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.
2.
3.
4.
5.
ValueS-based approach & Value-based approach
Reflections on current models of EoLC
Value-based healthcare: overview
The OBH approach to implementing Value
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,
Competence,
Communication,
Courage,
Commitment, Health
Equity, Justice
Unlock Value in
Health & Care for all:
Improve Outcomes
and build a
sustainable system
&
• 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
Value =
Health outcomes
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/
Guidelines
Patient
Satisfaction
Source: Michael Porter, VBHCD Course 2012, Harvard Business School
E.g. Care plans, registers
E.g. Staff certification,
facilities standards,
consumables
Patient
Reported
Health
Outcomes
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
3. Value-based healthcare: an overview
Outcome Indicators +/-
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
People*
Family
Carers
Providers
Commissioners
“Outcomes that matter
to people”
Moving the conversation from
“What is the matter to you?” to
“What matters to you?”
3rd Sector
Local authority
Social Services
True person-centred
care
*People within last year of life, not just those with cancer
4. Our approach: The outcomes heirarchy
Quality of Life
Tier 1
Health Status
Achieved
or Retained
Survival
Degree of recovery / health
Time to recovery or return to
normal activities
Tier 2
Process of
Recovery
Tier 3
Sustainability of
Health
Disutility of care or treatment process (e.g.,
treatment-related discomfort, complications,
adverse effects, diagnostic errors, treatment
errors)
Sustainability of recovery or
health over time
Long-term consequences of
therapy (e.g., care-induced
illnesses)
Source: Michael Porter, VBHCD Course 2012, Harvard Business School
Mortality
Symptom control
Less disruption to life
and impact on people
around
Control, confidence,
support, less anxiety
Reduced
complications
Right person, right
time, easy of access
Co-ordinated, timely,
planned care
Delayed preventable
complications
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: Going from “I statements” to Outcome measures
4. Our approach: Going 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
The MultiDisciplinary Team
IPU
Organisation
Core
Features
4. Our approach: Going from “I statements” to system re-design (IPUs)
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
4. Our approach: Going 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
Further reading and contact details
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–
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Porter, M.E. What is value in health care. NEJM, 2010
Lee, T. H. Putting the value framework to work.
–
NEJM, 2010
–
Kaplan, R. S. Porter, M. E. How to Solve the Cost
Crisis in Health Care. Harvard Business Review 2011
Porter, M. E. Lee, T. H. The Strategy That Will Fix
Health Care. Harvard Business Review 2013
www.ichom.org conference in Boston, USA,
November 2014
http://www.hbs.edu/rhc/index.html
West, M et al, Developing collective leadership
for health care, 2014,
http://www.kingsfund.org.uk/publications/develo
ping-collective-leadership-health-care
Dr Rachna Chowla BSc (Hons) MRCGP MBA
Segmentation and Education Lead at OBH
rachna@outcomesbasedhealthcare.com
@OBH_UK @drrachnac
www.outcomesbasedhealthcare.com
16-24 Underwood Street
London, N1 7JQ
Activity: Understanding the difference between Outcomes & Processes
Task
1) In your groups, take a look at the “recommendation” that you have been
given.
2) What Outcomes would these lead to? (5 mins)
(Remember Outcomes are person-centric, whole-pathway, holistic)
Activity: