A new way to measure outcomes in older adults
Anyone who has worked in senior housing and care has met that person: the care manager, nurse, social worker or doctor who goes the extra mile.
For me, that person was Jane, a health plan care manager in Wisconsin, caring for Mr. T, who lived in a senior apartment building. Mr. T was elderly, and so was Mr. T's cat, Claude. Mr. T loved Claude more than anything, and Claude returned the favor by infesting Mr. T's apartment with fleas.
The manager threatened to call animal control unless Mr. T had his apartment fumigated. Mr. T, on a fixed income, decided that the best way to afford fumigation was to cut back on his medications. The result was deteriorating health for Mr. T, which Jane discovered during a home visit — along with the stack of unfilled prescriptions. Jane talked to her boss, who talked to her boss, who talked to another person in a suit, and together they found money in the care management program budget to pay for fumigation.
The fleas were eradicated, Claude stopped scratching, Mr. T started taking his medications again, and — now that he could stop worrying about losing his beloved cat — began to eat better. He resumed the social life he had let slide, and his health began to improve.
Management's goal was to get rid of the fleas; Mr. T's goal was to keep Claude from going to a shelter; Jane's goal was to help Mr. T. In the end — thanks to Jane — everybody met his or her goal. And isn't that what good care is: helping people achieve their goals, improve health and well-being?
Yet, when we look at our current quality measures, none seem to capture that aspect of quality. Colorectal cancer screening, Blood pressure control, 30-day hospital readmission — they're good measures of care, but they might not speak to what matters most to older adults. Healthcare should consider a person's priorities and goals. Measures should capture what is most important to people, particularly older adults with complex health issues. This is a central tenet of Essential Attributes of a High-Quality System of Care for Adults with Complex Care Needs, developed by national experts in aging and disability.
With support from the SCAN Foundation and the John A. Hartford Foundation, the National Committee for Quality Assurance and six collaborating organizations are experimenting with a new way to measure outcomes in older adults, focusing on person-driven outcomes — identified by residents (and caregivers) as important. This work aims to balance the need for individualized, meaningful goals that guide care with the need for structured, reliable data for quality measurement.
We're testing two approaches:
- Goal attainment scaling: Measure progress toward goals using a defined range of outcomes (expected, better than expected, worse than expected).
- Person-reported outcome measurement: Assess progress on an individualized outcome using a validated set of questions.
Initial findings suggest that these approaches improve the care-planning process and provide valuable data on goals that are important to older adults and their caregivers. They can move us toward a more personalized approach to quality measurement for people with complex needs.
As we experiment with these new approaches, we are developing training materials and a digital application that can be disseminated broadly to organizations that want to use a structured approach to eliciting and monitoring progress on the unique goals of their population. Our next steps will be to create and test quality measures based on person-driven outcomes that can be incorporated into NCQA products, such as the new Long-Term Services and Supports Distinction for Health Plans and Accreditation of Case Management for Long-Term Services and Supports.
You can find information about NCQA's work in this area on our website.
Erin Giovannetti is a senior research scientist, Research & Performance Measurement, at the National Committee for Quality Assurance, a private, 501(c)(3) not-for-profit organization dedicated to improving healthcare quality.
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