Thames Valley End of Life SCN Masterclass: Developing a value-based approach Dr Rachna Chowla MRCGP MBA November 2014 www.outcomesbasedhealthcare.com @OBH_UK @drrachnac
OBH | əʊ biː eɪtʃ | Noun . Small organisation with big ideas. Health Outcomes | hɛlθ awtkəmz | 1. Measure the results of care. 2. Best co-defined by people - you, me, our families, other people that help to care. 3. Defined, measured and interpreted for a people with similar care needs. 4. The way to join-up care, improve and innovate. 5. The OBH Way.
End of Life care (EoLC): Developing a value-based approach “In life, as in all stories, he writes, “endings matter”. Dr Atul Gawande 1. ValueS-based approach & Value-based approach 2. Reflections on current models of EoLC 3. Value-based healthcare: overview 4. The OBH approach to implementing Value 5. Translation to EoLC: Considerations and Challenges
1. Values & Value in healthcare • What do we mean? Values-based healthcare Value-based healthcare Compassion, Care, Dignity, Empathy, Unlock Value in & Competence, Health & Care for all: Communication, Improve Outcomes Courage, and build a Commitment, Health sustainable system Equity, Justice • Approaches have to be complementary
2. Reflections on current EoLC • Relatively well-coordinated • Lots of great advocacy organisations • Good guidelines • High-profile for government • EPaCCS • Whole-cycle – recognition of those approaching end of life, care during illness and after death • ? Rest of the system can learn a lot from EoLC • But 81% want to die at home, 48% end up dying in hospital…
3. Value-based healthcare: an overview • Not seeing the right person/people, for the right care, at the right place, at the right time, repeatedly destroys Value , for patients/families and for the system/society as a whole • What is the purpose of Healthcare? Improve Outcomes • Value is defined as Outcomes relative to the real costs it takes to deliver those outcomes • Outcome improvement without understanding the true costs of care is unsustainable and does not help effective allocation of limited resources • Cost reduction without regard to the Outcomes achieved is dangerous and self-defeating
3. Value-based healthcare: an overview Health outcomes Value = Cost Michael Porter & Elizabeth Teisberg, Redefining Health Care (2006)
3. Value-based healthcare: an overview What is an Outcome? • Results of care for patients with similar needs , across the complete care cycle , often spanning different providers of care • Fundamentally different to quality process measures • Best co-defined with patients • More valuable when they are defined, measured and interpreted for a segment of the population with a medical condition and not an intervention Why are Outcomes important? • Shift the focus: processes in siloed provider to a person receiving care • Outcomes align interests across the care-cycle • Help inform service/system redesign Shifting to an outcomes-based system promotes moving towards a true-person centred system. Care that wraps around people and not less people wrapping themselves around a fragmented system.
3. Value-based healthcare: an overview What about costs? Costs should be measured across the complete cycle of care for the condition/across a unit of time, if a long term condition Examples of organisations measuring outcomes: Kings Health Partners ‘outcomes books’ (UK), Martini Klinik (Germany), Cleveland Clinic ‘outcomes books’ (US), Partners Healthcare Value dashboards (US), International examples of organisations applying TDABC (Time-Driven Activity-Based Costing): MD Anderson Head and Neck Cancer Care (US), Schon Klinik (Germany), Brigham and Women’s Hospital (US)
3. Value-based healthcare: an overview Outcomes are holistic, patient-centred and show how the whole system functions for patients, not just its individual parts. Protocols/ E.g. Care plans, registers Guidelines Patient Reported Patient E.g. Staff certification, Health Satisfaction facilities standards, Outcomes consumables Source: Michael Porter, VBHCD Course 2012, Harvard Business School
3. Value-based healthcare: why outcomes matter Protocols/ Guidelines Source: OBH, client work 2013
3. Value-based healthcare: why outcomes matter Protocols/ Guidelines Source: OBH, client work 2013
3. Value-based healthcare: why outcomes matter Outcome Measurement in Palliative Care, Bauswein et al, http://www.csi.kcl.ac.uk/files/Guidance%20on%20Outcome%20Measurement%20in% 20Palliative%20Care.pdf
Outcome Indicators +/- 3. Value-based healthcare: an overview Not a question of processes vs. indicators vs. outcomes, but what is the right blend? Process Indicators +/- Structure Indicators +/- Adapted from: An Introduction to choosing and using indicators, Veena S Raleigh, The King’s Fund, 2012 and Michael Porter, VBHCD Course 2012, Harvard Business School
3. Value-based healthcare: an overview The strategic agenda for moving to a high – value health delivery system Source: Lee, T. 2014, VBH Course HBS
4. Our approach: Outcomes and Value
4. Our approach: Co-definition outcomes “Outcomes that matter to people” People* Carers Family Moving the conversation from Providers “ What is the matter to you ?” to “ What matters to you? ” Commissioners 3 rd Sector Local authority True person-centred Social Services care *People within last year of life, not just those with cancer
4. Our approach: The outcomes heirarchy Quality of Life Mortality Tier 1 Survival Control, confidence, support, less anxiety Health Status Achieved Symptom control Degree of recovery / health Reduced or Retained complications Time to recovery or return to Less disruption to life Right person, right normal activities and impact on people time, easy of access Tier 2 around Process of Disutility of care or treatment process (e.g., treatment-related discomfort, complications, Recovery adverse effects, diagnostic errors, treatment Co-ordinated, timely, errors) planned care Sustainability of recovery or health over time Tier 3 Delayed preventable complications Long-term consequences of Sustainability of therapy (e.g., care-induced Health illnesses) Source: Michael Porter, VBHCD Course 2012, Harvard Business School
4. Our approach: Macmillan “I statements” are a great start, but can be expanded upon for EoLC Source: Macmillan “Nine I statements” for people with Cancer
4. Our approach: G oing from “I statements” to Outcome measures
4. Our approach: G oing from “I statements” to system re -design (IPUs) Healthcare providers that concentrate their effort and learn from experience in addressing a medical condition usually deliver the most value Source: Porter, 2014, VBH Course HBS
4. Our approach: G oing from “I statements” to system re -design (IPUs) 1. Organised around a medical condition or a set of closely related conditions (or around Features defined patient segments) of people that have similar sets of needs Core 2. Care is delivered by a dedicated, multidisciplinary team of clinicians who devote a significant portion of their time to the medical condition 3. The team takes responsibility for the full cycle of care for the condition 4. There is a single point of access to care Organisation 5. The unit has a single administrative and scheduling structure IPU 6. To a large extent, care is co-located in dedicated facilities 7. Providers see themselves as part of a common organisational unit (even if made up of separate organisations) 8. A physician team leader or clinical care manager (or both) oversees each patients care Disciplinary Team process The Multi- 9. The providers on the team meet formally and informally on a regular basis to discuss patients, processes and results 10. The team measures outcomes, costs and processes for each patient across the full cycle of care, using a common measurement platform 11. There is joint accountability for outcomes and cost
4. Our approach: G oing from “I statements” to outcomes -based contracts
5. EoLC: Considerations and Challenges Considerations: • Well defined segment • Good models of working together already in place • IT sharing happening • Need to define EoLC Outcomes - beyond cancer, beyond just dying at home • Potential to then implement EoLC IPU • Potential to develop PROMs tools for people in EoLC Challenges: • Not currently collectively accountable – how? But providers of care often in block contracts, local negotiations to implement Value and apportion some amount to Outcomes slice
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