How do we define outcomes and metrics?
A core component of Whole Systems Integrated Care is the concept of outcomes-based commissioning. (Please see Chapter 7: How can we commission integrated care? for more detail on commissioning and governance). The purpose of outcome-based commissioning is to measure outputs rather than inputs. This helps discourage unnecessary activity, supports capitation (where you are not measuring inputs) and encourages innovation (as the solution is not predefined).
Defining outcomes is core to the new approach to commissioning and reimbursing care. After selecting a population group to focus on, commissioners will define outcomes (e.g., quality of life and quality of care) and metrics for a particular population group. Based on this, commissioners and providers will measure and track these commissioner-defined metrics.
Commissioners will set targets for each metric to define if the outcomes are being achieved. Providers will come together in networks and form integrated care teams to deliver the model of care that will meet the metric targets set by the commissioners.
Providers will collectively manage the performance of these integrated care teams to ensure that they meet the quality-of-life and quality-of-care outcomes set by the commissioners. To do this, providers also need to track financial sustainability, professional experience and operational performance of their integrated care teams. These can be done through "service standards”, audits and surveys.
When deciding which outcomes to focus on, commissioners and providers will need to think across the five domains mentioned above. As a pre-step commissioners should know which population group they are setting outcomes for. For more information on choosing a population group, see Chapter 4: What population groups do we want to include?
Different stakeholders have different roles in the system and metrics should be set accordingly. However, the specific outcomes and metrics at all levels should be aligned and should support each other. For example, if the commissioners want people to achieve personal goals as an outcome, metrics that the provider networks and individual care professionals’ measure could be percentage of individual care plans that are co-created with service users or number of service users achieving personal goals. This way the whole system is working in the same direction.
The table below shows some suggested outcomes and metrics across the five domains. These are directly adapted from the frameworks that we considered. Commissioners and providers should use these as a guide to choose the outcomes on which they want to focus.
The above outcomes and metrics are only a selection of examples. Commissioners and providers will need to choose specific outcomes and metrics for their own locality, which will be tailored to local dynamics and influenced by current outcomes, their aspirations for their population and implementation capability.
Different population groups will have different needs, and therefore success in their care will be defined differently. Outcome measures can be either subjective or objective, and both are equally important when thinking about the needs of the different groups. We need to make sure that for every outcome, we are thinking about metrics that cover the spectrum from objective to subjective.
Objective outcomes are outcomes and metrics that are predetermined and able to be measured in a consistent way. These include things like HbA1C levels for people with diabetes, or number of days spent at home for frail elderly populations. Subjective outcomes are things that are measured in personal terms by each individual receiving care. These include things like service user satisfaction with their services, how independent people feel and how supported people feel by their care. It is usually only possible to get subjective measures through methods that directly interact with service users and their carers, such as surveys and interviews.
This section will provide some examples for commissioners and providers to start thinking about how outcomes could differ across the different groups. The exhibit below can be used as a discussion starter on which outcomes are most important for which groups.
- Which outcomes and metrics should your organisation focus on?
VALUE BASED HEALTH-CARE IN CAMDEN
Camden is a diverse and vibrant population of over 250,000 which face challenges.
- Health inequalities: Life expectancy gap is 11.6 years in men
- Elderly population: By 2017 over 85s will increase to 35% and by 2021 dementia prevalence will increase to over 25%
- Mental health: Second highest prevalence of long term mental health needs in England
- Outcomes: Above average results related to preventing people dying prematurely and below average for helping people recover and living with illness
- Value: 2nd highest spend per weighted population of London CCGs with variable outcomes and highest spend on acute in London.
Amidst these challenges, Camden has adopted an ambitious strategy to transforming care for the frail and elderly through system-wide integrated case management, placing patients and their carers at the centre of care delivery.
Co-design and co-production are at the heart of the partnership approach with providers and residents and they have adopted innovative outcome measures.
IMPACT ACHIEVED FOR THE FRAIL AND ELDERLY
Outcome measure: Number of days spent at home/not spent in hospital
- 7.08% improvement in number of days spent at home in cohort (n=93) 6 months post case management
In addition, significant impact had been achieved in other metrics:
- 51.8% reduction in emergency bed-days
- 47.7% reduction in A+E attendances
- 32.9% reduction in 1st/FU out-patient appointments
Excellent value has been generated for both the individual as well as the System
Mrs A who is a 78 year old woman had multiple hospital admissions in the last year as a result of her long-term conditions. She is the main carer for her husband who has undiagnosed dementia. Her annual cost was £9,100.
Since the programme started, assessment and care planning by MDT stabilised Mrs A’s condition and included a referral to the memory clinic for the couple. Mrs A has not been to hospital since the care plan was initiated. Her estimated annual cost is now £3,600.
Source: King’s fund, ICHP Board Seminar 6th March 2014