ASPIRE to Transform Care Issue 4

TL; DR: Don't skip "design"

Key insight: most teams that are not yet getting results skipped "design"!

Bonus: refresh your design

My laboratory is the healthcare delivery system. I observe, participate in, analyze, and redesign the parts of the healthcare delivery system that are involved in producing or avoiding the most expensive unit of care: a hospitalization.

Early in my career, I designed IHI's strategy to reduce hospital use, taking the state as the unit of intervention. At the time, there were very few ways to even establish a denominator upon which to improve. Given the information and assets available at the time, we determined that the best way to measurably reduce hospitalizations was to start by reducing repeated hospitalizations among those who are already in the hospital!

This approach was population focused from the start. If we want to reduce readmissions, we look at everyone in the hospital today and improve care in ways that anticipate and mitigate the reasons they might return. Identification was possible, making measurement possible. Engagement was possible, making risk identification possible. Engagement-in-context makes person-centered and whole-person risk identification possible. Being person-centered and whole-person makes us recognize the systems issues and the structural and systemic inequities in our healthcare delivery system.

As you read through that approach, you can see the "design" logic:

1. Know your data
2. Know who returns
3. Know why
4. Mitigate those reasons
5. It's the system that produces poor outcomes (not patients, not MD/RNs!)

The STAAR Method preceded and directly informed the ASPIRE Method. When we wrote the ASPIRE Guide we had already had all the benefit of working with state-wide cohorts of hospital-based cross continuum teams in all of the STAAR Initiative states plus 5 years of fieldwork for ARHQ with high-volume Medicaid hospitals in states with high rates of Medicaid readmissions.

For those of you who haven't read the ASPIRE Guide, it is organized according to a "driver diagram" which represents the minimal features needed to produce success. Those 2 features ("primary drivers") are:

1. Design
2. Deliver

Most teams who are working to reduce readmissions and not getting good results have skipped the "design" phase, and went straight to "deliver."

The reason I'm thinking about "design" today is because so many assets are changing, every hospital (accountable team) should take an opportunity to revisit their "design" of their readmission reduction initiative.

Over the past few months, teams I've worked with have added the following meaningful services to their inventory of assets:

• 24/7 virtual urgent care
• 24/7 access to behavioral health crisis line
• 24/7 intake to SUD care (virtual or in person)
• increased access to address HRSN: housing, food, transportation
• access to on-demand transportation through (eg) lyft, uber, etc
• in home post-hospital mobile care transition and SDOH care
• in home in person urgent care
• community paramedicine
• hospital at home
• team-based primary care practice for dedicated population of focus

The "design" phase includes the first 3 parts of ASPIRE:

1. Analyze data
2. Survey internal and external assets
3. Plan a portfolio of strategies

Consider: what internal and external assets have changed in your system/community this year? How do these assets impact your ability to even more successfully reduce readmissions?

If you're working to slow the cycle of the most expensive unit of care, refresh your design and update your inventory of available internal and external assets!