By Emma Opthof, Center for Health Care Strategies
Two years ago, the Blueprint for Complex Care — a strategic plan to strengthen the field — was published by National Center for Complex Health and Social Needs, the Center for Health Care Strategies, and the Institute for Healthcare Improvement (IHI). Among its many findings, the report indicated that for complex care to flourish, a standardized measurement approach is needed. While cost and utilization are common metrics in measuring the success of a health care intervention, many in the field of complex care are seeking better measures for patient health and well-being. Enter the Measuring Complexity report, published recently by the National Center and IHI. This report assesses the current state of quality measures in complex care, identifies opportunities to refine measures, and proposes eight recommendations designed to improve measurement and identification of people with complex health and social needs.
The Better Care Playbook recently spoke with the report’s authors — Heidi Bossley, MSN, MBA, and Keziah Imbeah, MSc, of IHI — who share insights into its findings and considerations for the field in adopting a more standardized approach to complex care measurement.
Q: Measures are used for many different reasons by health care organizations. Why is it important to determine the purpose of a measure?
A: H. Bossley: If you don't identify the intent or potential use of a measure, it can really mess up a project timeline and ultimately keep you from meeting project goals. The standardization of measures and defined populations become increasingly important when you start talking about publicly reporting this information or comparing the performance of two or more facilities. If we start with the same data and a similar approach to identifying populations, we can feel more confident that when we compare and make assessments of quality — it is with apples to apples, not apples to oranges or apples to elephants. Defining things the same way would make it easier for complex care programs to measure the effectiveness of their programs, track them over time, and compare and contrast them.
Q: What do you see as current strengths in the way that complex care categorizes and stratifies populations, and where do you think there are still gaps?
A: H. Bossley: I was encouraged to see that many in the field were moving beyond cost and utilization to define individuals by pulling in risk scores and assessing social needs. Unfortunately, there’s still a long list of who is considered complex, which is very dependent on what is occurring in the community, and it makes measurement more challenging. The other thing that we discovered is that right now, the way individuals are identified is based on an interaction with the health care system. There is still a gap in identifying the individuals who aren't interacting with the system, but who have complex needs and would benefit from these programs. Referrals are probably one of the ways to get started, as well as looking at social needs more rigorously.
K. Imbeah: It was interesting to see how different organizations were accounting for the heterogeneity in their populations and it was encouraging to see an assessment of social needs, but everyone defines and measures these concepts differently. It is important to acknowledge that communities may be dealing with things in different ways, but it does make things difficult to measure. One of our recommendations was an alternate path toward standardization — choosing certain things that everyone is collecting and seeing where there's overlap and how to define that.
Q: The report notes that there are a lot of measure concepts for equity, but no actual measures. What are some suggestions for health care organizations in measuring equity?
A: H. Bossley: Everyone has mentioned equity measurement for some time now. This National Quality Forum report has helped to begin identifying and defining equity measures. It can be challenging, however, to measure equity effectively. Historically, when we talk about equity, the other term that we use is disparities, but I don't think they're the same thing. Disparities are one avenue by which we can see whether access to health care has been equitable within a system. I would like the field to be more innovative and thoughtful about measuring equity — maybe that entails starting with stratifying more information and making it more transparent as to how care is delivered differently across groups of interest.
There are also other ways to look at equity besides measurement, through things like standards or accreditation. The Office of the Assistant Secretary for Planning and Evaluation just came out with a report that was required from the IMPACT Act looking at the use of social risk factors in quality measures. One of the things they proposed is having CMS and other HHS programs build in an equity component that specifically targets equity in a way that traditional quality and cost measures don’t.
Q: What is the value of patient-reported outcomes performance measures (PRO-PMs) and how do you think we can improve them?
A: H. Bossley: Historically, a lot of the measures on which programs report have been clinical in focus — they look at whether or not certain processes are completed or outcomes are met. There is an emphasis within the health care system, as well as with those in measurement, that we need to show the patient’s experience, what outcomes they report and how they can drive the care. It gets challenging because we want to be sure that we use the right tools that appropriately measure what's important to patients. There are a lot of tools out there, but trying to standardize them and making sure everyone collects the same information in the same way for measurement and comparisons is difficult. Getting patients involved at the start of this type of work and across development and implementation is important both from a patient and clinician perspective.
I don't know if there's a great way to improve PRO-PMs yet, because there's so few actually in use. We've got to get to the point where we're developing these measures, implementing them, and learning what works well and what doesn't before we can improve them.
K. Imbeah: Getting patients involved in measurement development at the very beginning is critical because that really ensures their voices will be heard. We talked to a couple of the National Consumer Scholars from the National Center for Complex Health and Social Needs and got their views on what was important to them, which was very helpful for us. The value of PRO-PMs is that programs are also accountable to the people they serve and the things that matter to them.
H. Bossley: If you have informed patients who understand their role at the start of a project in identifying clinical measurement concepts, they can change the conversation in a way that is fascinating to watch. Clinicians gravitate toward the typical processes and outcomes, but a patient might emphasize that a specific piece of their symptom management is the most important thing to them. It changes the conversation and you get a collaborative discussion that moves the needle in a direction that we don't get if we don't have patients at the table from the start.
Q: What do you see as the next steps for complex care stakeholders to advance quality measurement?
A: H. Bossley: I know the National Center would like to get an expert committee underway at some point to work on the report’s recommendations. Having individuals who are willing to participate in this work either through providing input, helping implement some of these measures, or detailing how they collect information is paramount. Also, I know there's more good work happening out there that we may have missed. Are there measures that groups are using now that could be potentially considered for broader use nationally? How easily could the measures of most interest be implemented by complex care programs now? This information would be incredibly helpful for folks moving forward on building a standardized set of measures for the field.