Transcript Retos de gestion clinica en Atencion Primaria: cronicidad

Measuring performance to support
systems’ integration
Dr Nick Goodwin
CEO, International Foundation for Integrated Care
Senior Associate, The King’s Fund
Paper to Challenging Ideas Seminar Series – Health Performance Reporting
Bureau of Health Information, Civil Pavilion, Chatswood Concourse
8 December 2014
www.integratedcarefoundation.org
International Foundation for Integrated Care
Who are we?
Mission Statement
Our Purpose
•
The International Foundation for
Integrated Care (IFIC) is a network
that crosses organisational and
professional boundaries to bring
people together to advance the
science, knowledge and adoption of
integrated care policy and practice.
The Foundation seeks to achieve this
through the development and
exchange of ideas among academics,
researchers, managers, clinicians,
policy makers and users and carers of
services throughout the World.
•
•
•
To develop a membership network
that provides a central, authoritative,
resource for information and
expertise on integrated care
To advance the study and science of
integrated care
To develop knowledge on the
evidence for, and application of,
successful approaches to integration
To bring people together from a
range of backgrounds to network and
exchange ideas to promote
integrated care
A Typical Problem of Disintegrated Care Systems
The complexity in the way care
systems are designed leads to:
• lack of ‘ownership’ of the
person’s problem;
• lack of involvement of users
and carers in their own care;
• poor communication between
partners in care;
• simultaneous duplication of
tasks and gaps in care;
• treating one condition without
recognising others;
• poor outcomes to person, carer
and the system
Frontier Economics (2012) Enablers and barriers to integrated care and implications for Monitor -
Integrated care is a concept centred around the
needs of service users
‘The
patient’s perspective is at the heart of any
discussion about integrated care. Achieving
integrated care requires those involved with
planning and providing services to ‘impose the
patient’s perspective as the organising principle of
service delivery’
(Shaw et al, 2011, after Lloyd and Wait, 2005)
Who is integrated care for?
• Integrated care is an approach for any individuals where gaps in care,
or poor care co-ordination, leads to an adverse impact on care
experiences and care outcomes.
• Integrated care is best suited to frail older people, to those living
with long-term chronic and mental health illnesses, and to those
with medically complex needs or requiring urgent care.
• Integrated care should not be solely regarded as a response to
managing medical problems, the principles extend to the wider
definition of promoting health and wellbeing
• Integrated care is most effective when it is population-based and
takes into account the holistic needs of patients. Disease-based
approaches ultimately lead to new silos of care.
Integration and Integrated Care
Integration is the combination of processes, methods and tools that
facilitate integrated care.
Integrated care results when the culmination of these processes directly
benefits communities, patients or service users – it is by definition
‘patient-centred’ and ‘population-oriented’
Integrated care may be judged successful if it contributes to better care
experiences; improved care outcomes; delivered more cost-effectively
‘Without integration at various levels [of health systems], all aspects of
health care performance can suffer. Patients get lost, needed services fail
to be delivered, or are delayed, quality and patient satisfaction decline,
and the potential for cost-effectiveness diminishes.’
(Kodner and Spreeuwenburg, 2002, p2)
Key forms of integrated care
• Integrated care between health services, social services and
other care providers (horizontal integration);
• Integrated care across primary, community, hospital and
tertiary care services (vertical integration);
• Integrated care within one sector (e.g. within mental health
services through multi-professional teams or networks);
• Integrated care between preventive and curative services;
• Integrated care between providers and patients to support
shared decision making and self-management;
• Integrated care between public health, population-based and
patient-centred approaches to health care. This is integrated
care at its most ambitious since it focuses on the multiple
needs of whole populations, not just to care groups or
diseases
Source: adapted from International Journal of Integrated Care
The promise of integrated care
The hypothesis for integrated care is
that it can contribute to meeting the
“Triple Aim” goal in health systems
• Improving the user’s care
experience (e.g. satisfaction,
confidence, trust)
• Improving the health of people
and populations (e.g. morbidity,
mortality, quality of life, reduced
hospitalisations)
• Improving the cost-effectiveness
of care systems (e.g. functional
and technical efficiency)
Understanding what aspects of
performance to evaluate
in an integrated care programme
What are you evaluating – some key questions
• Who and what is the programme seeking to influence?
Need to clarify aim and design of the integrated care
intervention by looking at the needs of patients/users
• What is the timeframe over which outcomes are expected
to be achieved?
Given this timeframe, which categories of outcomes have
the potential to be improved?
• Is there sufficient opportunity in a given population to
achieve this targeted improvement in outcomes?
• How can you measure the impact? How can you ensure
attribution?
What are you evaluating – some key questions
Before developing questions and/or survey instruments to
examine the experience and impact of integrated care from a
person’s perspective, there is a need to understand four
things:
 the programme theory of change – what are the
assumptions that lie behind the programme (why?)
 the (set of) problems to be addressed (where and who?)
 the (set of) interventions best suited to address the
problem (what and who?)
 the strategy best suited to develop, implement, and
evaluate the (set of) interventions (how, when and who?)
What are you evaluating – some key questions
For integrated care to be successful, it needs to execute the
following three functions:
 accurate identification of individuals within target
population (e.g. reliable predictive modelling, health risk
assessment, medication list and/or laboratory values from
EMRs);
 individuals must be enrolled and actively participate in the
program for a meaningful period of time (e.g. readiness to
change, motivational interviewing, incentives);
 the program must include a set of interventions that modify
or close deficits in participant and provider behaviour (e.g.
tailoring to needs).
Key Points to Consider
 Baseline data
 Define a comparison group
 Define nature and structure of integrated care being
implemented
 Include measures of the professionals’ perspective where care
is delivered through multidisciplinary teams
 Identify what good looks like from a patients’ perspective and
evaluate this through user feedback
 Include analysis of utilisation and costs of care
Experiences, care outcomes, utilisation & costs
Choosing Quality Measures for Integrated Care- 1
Indicators must be robust and
meaningful:
• Importance and relevance
• Validity
• Accuracy
• Reliability
• Feasibility
• Meaningfulness
• Implications for action
• Avoidance of perverse
incentives
Choosing Quality Measures for Integrated Care - 2
Considerations:
• Population size
• Representativeness
• Attributable
• Change detectible over time
• Unambiguous
• Meaningful to who? – users,
managers, professionals,
politicians
• Timeliness
• Routine data collection
Tin openers or dials
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Concept from Carter and Klein (e.g. 1992)
Tin openers open up cans of worms
Dials measure things
Most of the time you need to ask the right
questions as much as you need to get the right
answers
• If you want to be making robust judgements, the
measures need to be absolutely unambiguous
The dangers of performance measures
• Peter Smith identifies 8 perverse effects
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Unmeasured activity ignored
Reward structure distortive(too easy, too hard, wrong balance)
Discourages practice in challenging environments
Discourages collaborative actions
Gaming
Misrepresentation
Ossification
Increases managerial costs
Undermines professional ethic, morale and unremunerated
activity
Why the dangers?
Bevan and Hood identify four types of player
Type
Characteristics
Saints
public service ethos so high voluntarily disclose shortcomings, their
agenda will be motivated by their intrinsic motivations – external
incentives don’t work if these conflict
Honest triers
Report honestly what they have done, and will endeavour to improve in
response to reported poor performance. Less likely than ‘saints’ to have
an internal drive for improvement, respond to external incentives
Reactive
gamers
Like honest triers, gamers concentrate efforts on services which are
being measured and incentivized. Unlike them their responses will not
always be positive. If it is easier for them to give the appearance of doing
well than actually doing well, will spin or fiddle data
Rational
maniacs
Rational maniacs act entirely in self interest and respond to incentives in
unpredictable ways. In some instances this group will be unethical, even
criminal, in their behaviours. Will manipulate data to conceal their
operations
The lessons for choosing performance
measures
• Be very clear about what incentives you are using
• Think carefully about the perverse incentives and
seek to limit these
• Fear of loss trumps everything (Kahneman)
• Payment systems really do matter
If the existing reward is to be disintegrated, new
incentives to be integrated won’t work
International Drive to Develop
Quality Measures for Integrated Care
Policy reforms to support integrated care have also seen attention placed on
how to develop a set of quality indicators through which to monitor system
performance. For example:
• In New Zealand, the Integrated Performance and Incentive Framework
was drafted in 2013 containing an inventory of measures intended to
support District Health Boards identify and use locally relevant systemlevel measurements indicating progress towards care integration and
improved health and equity for all population groups (HIIRF, 2013)
• In England, a range of generic indicators for measuring the quality of
integrated care has also been developed. This includes 35 specific
indicators across six key domains of quality (Raleigh et al, 2014).
• In the USA, NQF indicators relevant to patient-centered and integrated
care include a range of endorsed measurements of patient centered care
and care coordination (National Quality Forum, 2014),
• In the USA, The AHRQ have also created a framework through which to
assess care co-ordination, including a range of measurement domains
(McDonald et al, 2007)
Care Co-ordination Measures Atlas
McDonald KM, Schultz E, Albin L, Pineda N, Lonhart J, Sundaram V, Smith-Spangler C, Brustrom J, and Malcolm E. Care Coordination Atlas Version
3 AHRQ Publication No.11-0023-EF. Rockville, MD: Agency for Healthcare Research and Quality. November 2010.
http://www.ahrq.gov/qual/careatlas/careatlas.pdf and http://www.ahrq.gov/qual/careatlas/careap4.pdf - 64 different survey tools
Domains for measuring care co-ordination
Co-ordination activity:
Service delivery approaches:
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Establish accountability/negotiate
responsibility
Communication – informational and
inter-personal
Facilitate transitions – e.g. across
settings or as coordination needs
change
Assess multiple needs and goals
Pro-active care planning
Monitor, follow-up, review
Support self-management
Link or refer to community resources
Align resources to meet individual or
community needs
Care management
Medicines management
Healthcare at Home
Multi-disciplinary teams
ICT-enabled integrated care (e.g.
telehealth)
Perspectives:
Family/patient
Professional
System/organisation
Key Domains and Indicators for Integrated Care
 System-level measures of community wellbeing and
population health including reductions in avoidable
deaths for treatable conditions, improved mental
health and wellbeing, and the proportion of
populations engaged in healthy lifestyle behavior;
 Service proxies for improved health outcomes such as
avoidable admissions to hospitals, lengths of hospital
stay, and reductions in adverse events;
 Personal health outcomes to people and communities,
primarily relating to measures of improved quality of
life, remaining independent, and reducing risk factors
to better manage existing health conditions;
Key Domains and Indicators for Integrated Care
 Resource utilization that seeks to describe measures which
demonstrate the reorientation of activities towards primary
and community care, for example in terms of the balance
of financial and human resources;
 Organizational processes and characteristics that support
evidence that systems to support high-quality PCIHS are in
place, for example in improving access to care, care
planning, better care transitions, self-care support, care
management and medications reconciliation;
 User and carer experiences of, for example, shared
decision-making, care planning, communication and
information sharing, and care co-ordination.
Domain 1:
System level
Measures
AREA
EXAMPLES OF POTENTIAL MEASURES
Amenable
Mortality
Numbers of avoidable deaths for treatable conditions, including:

Infections; Cancers; Cardiovascular disease; Diabetes; Injuries; Maternal
and infant conditions [B]
Excess winter deaths [A]
Excess mortality for people with severe mental illness and schizophrenia [D]
Healthy
Lifestyles
Amenable morbidity (obesity) [B]
Proportion of physically active and inactive adults [A], and children
Proportion of the population experiencing positive mental health [B]
Proportion of the population engaged in responsible sexual behavior [B]
Proportion of the population engaged in substance misuse [B]
Proportion of the population engaged in healthy behaviours (composite
measure) [B]
Smoking rates

Smoking status; % of smokers given or referred to cessation support; % of
hospitalized smokers provided with cessation advice; Smoking rates in
people with asthma [B]
Proportion of the population that experience injury [B], including self-harm
Population
Health
Prevalence of mortality for chronic disease [B]
Healthy births – e.g. measured by low birth weight [B]
Vaccination coverage

For influenza in older people [B, D]; For measles in children [D]; For
pertussis in children [D]
Management of skin infections in primary care [B]
Domain 2:
Service Proxies
AREA
EXAMPLES OF POTENTIAL MEASURES
Hospital
Admissions
Numbers of emergency admissions, stratified by age and risk group [A]
Avoidable inpatient activity for people with ambulatory condition sensitive (ACS) admissions
ACS hospital admissions that could have been avoided in both children and adults [B]:

Asthma in older adults [B]; Asthma in young children [B]; Asthma hospital admission
rates [D]

COPD in older adults [B]; COPD hospital admission rates [D]

Heart failure admission rates [B, D]; Angina without procedure admission rates [B]

Hypertension admission rates [B]

Diabetes short-term and long-term complications admission rates [B]; Uncontrolled
diabetes admission rates [B]; Overall diabetes admission rates [D]

Bacterial pneumonia admission rates [B]

UTI admission rates [B]
Acute care hospitalization, risk adjusted [C]; Acute care hospitalization rate for ACS
conditions [H]
Average lengths of stay [B]; Occupied bed days [B]
Hospital
Readmissions
People with multiple admissions to hospital per year by specific age group;
Readmission rates for selected patient groups [A]

Diabetes readmission rate [B]; Heart failure readmission rate [B]; Mental health
readmission rate [B]
Unplanned or unexpected hospital readmissions [B]
Emergency readmissions to hospital within 28 days of discharge [H]
Overall numbers of hospital readmissions [D]
Community
Based Care
Persons discharged from hospital for rehabilitation per 100k of the older population [A]
Deaths after discharge from suicide among people with severe mental disorders [D]
Quality of family planning services:

Informed choice to users

Contraceptive methods mix offered in care facilities [H]
Patient Safety
Reduction in adverse events [B]
Unintended harm from medications in people aged over 65 dispensed with five or more
long-term medications [B]
NSAID use in older people [B]
Domain 3:
Personal Health
Outcomes
AREA
EXAMPLES OF POTENTIAL MEASURES
Quality of life Self-reported quality of life [A]
Carer reported quality of life [A]
Improved mental health status and mood
Independent Proportion of older people (>65) who remain in own home after 91
living
days after discharge from hospital into rehabilitation services [A]
Injuries due to falls in people aged over 65 [A]
Proportion of patients with fragility fractures recovering to their
previous levels of mobility [A]
Improved mobility and independence [EQ5D]
Self
Proportion of people feeling supported to manage their (long term)
management condition [A]
People aged over 65 with more than 8 long-term conditions [B]
Management of risk factors in chronic disease [QOF]:
 Blood glucose and cholesterol control in people with diabetes
 Blood pressure control in people with stroke, TIA, heart disease,
CKD and hypertension
 Diet, nutrition and weight management in under- / over-weight
Domain 4:
Resource
Utilization
AREA
Hospital
utilisation
EXAMPLES OF POTENTIAL MEASURES
Bed days for selected patient types [A]
Hospital use in last 100 days of life [A] ; in last 6 months of life [B]
Residential
and long term
care
utilisation
Residential and nursing care expenditures per 100k older population
Numbers receiving long-term community-based care as a proportion
of total numbers of people receiving long-term care services [A]
Numbers receiving long-term social care as a proportion of the sum of
numbers receiving emergency hospital care and numbers receiving
long term social care [A]
Numbers of people receiving long-term community-based social care
relative to population [A]
Primary care
utilisation
Enrolment in a GP/primary care practice [B]
 for infants in the first 4 weeks of life [B]
Health care
costs
Health care cost per capita [B]
Rational use of finite resources / value for money and effectiveness [B]
GP referred pharmaceutical expenditure [B]
Alignment of resources to population needs [D]
Balance of
care
Ratio of primary care professionals (e.g. GPs) to specialists
Relative spend on primary, community, secondary and tertiary care
Domain 5:
Organisational
Processes 1
AREA
EXAMPLES OF POTENTIAL MEASURES
Access to care
Improved access to primary care services / GPs [A]
Access to health care [B]
- % in general practice [B]; screening [B]; time to access GP or community
services [B]; timely initiation of care [C]; waiting times for urgent treatment –
especially cancer [B]; severe mental health access [B]; waiting times for
elective treatment [B]; waiting time of more than 4 weeks to see a specialist [E]
Hospital use
Attendances at A&E [A]
Attendances at A&E without hospitalization [C]
Acute care hospitalization [C]
Care transitions Delayed transfers of care from hospital [A]
Transition record with specified elements received (hospital to home or any
other site of care) [C]
Timeliness of transition (hospital to home or any other site of care) [C]
Care planning
Holistic needs assessment
Personalized care plans
Advanced care plan [C]
Medications
management
Medication review in older adults [C]
Medications reconciliation [C]
Medications conciliation post-discharge [C]
Domain 5:
Organisational
Processes 2
Care coordination
PHC organizations who currently coordinate patient care with other
health care organizations using protocols [H];
Quality of care processes based on best practice guidelines
 look at integration of care across settings - chart reviews, medical
records [D, F]
Quality of clinical integration and/or co-ordination activities in multiprofessional teams [F]
 various survey methods
Administrative communication [C]
 percentage of patients transferred to another healthcare facility
whose medical documentation indicated that administrative
information was communicated prior to departure
Presence of key co-ordination activities [D]:
 accountable provider or professional with responsibility for care
coordination
 clarity of responsibility
 quality of inter-personal communication/ information transfer
 facilitate transfers across settings
 assess needs and goals with proactive care plans
 monitor, follow-up and respond to change
 support for self-management
 links to community resources – provide information and
guidance on care outside of health system
 multi-disciplinary teams in primary and community care
 home care support
 care management – case management and disease management
 medications management
 ICT enabled care coordination (telehealth)
Domain 6:
User and Carer
Experiences - 1
AREA
EXAMPLES OF POTENTIAL MEASURES
Experiences
Improved people’s experiences of care [A, B]
Patient reported satisfaction with care co-ordination/integrated care [A, D]
The proportion of people who use services who say these services had made
them feel safe and secure [A]
Continuity of
care
Proportion of people who use services who report that they have as much
social contact as they would like [A]
Person or family reports confusion or hassle [4]
Supporting
Proportion of people dying at home or a place of their choosing [A]
holistic goals and Proportion of people with LTCs reporting they had enough support to
outcomes
manage their conditions [A]
Proportion of people who feel confident in managing their own health [A]
People reporting that all their needs were taken into account [G]
People reporting they were supported to achieve my own goals [G]
People reporting that the care they received helped them to live their life to
the best of their ability [G]
Carers and family members needs taken into account [G]
Shared decision Doctor/nurse involving patients in decisions about care and treatment [E]
making
People reporting they could choose the kind of care and support they
needed and how they might receive it [G]
Domain 6:
User and Carer
Experiences - 2
AREA
EXAMPLES OF POTENTIAL MEASURES
Communication Ability and knowledge on who to contact for care, especially when primary
and Information care services are closed [A]
Doctor spending enough time with the patient [E]
Doctor giving easy to understand explanations [E]
Doctor giving time to raise concerns [E]
People reporting that they:
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were always kept informed about what the next steps in their care
would be [G]
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the professionals involved talked to each other and worked as a team
[G]
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knew who was the main person in charge of their care [G]

had one first point of contact [G], who understood the person and their
condition(s) [G]; could go to the care professional with questions at any
time [G]; and get other services and help, and to put everything
together [G]

had the information and support needed in order to remain as
independent as possible [GF];
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see personal health and care records at any time to check what was
going on [G] – ability to decide who to share them with and correct any
mistakes in the information.

information given at the right times, appropriate to person’s condition
and circumstances, easy to understand, and up to date [G]

told about the other services that were available, including local and
national support organisations [G].

not left alone to make sense of information [G]

ability to meet (or phone/email) a professional when needed to ask
more questions or discuss the options [G].
Domain 6:
User and Carer
Experiences - 3
AREA
EXAMPLES OF POTENTIAL MEASURES
Care planning
When being discharged from hospital, was the family or home situation
taking into account when planning discharge [A]
Participation in care planning [E,F]

Knowing what is in the care plan [G]

Care plan entered onto patient record [G]

Regular reviews of care plan [G]

Comprehensive reviews of medicines [G]

Care plan known in advance by professionals when using a new service,
and respected [G]
Care delivery Patients report unnecessary care (e.g. tests, procedures, ER visits and
and transitions hospitalisations) [D]
Patients report gaps in scheduled care – e.g. missed consultations, medical
test, and/or prescribed medications [E]
Clear plan when moving from one service to another [G]
Transitions undertaken without delays [G]
Advance knowledge of care transitions and next steps in care [G]
New service providers knew details of person and their preferences and
circumstances [G]
Entitlements to care protected when moving from one jurisdiction to another
[G]
Emergencies
People reporting they could plan ahead and could stay in control during
emergencies [G]
People reporting they had systems in place so they could get help at an early
stage to avoid a crisis (or crisis escalation) [G]
Some Conclusions on Measuring the
Performance of Integration
 Many different tools available:
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Need to define the client group
Need to understand the goal in terms of outcomes to patients and service users
Need to create ‘measurable’ outcomes and experiences
Measures need to mean something – i.e. that actions can follow
 Patients and users tend to understand the term ‘care co-ordination’ or
‘continuity of care’ – e.g. to what extent they feel that care is co-ordinated
around their needs
 Baseline on measures required on which to base progress over time
 Link measures to other data – e.g. on clinical outcomes, utilisation, costs
 Where possible, benchmark performance with others or investigate with a
matched ‘control’
 Use data in ‘real time’ to monitor progress and drive performance
Contact
Dr Nick Goodwin
CEO, International Foundation for Integrated Care
[email protected]
www.integratedcarefoundation.org