S224 - Day 1 - 1200 - Outcome measures in person centred co-ordinated care, what are we measuring

Outcome measures in person-centred careWhat are we measuring and why?

Dr Alf CollinsClinical Associate in Person-Centred Care

The Health Foundation

Dorothy

Dorothy is 79 and was recently widowed- she now lives alone and life is a struggle. Her knees are playing up- she is seeing a surgeon next month to discuss an operation. She is worried about that- her diabetes hasn't been good for a year or two and her doctor has recently told her that her smokers cough is more serious and is something called 'COPD'. All in all, she is feeling quite low; maybe she should talk to someone? Maybe she should even think about moving home- even the stairs are a struggle now.

1. How do we make sure thatthe system puts Dorothy first? In everything it does? Always?

2. What is the system trying to achieve?

If the system is (primarily) trying to:

• Manage HbA1c in its population of diabetics• Reduce unscheduled hospital admissions• Reduce length of stay for people with LTCs

It won’t necessarily put Dorothy first

Our system. The House of Care

Engaged,

informed patients

HC

Ps com

mitted to

partnership working

Organisationalprocesses

Responsive commissioning

Accurate contact details

IT: clinical record of care planning

Know your population

Test results and agenda setting

Consultation skills and attitudes

Integrated, multi-disciplinary team

and expertise

Senior buy-in and local champions

Prepared for consultation

Information and structured education

Emotional and psychological

support

Develop market to meet current and future needs

Identify needs, map resources

Quality assure and monitor

Establish and publicise menu of care

Ensure time for consultations, training and IT

Collaborative care and support planning

Successful systemsPrinciples, activities and purpose

• Focus on purpose (the outcome they are trying to achieve)

• Put in place processes (activities) to deliver on outcome

• Underlying the processes are principles; propositions that serve as foundations for a chain of reasoning

Successful systems

Principles Processes Purpose

Successful measurement systems

PrinciplesProcess

MeasuresOutcomeMeasures

Successful measurement systems:

• Focus on purpose (‘why measure?’)– Insight– Improvement– Assessment– Judgment

• Are parsimonious (fewest possible number of indicators- especially outcome indicators)

• Are coherent (indicators logically relate to each other)

High quality systems demonstrate process reliability

Outcome

Process 1

Process 2

Process 3

Measurement coherence

Outcomemeasure

Process measure 1

Process measure 2

Process measure 3

What are the principles of person-centred care?

Dorothy should always be treated with dignity, respect and compassion

Dignity, respect, compassion

She should also experience co-ordinated treatment, care or support

Dignity, respect, compassion

Co-ordination

She should also experience personalised treatment, care or support

Dignity, respect, compassion

Co-ordination

Personalisation

She should also experience enabling treatment, care or support

Dignity, respect, compassion

Co-ordination

Personalisation Enablement

Principles• Compassionate• Co-ordinated• Personalised• Enabling

Collaborative care and support planning

Outcome

What is our outcome?

Care plans and care planning

Care plans- outputs not outcomes

A primary assumption:Self management is usual care

Hours with NHS / social care professional = 3 in a year

Self management = 8757 in a year

The system should support Dorothy to develop the knowledge, skills and confidence to manage her own health

Measures of knowledge, skills and confidence to manage own health

• Unidimensional– Patient Activation Measure (PAM). 13 items

• Multidimensional– Health Literacy Survey for Europe Questionnaire

(HLS-EU-Q). 47 items. – Health Literacy Questionnaire (HLQ). 44 items– Health Education Impact Questionnaire (heiQ). 42

items

All are stable and reliable with high construct and face validity

Questions: Practical utility and predictive power

Patient activation measure: useful and predictive

• Unidimensional (ie measures a single concept)• Developmental (ie appropriate interventions

can support people to progress on a journey of activation)

• Knowledge, skills and confidence to self manage• 13 items• Score out of 100• 4 levels

7% of population

14% of population

21% of the population has low or no confidence to self manage

People at low levels of activation tend to:

• Feel overwhelmed with the task of managing their health

• Have low confidence in their ability to have a positive impact on their health

• Not understand their role in the care process• Have limited problem solving skills• Have had a great deal of experience with failure in

trying to manage, and have become passive with regard to their health

• Say they would rather not think about their health

As compared to people at low levels of activation, people at higher levels tend to:

• ‘Be engaged’– Come prepared– Ask questions– Make decisions– Have less unmet needs (nb inequalities)

• Have improved clinical outcomes (including mental health)

• Enjoy an improved quality of life • Use less healthcare resource• Feel satisfied at workWhy Does Patient Activation Matter? An Examination of the Relationships Between Patient Activation and Health-Related Outcomes. Jessica Greene and Judith H. Hibbard Journal of General Internal Medicine, published online Nov. 30, 2011

People with Lower Activation Associated with Higher Costs; Delivery Systems Should Know Their Patients’

‘Scores’

Tailored interventions can support people on their journey of activation

Thus tailored interventions improve all other ‘downstream’ indicators

Uses of patient activation measure

Segmentation• Target resources• Use resources

more effectively

Tailored coaching• Start where

people are• Personalise

support

Programme assessment• Quality assure

interventions• Improve quality of

interventions

Predictive modelling• More

sophisticated understanding of drivers of risk

Integration: a means to an end

integration Co-ordination Activation

The enabling process of scheduled collaborative care and support planning

PREPARATION

Professional Agenda

Personal Agenda

Follow upPersonal GoalsNegotiated agenda

Output= care planOutcome= activation

Downside is licencing

NHSE in active negotiation with licence holders (Insignia)

NHSE PAM learning setContact me:

alf_collins@hotmail.com

Launch of Kings Fund Monograph (Helen Gilburt and Judith Hibbard)May 6th 2014