Approaches to measuring outcomes in integrated care

Approaches to Evaluating and Measuring
Outcomes in Integrated Care
Key Issues for Consideration
Dr Nick Goodwin
CEO, International Foundation for Integrated Care
Senior Associate, The King’s Fund
Paper to: Health Quality and Safety Commission New Zealand
Workshop: Towards Integrated Care in New Zealand
Wellington, New Zealand, November 14th 2013
What is a ‘programme evaluation’?
• A systematic method of collecting, analysing and using
information to answer questions about projects, policies or
• In health care systems, they are particularly concerned with
quality of care, patient safety, system efficiency and/or cost
• They also seek to examine whether programme goals are, of
have been, appropriate and/or useful so can be used to
change and adapt strategic directions
• They tend to utilise both qualitative as well as quantitative
• They can be ‘formative’ or ‘summative’
Typical components of a ‘programme evaluation’
• Assessment of the need for the programme
– Needs assessment/gap analysis/population health planning
• Assessment of the design and/or theory and logic of the
programme in supporting its desired influence
– Are the assumptions of the programme justified?
• Assessment of how the programme is being implemented
– Process evaluation - is it going to plan?
• Assessment of the programmes outcome or impact; cost and
– Outcome level, outcome change, programme’s effect
Rossi, Lipsey and Freeman (2004) Evaluation: a systems approach, Sage
Understanding what 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
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
 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
 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
 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
Understanding what to measure
in an integrated care programme
Measurement Types - 1
Care Outcome Measures
 Patient outcomes
– e.g. mortality, morbidity, functional status, quality of life
 Cost and utilisation outcomes
– e.g. hospital admissions, bed days, LOS, nursing home placements
Care Process Measures
 Occurrence of recommended care activities
– e.g. presence of a care plan; patient follow-up – often processes that
are set out in best practice guidance
The measurement tools we have on outcomes and processes are mostly
disease-specific - for people with multiple needs, the process of care is
less well understood
Examples of outcome measures
 Hospital utilisation
– Emergency admissions; hospital readmissions; lengths of stay; number of bed days etc …
– Disease-specific hospital admissions etc …
 ‘Social care’ utilisation
– Levels of home care support packages
– Rates of long-term nursing home/residential home stays
 Mortality and disease-specific mortality
 Short-term clinical outcomes
– e.g., glycated haemoglobin levels for diabetic patients
 Functional status
– e.g., for CHF patients
 Quality of life
– e.g., functional dependence
 Other patient outcomes
– e.g., missed school days for children due to illness; experiences with system
 Treatment and service adherence
– e.g., remaining in contact with services for mentally ill patients
Measurement Types - 2
Measures of care co-ordination
 Information exchanges and transfers
 Relational co-ordination between organisations and professionals
– levels of awareness/interaction among participants
– is there a common understanding of care activities and goals
– shared culture and mission?
Co-ordination Mechanism Measures Approaches
Direct observation
Interviews and staff surveys (self-report)
Medical record audits on information transfer
Measures of inter-professional collaboration within teams and
ITMA - Integrated Team Monitoring and Assessment Tool – see
POET – Partnership Outcomes Evaluation Toolkit – see
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. and - 64 different survey tools
Domains for measuring care co-ordination
Co-ordination activity:
Service delivery approaches:
Establish accountability/negotiate
Communication – informational and
Facilitate transitions – e.g. across
settings or as coordination needs
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.
Measurement Types - 3
Patient, carer, family-reported perceptions
do you feel better?
have your symptoms improved?
recommend to a friend?
how satisfied are you?
 * PACIC patient assessment of chronic illness care
 * Care Transition Measures (CTM) – patient assessment of discharge from
The more ‘robust’ measures are those that ask about specifics of care co-ordination
rather than generalities, and which link data sets together to understand
association between responses. Two key things: measures that are specific to a
particular group of people; measures that translate to actionable service
Patient Reported Outcome Measures in England
Since 2009, PROMs have been collected for
four elective procedures: hip surgery,
knee surgery, hernia repair and varicose
veins – these costs the English NHS
Cataract surgery was to be included, but
concerns on methods of data collection
250,000 patients a year invited to complete
survey – all NHS providers (100%) collect
PROMS being extended to cover: anxiety and
depression, cancer care, asthma, COPD,
diabetes, epilepsy, heart failure, stroke
It’s a careful process – identify the right
PROMs instrument; pilot before roll-out;
implement data collection; evaluate
Uses EQ-5D – part 1 about mobility, selfcare, usual activities, pain/discomfort,
anxiety/depression; part 2 gives overall
assessment of health on 0-100 scale
NOTE: Not sensitive to looking at people
with multiple conditions/needs
Some Conclusions on Measuring Integration
 Many different tools available:
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
Case Example
Integrated Care Metrics
NHS London (2012)
Activity metrics currently used in IC systems in London, across all settings of care
Emergency admissions
Number of unplanned admissions for ACS conditions that should not usually
require hospital admission
Number of emergency admissions for the IC cohort (over 65/75/ top ICD 10
codes/ community ward patients)
Case file audit results for reviews of avoidable ED admissions
Emergency bed days (No.)
Number / total number of emergency hospital bed days for IC cohort (over
65/75/ top ICD 10 codes/ community ward patients)
Emergency bed days associated with multiple acute hospital admissions
SUS/ HA data
A and E attendances (No.)
Number / Total number of A and E attendances for the IC cohort (over 65/75/
top ICD 10 codes/ community ward patients)
SUS data
Acute re-admissions (No/
All emergency re-admissions that occur within 30 days of discharge for IC
cohort (over 65/75/ top ICD 10 codes/ community ward patients)
SUS / HA data
Length of stay (No.)
Data source
SUS / HA data
Difference between the discharge time and the admittance time for both
Dr Foster/ SUS / HA
elective and non elective episodes divided by the total number of spells for IC
Average Length of Stay for patients in the IC cohort (over 65/75/ top ICD 10 codes/
community ward patients)
Permanent admissions to
residential and nursing care
homes (No./ %)
Number of patients in long term care homes as a proportion of the total
number of patients in the pilot (%)
Number of new permanent admissions to residential and nursing care homes,
65+/ -65
Case file audit results for reviews of recent care home admissions
Referral Assessment
Provision (RAP) stats
Number of people
completing re-ablement
Proportion of service users independent following re-ablement
Readmission within 1 year for patients who have completed re-ablement
Referral Assessment
Provision (RAP) stats
Community nursing hours
per person (No.)
Total number of community nursing visits or units delivered divided by
number of patients in pilot
People supported at home
with low/med/high care
packages (No.)
Number of people 65+supported at home with low/med/high care packages
Referral Assessment
Provision (RAP) stats
Urgent GP response
DH survey (Q14-17 seen on same day within primary care 'how convenient'
Process metrics currently used by IC systems in London
Number of health assessments
completed (No.)
Number of assessments complete versus target
Outcomes of health assessments
Emergency admissions of patients who had health assessments
Local ICS collection
Number of people case managed
Numbers of case managed patients
Caseload, analysed by length of stay, source of referral and
state of care plan
% currently case managed patients with no ED contact
‘Referral bounce’ for case managed patients
Local ICS collection
Number of care plans completed
Numbers of patients with personalised care plans
Number of people in cohort on a care plan as a proportion of
total number of people that should be on a care plan
Local ICS collection
Adherence to care plan (No.)
Number of patients with one or more delay or incomplete
actions as a proportion of the total number of patients in the
pilot (%)
Local ICS collection
MDT operation (No.)
Numbers of case managed patients discussed at MDT for
whom follow up actions took place
Local ICS collection
Attendance at MDT meetings
Number of meetings scheduled / held / fully attended
Number of clinicians attending monthly MDT case conferences
and quarterly review meetings as proportion of total number
expected at these meetings (%)
Local audit
Frequency of MDT meetings
Virtual Ward: number of monthly MDT meetings held
Local ICS collection
Degree of joint working
Attendance rates at joint meetings
Exception reporting –
local ICS collection
Outcome metrics currently used by IC systems in London
Control measures
Hard outcomes
Patients with T1/T2 DM with HbA1c less than or equal to 10
% of patients with blood pressure targets achieved as per NICE
Percentage of patients with cholesterol less than or equal to 5
BMI less than or equal to 30
proportion of patients receiving medication review who should
Speed of referral for recognised foot complications,
Amputation rate below the ankle,
Falls rate among the frail elderly,
Number of fractures
Patient and staff experience measures used by IC systems in London
Measure of quality from the patient perspective covering four
clinical procedures: hip replacements, knee replacements,
hernia, varicose veins
NHS Information Centre
Measure of patients experience based on range of different
possible metrics: patient recommendation, overall
satisfaction, complaints, patient confidence
Patient surveys and
questionnaires, focus groups,
complaints data, one on one
patient interviews
Results of ICS service user survey
Percentage of people with LTCs who feel supported to
manage their condition
The proportion of people who use services who feel safe
DH GP survey 032
LTC6 survey
1. Did you discuss what was most important for you in managing
your own health?
2. Were you involved as much as you wanted to be in decisions
about your care or treatment?
3. How would you describe the amount of information you
received to help you to manage your health?
4. Have you had enough support from your health and social care
team to help you to manage your health?
5. Do you think the support and care you receive is joined up and
working for you?
Local health observatory
6. How confident are you that you can manage your own health?
Staff satisfaction
Staff survey to determine satisfaction of IC pilot, to
determine number of staff responding very satisfied and
satisfied to survey as proportion of total number of staff
Local ICS collection
Dr Nick Goodwin
CEO, International Foundation for Integrated Care
[email protected]
Appendix 1: From a measure to an indicator that can be used
for quality improvement
In developing ‘indicators’ to judge comparative performance, the following
criteria are important:
 Statistical validity
Accurate – measures what is says it measures!
Reliable – can be tracked over time
Consistent – data collection robust and reproducable
Avoids bias
 Data considerations
Data source – sample or full population; existing or new data source?
Unit of assessment – country, region, locality, practice etc
Client groups covered – what is the targeted population? account for bias/case mix?
Significance – smaller groups, reduced statistical power
Patient reported data is indirect – how cross-compare to other data (multi-methods)
Coverage – health, health & social care, health, social care and housing ….
 Face validity
Meaningful to public; clinically credible;
Potential to support quality improvement;
Cost and value for money
Appendix 2: Key Resources on Care Co-ordination Measures
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.
ttp:// - 64 different survey tools
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