In 2018, the Blueprint for Complex Care released by the National Center, the Center for Health CareStrategies (CHCS), and the Institute for Healthcare Improvement (IHI) outlined the emerging field of complex care. The Blueprint identified measurement as a primary area in need of attention and standardization. In response, this report sought to identify what work currently exists or is needed to establish a set of potential quality measures for the field.

Measurement is critical to allow groups to track how well they improve patient outcomes and make sure that we are able to determine the effectiveness of complexcare programs across the United States. To that end, IHI completed a search of the literature, interviews with subject matter experts, and a scan of existing quality measurement efforts to identify quality measures currently in use, work still needed to develop or clarify measures, and potential partners in this work.

Our research led to findings across four areas:

1.  defining the population,
2. data availability and potential sources,
3. measure domains, and
4. measures and measure concepts. For each area, the report outlines a set of recommendations for future work.

Assessment of the current state of quality measures in the complex care-field

If the goal is to understand which programs provide high-quality care to individuals with complex need sand to allow the field of complex care to track how well each program meets that goal, it is important to understand who should be considered part of the complex care population and what data are available to capture this information.

Allowing groups to define individuals with complex needs differently based on who they serve must be balanced with creating a population definition that can be implemented across programs to allow us to compare how well each delivers care and improves outcomes in a way that is fair and consistent.

Current complex care programs use several criteria to identify people who would be considered to have complex health and social needs, including their age, chronic conditions such as diabetes or heart disease, behavioral health, what insurance they have, and how many times they use the emergency department or are admitted to the hospital. These programs also have access to different types of data such as insurance claims and medical records but not everyone uses the same sources and may not collect the same information. Because of this variation between programs, we need to identify a standard way to define these individuals and how to collect that data.

The same challenge exists in identifying what areas are most important to measure since complex care programs may prioritize different measures. Most track whether they are able to decrease use of the healthcare system and/or costs along with other measures on specific areas of interest to that program. Based on our literature searches and conversations with experts, we propose important areas or domains of measures that expand the current focus beyond just cost and identified what measures or measure concepts might be considered for use within each area. We also identified areas where other solutions such as reporting stratified data or creating standards might be better solutions.

Recommendations

While the four areas could be viewed as barriers to moving forward, they can also be viewed as opportunities due to the number of groups working within this space and the interest of many to advance this field. Based on our findings, we developed the following recommendations:

1. Determine a process for measure development/alignment based on the intended use(s) of the measures. If the goal is to compare how well programs provide care and improve patient outcomes, then there will need to be agreement on who should be considered“complex” and what data will be used.
2.  Determine a pathway toward a standard denominator.
3. Consider alternative approaches to standardization. For example, could we allow groups to use their own screening tools as long as we are able to map the results back to standardized data definitions?
4.  Target measurement, standards, and data stratification within five domains:Effectiveness/quality of services, equity, health and well-being, service delivery, and cost/utilization.
5.  Promote the development and selection of measures based on patient-driven priorities.
6. Develop and/or select a core set of measures for longitudinal evaluations of program effectiveness paired with additional sets based on the populations of interest and prioritized domains of care.
7. Collaborate with key partners working in this space.8. Build capacity and processes to capture best practices and innovative approaches used in the field for broader dissemination.

Find this report’s accompanying brief, Standardizing quality measurement in complex care, here.