[PPT] - Thames Valley End of Life SCN Masterclass: Developing a value-based PowerPoint Presentation

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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

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OBH | əʊ biː eɪtʃ | Noun. Small organisation with big ideas. Health Outcomes | hɛlθ awtkəmz| 1. Measure the results

f 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.

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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

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1. Values & Value in healthcare
What do we mean?
Approaches have to be complementary

Compassion, Care, Dignity, Empathy, Competence, Communication, Courage, Commitment, Health Equity, Justice Unlock Value in Health & Care for all: Improve Outcomes and build a sustainable system Values-based healthcare Value-based healthcare

&

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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…

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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

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3. Value-based healthcare: an overview

Michael Porter & Elizabeth Teisberg, Redefining Health Care (2006)

Value =

Health outcomes

Cost

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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.

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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

f 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)

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Outcomes are holistic, patient-centred and show how the whole system functions for patients, not just its individual parts.

Protocols/ Guidelines E.g. Staff certification, facilities standards, consumables E.g. Care plans, registers

Patient Satisfaction Patient Reported Health Outcomes

Source: Michael Porter, VBHCD Course 2012, Harvard Business School

3. Value-based healthcare: an overview

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Protocols/ Guidelines

Source: OBH, client work 2013

3. Value-based healthcare: why outcomes matter

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Protocols/ Guidelines

Source: OBH, client work 2013

3. Value-based healthcare: why outcomes matter

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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

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Process Indicators +/- Structure Indicators +/- Outcome 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

Not a question of processes vs. indicators vs.

utcomes, but what is the right blend?
3. Value-based healthcare: an overview

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Source: Lee, T. 2014, VBH Course HBS

The strategic agenda for moving to a high–value health delivery system

3. Value-based healthcare: an overview

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4. Our approach: Outcomes and Value

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4. Our approach: Co-definition outcomes

People* Carers Family Commissioners Providers 3rd Sector Social Services Local authority “Outcomes that matter to people”

Moving the conversation from “What is the matter to you?” to “What matters to you?”

True person-centred care

*People within last year of life, not just those with cancer

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Tier 1 Tier 2 Tier 3 Health Status Achieved

r Retained

Process of Recovery Sustainability of Health Survival Degree of recovery / health Time to recovery or return to normal activities Sustainability of recovery or health over time

Disutility of care or treatment process (e.g., treatment-related discomfort, complications, adverse effects, diagnostic errors, treatment errors)

Long-term consequences of therapy (e.g., care-induced illnesses) Mortality

Quality of Life

Symptom control

Source: Michael Porter, VBHCD Course 2012, Harvard Business School

Control, confidence, support, less anxiety

Reduced complications Less disruption to life and impact on people around Right person, right time, easy of access Co-ordinated, timely, planned care Delayed preventable complications

4. Our approach: The outcomes heirarchy

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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

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4. Our approach: Going from “I statements” to Outcome measures

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Healthcare providers that concentrate their effort and learn from experience in addressing a medical condition usually deliver the most value

4. Our approach: Going from “I statements” to system re-design (IPUs)

Source: Porter, 2014, VBH Course HBS

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1. Organised around a medical condition or a set of closely related conditions (or around defined patient segments) of people that have similar sets of needs 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 5. The unit has a single administrative and scheduling structure 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 process 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

Core Features IPU Organisation The Multi- Disciplinary Team

4. Our approach: Going from “I statements” to system re-design (IPUs)

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4. Our approach: Going from “I statements” to outcomes-based

contracts

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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
ften in block contracts, local negotiations to implement Value and

apportion some amount to Outcomes slice

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Thames Valley End of Life SCN Masterclass: Developing a value-based - - PowerPoint PPT Presentation