Value and Outcome Measurement in Health Care Delivery

Transcription

1 Value and Outcome Measurement in Health Care Delivery Grecia Hospital, Costa Rica March 2014 Profs. Elizabeth Teisberg and Scott Wallace The Geisel School of Medicine at Dartmouth

2 Health Care s Challenges Safety Efficiency Compassion Communication Effectiveness Access Variation Convenience Spending Timeliness

3 Cost containment is not the only goal

4 Health care Patients and families want more health, not more treatment.

5 Why has it been so tough to fix? Competition occurs over cost shifting. Zero Sum competition divides value and increases costs. Positive sum competition to improve health results creates value.

6 Defining Value in Health Care Outcomes are the entire set of patient health outcomes over the full care cycle. Costs are the total costs of care for the patient s condition, not for a single provider or a single service.

7 Health Care Delivery Transformation is Essential The challenge is to drive dramatic and ongoing improvements in health care value.

8 Increase value by improving outcomes in ways that reduce cost Living in good health is inherently less expensive than living in poor health. Better outcomes often drive costs down. Improving value includes, and goes far beyond waste reduction.

9 Innovation Imperative Innovation is needed in structure and organization, not only in devices and medications.

10 Innovate in Chronic Disease Care Chronic disease drives 75% of spending because success rates are low. Increasing funding is not enough More of the same won t work Adding coordinators is a patch, not an answer Being all things to all patients is too difficult to do well

11 What is your sushi? Is it even safe?

12 Keys to accelerate dramatic improvement in value Define services from patients perspectives. Organize care delivery around solutions. Create interdisciplinary teams. Measure results to accelerate learning. Align financial success with medical success.

13 Implementing Integrated Practice Units Patients Teams

14 Redefining Health Care Delivery: Patients Patients

15 Design Care from a Patient s Perspective Define care by conditions (patient segments with shared health circumstances) Not procedures; not medical specialties Include common co-occurring conditions Extend through the full cycle of care (breast cancer, not surgery) Care today is organized for exceptions, rather than for frequently shared needs

16 Patient Perspective: Diabetes Outpatient Endocrinologist Podiatry Psychiatrist/ Psychologist Visit Social Worker Nutritionist Primary Care Physician Diabetes Nurse Education Visit Outpatient Laboratory Outpatient Neurologist Outpatient Nephrologist Cardiology Vascular Surgeon Inpatient Cardiology Ophthalmologist Kidney Dialysis Laser Eye Surgery Inpatient Endocrinology Inpatient Vascular Surgery

17 Patient Pathway in the JoslinCare Model Joslin Diabetes Center and Steno Center each coordinate appointments 1. Check-in!! 2. Endocrinologist!!! 3. Nurse Coordinator!!! 4. Eye Exam!!! 5. Laboratory Blood, urine! 6. Diabetes Education! 7. Mental Health! 8. Nephrologist! 9. Check-out Source:!Joslin company documents.

18 Redefining Health Care Delivery: Interdisciplinary teams Patients Team

19 Clinically Integrated Care Team or Collection of Fragmented Services? Patient Pong!

20 Learning Satisfaction Coordination Health Outcomes Efficiency Research Clinical Judgments

21 Driving Learning Broad expertise develops over the care cycle for the patient.

22 Redefining Health Care Delivery: Solutions Patients Team A solution conveniently, effectively and efficiently enables better health

23 Solutions for Type 2 Diabetes include lifestyle support and non-medical services. Patients Team

24 Improving Value in Chronic Care is urgernt. Variable & often unsuccessful Expensive & often wasteful Complicated & poorly coordinated

25 Redefine to Improve Value for Patients and Families effective efficient SOLUTIONS convenient

26 What you measure will improve so measure what really matters. Patients Teams

27 Heuristics and Biases Professors and Teaching Ability: 95% rate themself above average 68% rate themself in the top 25% Students Ability to Get Along: 85% rate themself above average 25% rate themselves in top 1% Source: Alicke and Govorun (2005)

28 Creating Value in Care Delivery In health care, value is created at the level of the individual patient Teams measure outcomes and costs for individual patients

29 Measure Outcomes and Cost for Each Patient Patient Engagement Patient Initial Conditions Processes Indicators (Health) Outcomes Measuring inputs is not sufficient. Protocols/ Guidelines Structure E.g., Hemoglobin A1c levels for patients with diabetes E.g., Staff certification, facilities standards

30 Outcome Measurement Drives Improvement Measured outcomes provide information to clinicians, whether or not consumers use the information Consistent improvement for patients results from outcome measurement 3 0

31 Measuring Value: Essential Principles Clinicians need to measure results. Drive value improvement and learning. Adjust outcomes for initial patient conditions. When used, measures and risk adjustment methods improve rapidly. Failure to measure outcomes slows improvement and invites costly micromanagement

32 Chronic Health Measures Health Status Achieved or Retained Results During Experience of Care Survival Capabilities Achieved or Retained; Degree of Health or Recovery Days lost from work or normal activities Days or hours spent in treatment or going to appmts Utility of care (e.g. education, confidence, lifestyle change) Disutility of the care (e.g., diagnostic errors, ineffective care, treatment-related discomfort, complications, adverse effects, treatment errors and consequent care) Sustainability of Health (or disease progression) Sustainability of health; rate of disease progression; development of complications or co-morbidities Long-term consequences of therapy (e.g., care-induced illnesses, effects of medications OR improved HRA, screening results above risk adjusted expectation) Progression Care-induced Illnesses 3 2

33 Evolution of measurement success: Minnesota diabetes measures STAGE Resistance & Suspicion NEW UNDERSTANDING For learning, not judgment. Measure processes Measure indicators & short term outcomes Controllable experience success. Ask: are patients better off? Improving professional satisfaction. Team-wide excitement We CAN measure and improve! Improving the measures Outcomes for patients are better Evangelists for measurement Team inspired by improving value

34 Adult Kidney Transplant Outcomes U.S. Centers, Percent 1 Year Graft Survival Number of programs: 219 Number of transplants: 19,588 One year graft survival: 79.6% 16 greater than predicted survival (7%) 20 worse than predicted survival (10%) Number of Transplants 34

35 Adult Kidney Transplant Outcomes U.S. Centers, Percent 1 Year Graft Survival Number of programs: 240 Number of transplants: 38,515 One year graft survival: 93.2% 16 greater than expected graft survival (6.6%) 19 worse than expected graft survival (7.8%) Number of Transplants 35

36 Don t wait for perfect measures. Enable Teams. Reward participation in measurement. Move from fragmented to national registries. Measurement will improve both the health outcomes and the measurements.

37 Oral Cavity Cancer Survival At MD Anderson Stage: Local Stage: Regional Survival Rate Survival Rate Months after Diagnosis Months after Diagnosis Source: MD Anderson Cancer Center 37

38 Functional Outcome Measurement Pediatric Psych Patient Reported Really?

39 Measures for OCD Therapy at CCHMC Needed measure to track progress in treatment Existing measure (CY-BOCS) too cumbersome Developed session-by-session focused on Control, Distress, and Functioning Called the Short Obsessive Compulsive Symptom Scale (SOCSS) Source: Copyrighted material of the Cincinna6 Children s Hospital Medical Center. Used by permission of the authors.

40 Measuring OCD Treatment Outcomes at CCHMC Show me how much your thoughts/worries and the things OCD tells you to do have interfered with concentra6on, work, fun. Source: Copyrighted material of the Cincinna6 Children s Hospital Medical Center. Used by permission of the authors. 40

41 Appearance of graphs from original database Outcome Patterns of OCD Treatment at CCHMC No Improvement Saw Tooth Slow Decline Rapid Decline Source: Copyrighted material of the Cincinna6 Children s Hospital Medical Center. Used by permission of the authors. 41

42 Measurement Enabled Improvement at CCHMC 65% of the patients had significant severity reduction in 4 sessions Average sessions: 12. Predicted Drop out rate: 7%. Average 15-20%. 97% of the patients completing treatment achieve subclinical status (CY-BOCS of <13) Source: Copyrighted material of the Cincinna6 Children s Hospital Medical Center. Used by permission of the authors. 42

43 Redefined Goals require a Change of Mindset The goal is treatment. The goal is health. Increase price sensitivity of patients. Increase value for patients. Reduce waste in treatment process. Redesign to improve outcomes in ways that reduce costs.

44 Elizabeth Teisberg Professor Department of Family and Community Medicine Geisel School of Medicine at Dartmouth Scott Wallace Visiting Professor Department of Family and Community Medicine Geisel School of Medicine at Dartmouth