By Heidi Bossley, Faculty at the Institute for Healthcare Improvement, and Keziah Imbeah, Research Assistant at the Institute for Healthcare Improvement
As the field of complex care continues to grow, a measurement strategy that allows for relevant and accurate assessment and evaluation of complex care programs is necessary. A new report published in May 2020, Measuring complexity: Moving toward standardized quality measures for the field of complex care, summarizes the findings from a landscape analysis to determine what existing quality measures might be applied to the field of complex care. The report outlines specific recommendations for applying existing measures to complex care programs or developing new measures where needed.
The new report builds on the Blueprint for Complex Care — a strategic plan to improve care for individuals with complex health and social needs —published by the National Center for Complex Care and Social Needs, the Institute for Healthcare Improvement, and the Center for Health Care Strategies. The Blueprint recommends establishing a workgroup to develop or select measures to evaluate complex care programs. Measuring complexity provides a foundation for the quality measure development process.
Below we summarize a set of recommendations discussed in the Measuring complexity report to guide development of a measurement strategy for complex care programs.
Define the intended use and standardize measures
Developing a complex care measurement strategy requires defining the intended use and standardizing selected measures. Measures used for accountability purposes require a greater degree of standardization and rigor than those used for quality improvement. As the purpose for the selected measures becomes clearer, it will be easier to develop an appropriate measurement strategy.
Measures also require a standard denominator. Based on a literature review and interviews with health care professionals caring for individuals with complex needs, we noted significant variation in how complex care programs identify this population and the specific outcomes and processes they measure. Measuring complexity defines criteria for identifying individuals in this population, informed by more than 30 complex care programs in the US such as cost/utilization, chronic conditions, behavioral health, or social needs. It also recommends an approach to establish a standard denominator: identify shared elements across the subpopulations of interest, to create common definitions and code sets that further align measurement and allow for reliable and valid comparisons.
Create patient-centered measures
During our interviews, health care professionals expressed the need to ensure that the uniqueness of individuals with complex needs is not lost in the measurement strategy. Variation in a person’s health, social, and environmental circumstances naturally result in differing perspectives on what matters most to them in regards to their health and well-being. Many complex care programs address this by focusing on patient- and goal-centered care. Maintaining this principle in complex care measurement will require the development of measures that focus on health and well-being, ensuring that those measures are in line with individual patient priorities, and evaluating access to resources in the health system and the community to meet their needs.
To ensure that quality measures align with patients’ own goals, individuals with complex needs must be directly involved in measure development and selection. Measuring the effectiveness of complex care programs in helping individuals meet their own goals must be integral any complex care measurement strategy.
The report also recommends development of a core set of measures along with additional measure sets based on populations of interest and prioritized by domains of care. Core measures will enable the field to collectively assess program effectiveness and allow for comparisons across programs. The additional measure sets provide programs with flexibility to focus on subpopulations and areas that may be unique to the individuals they serve, yet are closely linked to driving improvements in the core set of measures.
Move beyond cost and utilization measurement
Managing cost and utilization is a goal of many complex care programs. However, it is not the only priority. The report outlines four additional measurement domains (and various subdomains) in which programs need to establish outcome and process measures: (1) effectiveness/quality of service; (2) equity (3) health and well-being; and (4) service delivery. While some domains are more easily measured, we realize that others may be better addressed through standards (e.g., integration of social services, access to needed services) or data stratification of existing measures (i.e., provide measure results by race/ethnicity, gender, insurance status, income, social needs, and other key characteristics). We hope that this broadened view will give complex care programs the latitude to continue pursuing patient-driven goals and assessing their programs with that in mind.
Prevent measurement fatigue
Many programs are already under pressure to meet certain criteria, so minimizing measurement burden is essential. We reviewed existing quality measures and identified a significant number that are applicable to the complex care population. Some measures need to be altered as they currently exclude populations of interest (e.g., those with disabilities, frail elderly). Other measures (e.g., clinician-specific measures) may need to be redesigned and tested to see if they might be applied at the program level. We also recommend that development of the measurement strategy should not be completed in siloes, but rather in collaboration with key partners. Building capacity to capture best practices and innovative solutions from the field will be vital.
Complex care programs interact with individuals who have unique needs and specific circumstances that must be accounted for in any measurement strategy. These design principles and the recommendations in Measuring complexity provide helpful guidance to develop such a measurement strategy with the goal of improving the health and well-being of individuals with complex needs in a meaningful way.