Measuring What Matters to Improve Health and Well-Being
With technology constantly evolving, the health care industry pushes forward developing new ways to look at and assess population health so that patients, providers, and payers alike will see improved outcomes and reduced costs. An increasingly important measure includes factoring in social determinants to see the entirety of patient care package.
The need to improve quality of care and reduce cost—a mantra of the day—is underpinning a range of innovative ideas and programs that are widening the net to capture components of health beyond disease states. Social determinants of health are increasingly being considered as part of a health package that policymakers, administrators, and clinicians are considering to improve the health of people and populations.
Population health is also more in focus, particularly as organizations try to grapple with the high cost of people with chronic diseases. And new reimbursement structures, such as value-based purchasing, are placing pressure on organizations to develop metrics to measure quality of care.
Also in this mix are technological advances such as machine learning and artificial intelligence that rely on big data to help health care systems improve care delivery to populations of people based on algorithms that can help, for example, predict which patients will be at high risk of certain diseases.
Combining all of these changes is an emerging way of thinking about health care called the learning health system approach, which according to the Agency for Health Care Research and Quality, is defined as a “health system in which internal data and experience are systematically integrated with external evidence, and that knowledge is put into practice. As a result, patients get higher quality, safer, more efficient care, and health care delivery organizations become better places to work.”
At its core, this approach recognizes that improving health of individuals, populations, and communities requires working with partners across sectors to address variables affecting health while continually learning and adapting to what works and what does not. In this framework, health care is only one of a myriad of components that comprise health for an individual and population. Other components include the social, economic, and environmental variables that are increasingly recognized as integral to health.
But this is not just about including the social determinants of health into the health care system. At its essence, a learning health system takes this a step further. It asks for a transformative view of health care, one that focuses first on the well-being of persons and populations vs a primary focus on remedying the lack of well-being. Instead of focusing on treating and even preventing illness, the focus is on understanding the conditions needed to create and sustain well-being and health for everyone and, in particular, those who are most likely to experience poor outcomes.
As is difficult for all of health care, the challenge is translating this way of looking at health into actionable and operational ways on the ground. The development of a measurement system that can truly capture the needed metrics to measure improvement is critical.
Somava Saha, MD, MS, executive lead, Well Being in the Nation Network, has been working to help advance what she and her colleagues in a recent Health Affairs blog call a learning measurement system that would help streamline and align metrics across sectors to capture those that truly impact health and well-being.
“We don’t have a mechanism to easily learn across sectors and we don’t have a way of easily seeing what the solutions might be far less what the problems might be,” she said. “One of the things this kind of learning measurement approach offers is the ability to see the whole patient and influence people in all stages of their lives.”
Streamlining measurements to reduce duplication and eliminating those that do not actually lead to an impact is fundamental to this approach. “Right now we are dying of thirst in an ocean of data,” Dr Saha said.
So how would this work?
Well-Being of the Nation (WIN) Measurement Approach
Dr Saha pointed to a number of examples of innovative measurement approaches that are integrating measures across sectors to measure health and well-being. Among these is the WIN measurement system, a system of multi-sector measures given its initial framework by the National Committee on Vital and Health Statistics (NCVHS) with subsequent development and facilitation by an initiative called 100 Million Healthier Lives. The WIN measures are comprised of three core measures (well-being of people, well-being of places, and equity) that illustrate how well-being, social conditions, health, and community are connected based on leading indicators (demographics, health, food and agriculture, community vitality, environment, economy, education, housing, public safety, transportation, well-being of people, and equity).
Bobby Milstein, PhD, MPH, director of system strategy, ReThink Health, Fannie E Rippel Foundation, Cambridge, MA, describes these measures as a “one-stop shop” that “illustrate a whole spectrum of value” that is not often seen if measures are only about, for example, lowering the rate of disease.
“There is a long history of measuring rates of chronic disease and health care utilization, urgent events, and cost related to diseases,” Dr Milstein said, adding that traditionally in medicine the approach to these measures has been to start with the disease and health care service metrics and then look back on the behavioral, economic, and social drivers that could have contributed to the disease, and after all that, then look to policies and circumstances that provide opportunities to change.
The WIN measures appear to turn this sequence of measuring on its head. Instead of putting the disease or adverse event first, the WIN measures begin with looking at the well-being of the person or place. “The WIN measures bring all of that into a connected suite where the focus first and foremost is on who is thriving and who is struggling or suffering,” he said, explaining that these are very precise terms on which the WIN measures are built.
Dr Saha explained that one of the innovative WIN measures used to measure well-being of persons is a measure developed in business called Cantril’s Ladder (see figure). People are asked to imagine a ladder with 10 rungs, the bottom rung is 0 representing the worst possible life and the top rung is 10 representing the best. Those who report being on rung 4 or below are considered suffering, those on rung 5 or 6 are considered struggling, and shot higher than 6 are thriving.
“This is a simple measure showing people thriving, struggling, or suffering and it offers the ability to know how people feel about their lives, which correlates with morbidity, mortality, cost, and worker productivity,” said Dr Saha.
This initial measurement of a person’s well-being is then used as a starting point to address the issues that may be interfering with well-being, such as living in a poor neighborhood or not having access to good nutrition.
Dr Milstein emphasized that the WIN measures are built around unlocking the value trapped in a badly designed and dysfunctional health care system. “The business of health care delivery is notorious for inefficiency, ineffectiveness, and not being equitable, and the WIN measures are a good way to expose the untapped potential that can come if people actually start investing in the vital conditions that actually expand well being and not just focus on limiting affliction or controlling disease,” he said.
Application of WIN: Early Adopters
Among the early adopters of the WIN measures is the American Heart Association (AHA). Kim Stitzel, MS, RD, senior vice president of the Center for Health Metrics and Evaluation at the AHA, said that the organization is incorporating the WIN metrics, including Cantril’s Ladder, into their programs. For example, they are adding fields based on the WIN measures into their “Get With the Guidelines” clinical program. The program offers evidence-based treatment guidelines for hospitals on a number of heart-related events, such as coronary heart disease, stroke, and heart failure. The guidelines are continuously updated with data imputed through electronic health records. The AHA has just started imputing the WIN measures in the program.
According to Ms Stitzel, the AHA is working with electronic health record companies to put new fields in the electronic health record to reflect the WIN measures. For example, a new field would include a measure on transportation access for any given patient. During a clinic visit, a pop-up message could occur that shows the clinician whether a patient has a high probability of not having access to fill their prescriptions or transportation challenges to getting to a follow-up appointment and could prompt the clinician to ask the patient about this barrier. “That is how these measures can be used to translate into real-time data with the patient.”
In terms of cost, she highlighted that health systems, including managed care, could use this type of information to rethink how and where they spend their dollars. “There are some organizations looking at how do they transfer the cost of expensive care in the emergency room to more preventive opportunities,” she said, adding that one option is the use of community health workers who go into the community to provide preventive care to patients where they are or
another option is to find ways to get them transported to their appointments.
Overall, she stressed that the use of WIN measures and other strategies is to focus on needs up front rather than waiting for problems downstream. “We are trying to get people more accessible, quality care on the front end, on the prevention side, so we can really prevent as much as possible sick care,” she said. “And then when we get to sick care, we are trying to make sure people can access quality care as soon as possible.”
Another early adopter of the WIN measures is the Delaware Substance Abuse and Mental Health Agency. Elizabeth Romero, MS, the director of the agency, said that they use these measures within their coordinated care ecosystem via a shared platform. For people in a crisis due to mental health or substance abuse issues, use of the shared platform helps to triage appropriate acute care, facilitate ongoing access to services, and improve patient to provider engagement. For example, the agency has created a statewide automated system called the Delaware Treatment and Referral Network that serves as a bidirectional referral platform that expedites placement for patients with mental health or substance abuse disorder needs.
The network includes coordination of support services like housing, transportation, or employment. According to Ms Romero, the use of the network allows less complex patients to be expedited to receive services within 30 minutes of referral. “This used to be a frustrating endeavor that is becoming more efficient,” she said. Success with these patients, she emphasized, frees up the system to focus on patients with complicated cases.
Dr Saha highlighted how the agency is using Cantril’s Ladder in the emergency room or primary care clinic to help clinicians understand the level of a patient’s well-being and what specific needs they may need addressed to ensure optimal care. For example, she said that the agency is using WIN measures to stratify risk for people who present to the emergency room with a mental health or substance abuse crisis to ensure that people with a low score on Cantril’s Ladder get extra support and management.
Ms Romero, who is trying to partner with managed care, emphasized the need to streamline quality measures for behavioral health. “Behavioral health providers want to make things simple for their clients, which requires analyzing multiple measures as an administrative function before they connect with their clients,” she said. “So common quality measures for behavioral health is going to be really critical so that we don’t drive everyone crazy trying to improve quality.”
