough how

problematic this is from a quality assurance standpoint. We’ve

always had a problem with readmission, but because of the

Affordable Care Act, this problem has become especially costly

for us—and I know that Vila Health is highly concerned.

Readmission rates are high for a number of reasons. For one

thing, I don’t think we’re doing a good enough job assessing

barriers to care—especially the barriers involving �nancial and

logistical concerns. We’re sending people home with

instructions for follow-up care, and then people don’t follow up

because we’ve asked them to do things that they can’t. So for

example, we tell them to make a follow-up appointment with a

provider who’s an hour away in Fargo, and they don’t have

easy access to transportation, so they don’t ever schedule the

appointment. That scenario happens quite a bit around here,

since we don’t have a lot of health care providers in the area,

and there’s a lot of poverty. And there’s just the simple fact that

people can’t always pay for medication and follow-up care—so

they skip these things and then end up back at the hospital.

Insurance deductibles are higher than ever and people are

really struggling �nancially around here, and even with the

Affordable Care Act, we have a fairly high percentage of

uninsured patients.

Also, with smaller hospitals like ours, you always get issues

involving economy of scale. We’re a small hospital, which

means that cost per case tends to be higher. And when you’re

smaller, that means your �nancial position is less predictable,

which makes long-range planning and contingency planning

dif�cult.

2. What are some of the major patient care
concerns for SHH?

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Considering the constraints we have as a rural hospital, I’m

proud of the care we’re able to provide. But there’s serious

room for improvement. Like many hospitals, one of our biggest

problems is turnover. It’s very challenging to get talent to come

to a community like this one and stay, especially when we can’t

compete �nancially with the pay in larger cities. It’s a brain

drain. We’ve had a heck of a time retaining doctors—they come

here, get some experience, and move to a bigger city at a

hospital that can pay more. Or if they want to stay in the

general area, they wait for something to open up at Valley City

Regional Hospital, or in Fargo. Turnover de�nitely impacts

patient care, as does our ability to �nd new talented people.

3. What are some particular challenges with
the population of this area that relate to your
ability to achieve Triple Aim outcomes?

One of our biggest problems is that this population is not

getting the preventative care it needs. Part of that has to do

with income. Part of that has to do with education—this isn’t

the most educated population, and that demographic tends to

know less about health care and use preventative services less

often. But a lot of it has to do with geography. For a lot of

people, going to a doctor or a specialist means driving to Fargo,

which is an hour away. An hour drive might not seem like a big

deal, but for an older person who doesn’t drive much anymore,

or someone who doesn’t have access to a vehicle because of

poverty? That hour is a real barrier to care. And there are a lot

of family farmers in this area, and they can’t drive for an hour,

go to a time-consuming trip to the doctor, and then drive for an

hour back, because they literally can’t get away from the farm

for that long. They have time-sensitive chores like milking the

cows, and �nding someone else to do these chores might be an

expense they can’t afford. And frankly, some of our patients are

simply stubborn, old guys who won’t go to the doctor because

they’re too self-reliant. They refuse to go to the doctor when

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they think they can take care of things themselves—which is

�ne if they have a minor cut, but it’s not �ne when they have

undiagnosed diabetes.

Courtney Donovan
Emergency Room Doctor

1. What are some of the major patient care
concerns for SHH?

Older equipment is a huge problem here. We de�nitely see that

in the ER. We can’t afford state-of-the-art equipment here. In

fact, we often can’t afford new equipment at all, so we wind up

pumping money into �xing the older stuff as best as we can.

The building itself really could use some work too. The hospital

rooms get really cold, and we wind up eating up a lot of money

on heat—and it’s still cold! I mean, this is North Dakota, right?

Basic problems like room temperature can really impact patient

experience. I mean, nobody expects this place to be a luxury

hotel, but if the rooms aren’t warm and comfortable, people are

going to be very unhappy.

We’re also struggling with patient wait times. We’re often

understaffed because it’s so hard to retain people at a rural

hospital, but the demand on the hospital is increasing—for a

number of reasons. For one thing, the population is older, and

that means more trips to the hospital per person. On top of

that, there are more people with access to medical care than

ever before—which is a wonderful thing, except that we

haven’t been able to increase our budget to the level we need

to accommodate that increased demand. I know the care

coordinators have been dealing with those issues as well. I’m

so glad they hired you, because I know the current care

coordination team has had a dif�cult time keeping up with their

workload! Many of our patients have lots of barriers to care

and complicated needs, and it’s time-consuming for care

coordinators to work with them effectively.

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2. What are some of the major cost concerns
for SHH?

Well, that over-reliance on the emergency room is very

expensive for the hospital! We see people in here all the time

with issues like uncontrolled diabetes, or infections that could

have been cleared up with antibiotics. You know—issues that

could have been addressed with a primary physician? Or we

get people coming into the ER with advanced cancer that they

could have caught early. Just a few days ago we had a 65-

year-old man in here with a form of colorectal cancer that

would have been highly treatable if we’d caught it early. But

this man has never had a colonoscopy. That’s the kind of

heartbreaking thing we see all the time here—and in addition

to the human tragedy of this, it escalates costs. The people in

this community need preventative care!

3. What are some particular challenges with
the population of this area that relate to your
ability to achieve Triple Aim outcomes?

The biggest challenge is simply that the population is older.

That’s what happens in rural communities like this. Younger

people move away—especially when there’s a decent sized

city like Fargo an hour from here. So we have a huge

population of older people here who don’t have younger

relatives to help them out. And the majority of older people

here are on very modest incomes. When you’re thinking about

updating the care coordination process, you should de�nitely

think about how care coordinators can better serve the elderly

population. I know they’re not always getting the follow-up

care they need because of barriers to care. And I also know

that falls are a real problem. I can’t even tell you how many

elderly people we’ve had in here because they’ve fallen. That’s

always dangerous for an older person, but it’s worse for older

folks who live alone in isolated areas and who don’t always

have frequent contact with people who check on them. A few

months ago we had a 90-year-old woman who was alone on

the �oor of her kitchen for almost two days before her daughter

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found her! She was lucky to be alive. These kinds of issues for

rural elderly people are ones that I’d like to see care

coordinators address more.

Sarah Kealey
Nurse Practitioner, Southwest
Medical Center

1. Can you tell me about the people you see in
your clinic?

Well, it’s funny you should ask me. I’m actually from

Minneapolis and married my way into this community—I fell in

love with a turkey farmer! So I think I have a lot of perspective

on the population here because I’m an outsider. And you know

for the most part, I really like the people in this community.

They’re kind of rugged… very German and Norwegian at heart.

They don’t like to go to the doctor unless it’s an emergency—

they see it as an unnecessary expense, especially because

money is pretty tight for a lot of the folks around here. We try

to build relationships with them so that they like and trust us,

but that’s a challenge. There’s been a lot of turnover at this

clinic, unfortunately, and they don’t like that—but you know

how it goes. Retaining medical professionals in a rural area

isn’t easy. I guess you could say that going to the doctor and

getting preventative care just isn’t part of the culture here?

People just didn’t grow up going to the doctor every year to go

for a checkup, and now that they’re older and they really need

regular appointments, they don’t get them. But it’s also part of

the culture out her for people to help each other out, and that’s

really nice. When someone is sick, people line up with

casseroles. They might not get the medical attention they need,

but at least they have some chicken tetrazzini!

Oh, and another thing I should mention about the population in

this area…there are a lot of returning vets who served in

Afghanistan and Iraq. There aren’t a lot of jobs for young

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people around here, so a lot of high school grads go into the

military. And a lot of them have come back with post-traumatic

stress disorder. If you look at the Barnes County Community

Health pro�le, you’ll see that suicide rates are higher than you

might expect? That’s mostly because of PTSD. And that’s really

awful. We see some of those people in our clinic sometimes…

the fact that we’re in the middle of nowhere is actually helpful

for PTSD patients, since a lot of them have anxiety around

crowds and would rather come here than the hospital. I wish

the hospital would do more to help out with that!

2. What are some of the biggest challenges
you face at your clinic?

Geography. People just can’t get here! We have a pretty decent

facility as far as middle-of-nowhere clinics go, but we’re a

good 20 miles from Valley City. A lot of our older patients don’t

drive anymore, or they only drive to a few familiar places. And

if they need a specialist, that usually means driving to Fargo,

which is an hour away—or even further to Minneapolis, since

Fargo isn’t exactly a health care mecca. I don’t think the care

coordination process at the hospital takes that into account

enough. Like…here’s a good example. There’s a woman in her

eighties who lives on a farm out here who has a heart

condition. She was hospitalized, and the care coordinator gave

her instructions to come to our clinic four times a week for a

blood pressure check. I guess the care coordinator thought that

wasn’t a big deal because they only live about �ve miles from

here. But the thing is, this woman and her husband own an

older vehicle that’s not good in the snow. So she doesn’t feel

comfortable driving to the clinic when it’s snowy out—I mean,

it’s not like they plow the roads around here, other than the

main ones. And on top of that, she’s very forgetful. So she

didn’t come to the clinic very often and wound up back in the

hospital. Care coordinators need to come up with better plans

for helping people like this. I don’t know why they don’t call up

the churches around here and ask for help. There’s a lot of nice

people who would be perfectly happy to give an old lady a ride

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to the clinic a few times a week. Someone just has to organize

that. Or in this particular case, they could have just sent her

home with a blood pressure monitor. I don’t know why nobody

thought of that.

3. Do you have any other suggestions for how
SHH could better serve the patients out here?

I wish the hospital would invest in telehealth or mobile health

options. There’s been talk about telehealth, but the hospital

hasn’t followed up on that yet. Telehealth for mental health

would especially help with PTSD, since some of those patients

don’t like to leave home. I also think we could use telehealth to

help with issues that otherwise tend to escalate to the ER. For

example, I had a man in here with a bad cut that had gotten

infected. I had to send him to the ER. He didn’t want to see a

doctor about the cut, so he kept trying to treat it himself until it

got so bad that amputation is actually a possibility. If he could

have contacted a health professional remotely, then maybe he

could have gotten instructions of how to treat the cut properly

—or maybe someone could have looked at the cut remotely

and told him that he needed to go to the clinic right away. And

there’s so many things we could do with mobile care—maybe

even mobile mammogram units? If you look at the Barnes

County data, you’ll see that one of our biggest problems is that

women aren’t going to the doctor for Pap smears and

mammograms. We could really use a mammogram mobile.

Floyd Knutson
Mayor of Valley City

1. Can you tell me a little bit about the people
in this community?

Oh, Valley City’s a great place to live. I’ve lived here all my life

and I’ve been the mayor for 36 years now! I’m a lucky guy.

People come from all over the state to see our beautiful bridges

and the Sheyenne River Valley Scenic Byway. The people here

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are terri�c. Very helpful. Very self-reliant. People don’t like to

take advantage of government services around here unless

they really have to. I guess the same applies to health care? I

know I’m a stubborn old mule when it comes to the doctor. I

only go if my wife nags me enough!

2. What are the biggest problems around
here that have to do with health care?

Well, we have a lot of us old folks around here. There are a lot

of falls. That’s an issue that hits close to home for me. My sister

passed away recently after she broke her hip. She was

reaching for something on a high shelf. That happens way too

much around here. Like I said, we pride ourselves on being self-

reliant, but maybe we need to do a better job looking in on

people like my sister. And we also have to do a better job

looking in on our boys who fought in Iraq and Afghanistan. We

have a lot of them here and some of them aren’t doing so well.

Depression, suicide, that sort of thing. It’s a darned shame.

Those boys fought for our country and they deserve our help.

3. What changes can we make at Sacred
Heart that would bene�t this community?

Oh, gosh, the wait time in the ER is so long. I was there with my

wife because she broke her �nger—nothing too serious, mind

you, but it hurt like a bear—and we were there for hours. I

guess that’s because people are going to the ER because they

let minor health problems go for too long. And then we had to

go to Fargo to a specialist because they didn’t have the right

equipment at the hospital here. The hospital needs to update

their equipment. I know that those sort of things cost money,

and I for one do not want to raise taxes around here. But

maybe we could spend a little more money so that patients

have a nicer experience in the hospital? I hear a lot of people

complaining—they have to wait a long time, the paint is

chipping, the heat is broken, stuff like that.

Mary Loudsinger

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Social Worker, Sacred Heart Hospital

1. What are some of the major patient care
concerns for SHH?

I think we’re not doing a good enough job meeting the speci�c

needs of this community. There’s a lot of turnover at the

hospital—I guess a lot of rural hospitals have that problem—

and one problem that creates is that the people in the hospital

don’t know the population well enough. They treat patients

here the same way they would treat patients in Minneapolis or

some larger community, and that doesn’t work. And to be

completely honest with you… well, a lot of patients think that

the hospital staff is talking down to them. A lot of our patients

are farmers or mechanics, or they’re in the military, and most of

them don’t have a college education. And we get these doctors

and nurses from out of the area who are here to get some

experience and move on—and they don’t always treat our

patients with the respect they deserve. And even when

hospital staff is respectful, I think they don’t always pay

enough attention to the health care needs of this particular

community. They need to understand that there’s just not an

established norm around here for getting preventative care,

and that a lot of people have real obstacles that make it

dif�cult to get to specialists in Fargo or even just to the local

clinics.

2. What are some of the major cost concerns
for SHH?

There’s a lot of cost associated with readmission rates. We get

people back in the hospital because they don’t follow the care

coordinators’ instructions. I hear a lot of venting about this in

the hospital, and the tendency is to blame the patients for

failing to follow through. And there’s something to that—I

mean, it really is frustrating when patients don’t take care of

themselves–but I think we also need to look at how care

coordinators can do a better job so that patients can follow

instructions. Some of that has to do with addressing barriers to

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care–like working with churches and community organizations

to make sure older people have a ride to the doctor, or helping

people �nd ways to pay for their medication. And some of that

is just developing better relationships with patients so that they

trust the people who are giving them instructions about their

care. I think we all need to take the time to �gure out what

each patient speci�cally needs before we try to send them

home with a care plan. I know we de�nitely don’t do a good job

of taking cultural considerations into account. Obviously this

isn’t a very diverse area, but we do get people in here who

have last names other than Johnson and Nelson! And

unfortunately our staff doesn’t always have enough experience

to help them. Like, I recently met with an older Vietnamese

woman who lives in this area.

3. What are some particular challenges with
this area’s population that relate to your
ability to achieve Triple Aim outcomes?

It’s really hard getting people around here to get the

preventative care they need. There’s a lot of reasons for that,

including cost. But some of it is that going to the doctor just

isn’t something people do around here. People are very self-

reliant. They’d rather take the time to stock their �rst aid kits

than to get a check-up. So if you look at the Barnes County

Community Pro�le, the numbers for things like Pap smears and

mammograms are really low. It’s going to be dif�cult to achieve

Triple Aim outcomes with numbers that are that low.

Bob Van Ness
Home Care Liaison

1. What are some of SHH’s major patient
care concerns?

Getting patients the home health care they need is really tough.

Part of the challenge is helping people pay for their home care,

and that’s a big part of what I do—helping people navigate

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their way through Medicare and insurance, or �nding them

alternative resources if they need it. The hardest part, though,

is that there aren’t enough home health care resources in this

part of the state for the aging population. That means that

people who really need care right away get waitlisted, or they

can only have someone come to their homes a few times a

week when they really need more than that. Unfortunately, this

is the kind of region where we need more home health care,

not less, because the population is older and because

transportation is harder for people in rural areas.

We also don’t have nearly enough assisted living or nursing

home care in this area—or hospice either, for that matter—

which means that people who really need assisted living either

have to leave their community and move to Fargo, or they stay

at home. That means we have to get creative, like making sure

there’s a relative who can look in on someone to �ll in care

gaps, or someone from the neighborhood or a church. Or

sometimes it means calling to check on people ourselves. All of

that is time-consuming and less than ideal, but we really do

have to make do. I think that the care coordinators need to be

more aware of this home health care gap and put more effort

into helping to �ll that gap. I do what I can, but I’m just one

person.

2. What are some of SHH’s major cost
concerns ?

Well, what do you think happens when people don’t get the

home health care they need? They wind up back at the

hospital! I can’t even tell you how many older people get sent to

the hospital with injuries related to falls. We can’t prevent all of

that, but we could de�nitely cut that down with better home

health care. I don’t think this will ever happen, but I think the

hospital could save a lot of money if they opened an adjacent

facility – maybe in partnership with Valley City Regional

Hospital – that offered nursing home care, and possibly

assisted living and hospice as well. Then we’d have a place to

send people who really shouldn’t be at home.

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3. What are some particular challenges with
this area’s population that relate to your
ability to achieve Triple Aim outcomes?

I’ve already talked about some of the challenges of our older

population. They don’t have a lot of money, they live in remote

areas, and we don’t have enough health care resources for

them in the community. But another population I’m concerned

about are returning vets. I don’t know if anyone else is

particularly concerned about these guys, but I’m a vet myself. I

served in Iraq, and I count myself lucky that I came back

healthy both physically and mentally. Injured vets have home

health care needs too, and we don’t even have the resources in

the community to provide for older folks’ home health care

needs, never mind a population that people don’t think of as

needing that kind of care. And on top of that, we have many

returning vets in this area who are depressed and who

sometimes take their lives. That’s a hard population to reach

before it’s too late, because there’s such a stigma associated

with mental health care for a lot of them. I don’t think we can

achieve Triple Aim outcomes until we make sure the vets in this

area are taken care of better.

Ned Walsh
Barnes Community Health
Department Director

1. What do you think are this community’s
most serious health care needs?

People aren’t getting preventative care and seeing primary

physicians on a regular basis. Did you look at the Barnes

County Community Health Pro�le? About one in four people

don’t have a regular primary physician, and I know that even

the people who do have a primary physician don’t often go for

an annual checkup. Only one out of four people have gotten a

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cholesterol test in the last �ve years. More than half of people

over 50 have never had a colonoscopy. Too many women are

not getting Pap smears and mammograms.

There are a lot of reasons for this. For one thing, there just

aren’t enough providers in the area. Physicians’ of�ces have

long waiting periods. And of course, cost is an issue, as is

transportation for some residents. But part of it is that many

people just aren’t educated about the importance of health

care, and especially preventative care. It’s not the culture of

what people do around here.

2. How can SHH do a better job serving this
community?

I think Sacred Heart could do a better job working with the

community. They need better partnerships with the local clinics

and the health department. They also need to be integrated

better with informal networks of care—like churches and

schools, and other community organizations that can help

people out with health care needs. In a small community like

this one, care coordinators should be able to call upon those

informal networks for help. I think we could have programs in

places like churches to teach people about health care, or even

to do screenings—and we ask places like churches to help

people get to their appointments and things like that.

3. What are some ways the Valley City Health
Department could partner with the hospital
to help achieve Triple Aim outcomes?

I would love to see the hospital and the health department

come together for public health initiatives to promote

preventative care, that emphasize the importance of seeing a

primary care physician on a regular basis. These things are in

the best interests of patients, of course, but they’re also in the

hospital’s best interests because they drive down costs. If we

could get people to go to the doctor when they’re sick, then

they wouldn’t be going to the emergency room for expensive

care. We could partner with schools as well to help kids learn

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about nutrition and healthy eating habits. Obesity levels are

high in this area. I don’t have statistics about childhood obesity,

but my sense is that it’s pretty high around here. That’s an area

where we could work together. And I’m sure there are creative

ways that care coordinators could team up with the public

health department to help meet patients’ needs better. For one

thing, we could be more involved in helping coordinators and

patients �nd the resources they need.

Trish Walstrom
Care Coordination Manager

1. What could care coordinators do better
that would help control costs?

We absolutely need to get readmission rates under control.

People are coming back to the hospital way too often because

they’re not following the care instructions that we’re sending

them home with—and I know that costs the hospital a fortune.

And it’s tempting to blame the patients for not following

through. I know I hear a lot of venting about this, and some of

that is justi�ed—I mean, we have some stubborn old people

around here that just refuse to go to the doctor and think they

can solve their problems by themselves! But I have to keep

reminding myself and my staff that venting does nothing to

control costs.

We also need to �nd ways to update our care coordination

process so that people follow through as instructed. That

means we have to do a lot of things differently. First of all, we

have to make sure patients understand the instructions we’re

giving them. Then we have to take the time to make follow-up

calls with patients to make sure they’re doing what we told

them to do, and help them problem-solve if they’re running into

any problems. Follow-up calls just are not a part of our process,

mostly because we’re just so busy. And that has to change. We

have to prioritize follow-up calls or people are going to

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continue to end up back in the hospital. In addition, I think we

need to better address barriers to care—cost, transportation,

and whatever it is that’s keeping people from taking care of

themselves. It’s a huge problem that there aren’t a lot of

specialists around here. We need to �nd ways to help people

get to Fargo who don’t have the time or the money or the

vehicle to get there—because that’s where the specialists are.

2. What could care coordinators do better
that would help improve patient care?

Frankly, I think we need to build up a better sense of trust with

our patients. We have so much turnover at the hospital, so they

don’t know us. They know me, because I’ve been here a long

time, but I’m the exception—and I’m often supervising and not

working directly with patients. In a small community like this

one, trust is essential. If we tell a patient she needs to get a

follow-up test done, she needs to believe we have her best

interests in mind—and she needs to know we know what

we’re talking about. Maybe that means more community

outreach? If the people in this community felt like they knew us

better, they would feel more comfortable at the hospital.

3. What are some particular challenges with
the population of this area that relates to
your ability to achieve Triple Aim outcomes–
and to be effective care coordinators?

You know, there are a lot of challenges, but there’s one that

kind of creates them all: Nobody in the process sees

themselves as part of a bigger picture. The health care

department, the patients, us, the churches – we’re all doing our

own thing and seeing only our own turf, and the whole idea of

working together seems like a huge leap. But unless we get

creative about working together, none of those individual

factors will ever get solved. There are always going to be

transportation issues and self-reliant, stubborn older folks in a

place like this. The question is, how can we get creative so that

those things – which aren’t going to change – don’t stand in the

way of our attempts to change for Triple Aim?

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Email Response

Email from Karen
Review Karen’s latest message to you and send a reply with

your initial thoughts on what Sacred Heart Hospital needs to

do to achieve Triple Aim Outcomes.

From: Karen Dellington, Admissions and Discharge Director

Subject: Triple Aim Outcomes

Thank you for conducting emails with individuals from the

hospital and the community! You should now have the

information you need to create a Power Point presentation

outlining a strategy to achieve Triple Aim Outcomes at Sacred

Heart. Remember, as you create your presentation, you will

also want to draw upon the data in the Barnes County

Community Health Pro�le.

In the meantime, could you please email your initial thoughts

about strategies for achieving Triple Aim?

Thank you for all your hard work!

–Karen

Your Email Response:
You are welcome

Conclusion

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You have completed the Vila Health: Triple Aim
outcomes challenge. You should now be able to
complete a PowerPoint presentation in which you
present your ideas for improving the care
coordination process at SHH and support the
effort to achieve Triple Aim outcomes. If you do
not feel you have enough information to write this
report, click Try Again and interview more
individuals in Valley City who may have more
information to help you.

Develop strategies for modifying a hospital’s care

coordination process in order to achieve the Triple Aim.

Analyze population data in order to develop strategies for

achieving the Triple Aim.

Interview stakeholders in order to develop strategies for

achieving the Triple Aim.

Licensed under a Creative Commons Attribution 3.0 License

(https://creativecommons.org/licenses/by-nc-nd/3.0/)