Achieving the Triple Aim: Linking Clinical Health Services and Public Health to Improve Outcomes & Costs

Topic Overview

A promising strategy for controlling the costs of health care (and entitlement spending for Medicare/Medicaid) is to address the so-called “super-utilizers”, Americans with multiple chronic health conditions and social needs who account disproportionately for health care costs in the United States.

Presenters at this briefing will show how researchers are using “hot spotting” to locate the areas in which such patients live and the leading diagnoses responsible for their admissions. Often it is the lack of health-promoting resources in their home and neighborhood environments (what some call “cold spots”) that is at the root of their illnesses. Many hospitals are finding business arguments for investing in community-based solutions to reduce admissions and demands on the health care systems.

Public health systems in many localities are testing solutions such as integrating primary care with public health interventions and building partnerships with businesses, schools, and community and faith-based organizations to work collectively to improve health outcomes. Presenters will highlight policies that support public health systems and hospitals in implementing solutions that link health care with other sectors such as housing and education to decrease the rates of chronic disease and reduce health care spending.


Steven Woolf, MD, MPH

Dr. Stephen Woolf serves as director of the Center on Society and Health and is a professor of Family Medicine and Population Health, both at Virginia Commonwealth University. has published more than 150 articles in a career that has focused on promoting the most effective health care services and on advocating the importance of health promotion and disease prevention.  In recent years, his work has turned to social determinants of health.  

Forum Briefing: Achieving the Triple Aim(9 page PDF)


Chris Allen, FACHE

Chris Allen, the first Executive Director of the Detroit Wayne County Health Authority, has health care and hospital administration expertise that spans more than 35 years. Mr. Allen pioneered the award-winning Family Road Program, providing prenatal and health education services to more than 184,000 young mothers throughout the City of Detroit. 

Panel Presentation: Health Re-Imagined(18 page PDF)

Nick Macchione, MS, FACHE, MPH

With 26 years’ experience in the delivery, management and policy of health and human services, Nick Macchione serves as San Diego County’s Director of the Health and Human Services Agency. He is a Public Health Leadership Scholar Alumni with the federal Centers for Disease Control and Prevention and a Creating Healthier Communities Fellow Alumni with the American Hospital Association’s Health Forum.  In addition, for the past 13 years he has been an active faculty member at San Diego State University (SDSU) in the Graduate School of Public Health teaching both graduate and undergraduate courses in health care and executive management.  

Panel Presentation: Achieving Population-Based Health and Social Well-Being(20 page PDF)

Katherine Neuhausen, MD, MPH

Dr. Katherine Neuhausen is the Associate Director in the Office of Health Innovation and an Assistant Professor in the Department of Family Medicine and Population Health at Virginia Commonwealth University.  She conducts research on the geographic “hot spots” with the highest health care costs in Richmond and on the health care costs associated with mental illness and substance abuse.  She is also the Director of Integrated Care Initiatives and Medicaid Innovation for Virginia’s State Innovation Model design award from the Center for Medicare and Medicaid Innovation.  

Panel Presentation: Achieving the Triple Aim in Richmond(13 page PDF)


Monica Feit, PhD., MPH

Monica Feit joined the Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation in 2013. She currently directs the Public Health Services Division in the Office of Health Policy. Prior to joining ASPE she served as a senior program officer at the Institute of Medicine where she directed health policy studies on a variety of topics including the integration of public health and primary care, developing a research agenda on LGBT populations, and surveying the science of child abuse and neglect.