Care Coordination PROMs

Patient-reported outcomes measures (PROMs) are a critical component of assessing whether clinicians are improving the health of patients. Unlike process measures, which capture provider productivity and adherence to the standards of recommended care, or patient experience measures, which focus on aspects of care delivery such as communication, PROMs attempt to capture whether the services provided actually improved patients' health and sense of well-being.

As an invited speaker at this year's CMSA conference in 'weird' Austin, Texas, I spoke about the infrastructure, organization and outcomes of a value based hospital case management program. Inasmuch as hospital case management is typically used to describe a compilation of several services,  in the short time I had available, I chose to focus on the key component of a fully successful case management program: care coordination.  

Paraphrasing the NQF and the AHRQ, care coordination is the deliberate, proactive, and longitudinal process to advocate for patients across the continuum to reduce excessive, wasteful, duplicate or potentially harmful interventions; to promote safe, timely delivery of care; to encourage and facilitate communication between patients and families and care team members; to promote continuity as the patient navigates the system; and to make sure each member of the care team understand the goals of treatment and work together for timely transition.

Value  is defined as the usefulness of a product or service weighed against the costs of that service and is often displayed as an equation:  Value = Quality/Costs.  Therefore, case management program directors must focus on developing report cards that demonstate the value of of each component of the hospital's case management program but most especially, care coordination.

Most hospital leaders capture the process of care to measure improvement but value based care coordination requires that we define what consitututes a good outcome from the patient's perspective.  The difference is substantial.  An important process outcome might be that all the hip replacement patients receive care according to a standardized evidenced based protocol. But the patient that comes to the hospital for a hip replacement gives little thought to whether the surgeon uses a protocol.  This metric fails to capture the very reason that most patients seek care, which is to improve their symptoms. A patient-centered outcome for a hip replacement would therefore require that we evaluate, among other things, the patient's level of function over time to measure the value of the procedure.

Patient Reported Outcome Measures (PROMs) are powerful tools to use because they use validated questionnaires to turn a symptom into a numerical score.  They have become the gold standard for assessing subjective experiences of patients. Many PROMs capture quality-of-life issues that are the very reasons that most patients seek care and are relevant for nearly every diagnosis.  PROMs matter to the patient and are always reported by the patient such as pain, fatique, anxiety, depression, quality of life, and functionality.  Among the tools that have been around for a while are the SF-12 and the SF-36, multi-item, patient reported survey of  perceived health status and overall physical and emotional well-being that is not specific to any disease.

There is the Breast Cancer Chemotherapy Questionnaire that was developed to measure outcomes of women with stage II breast cancer receiving adjuvant chemotherapy.  There's also the How's Your Health? questionnaire that's been around since 1994 and is regularlty used by Mayo Clinic and many primary care clinics and practices across the country.  The EAS temperament questionnaire self-reports 20 items to measure distress, fearfulness, anger, activity, and sociability, and the generic quality of life tool, EQ-5D, measures 5 dimensions of health including mobility, self-care, usual activities, pain/discomfort and anxiety/depression.  There are tools for prostate surgery (EPIC-CP) and the Seattle Angina Questionnaire used by patients to evaluate how much their chest pain has dissipated following cardiac cath. 

These are just a few examples of PROMs but it takes some careful planning to elicit the patient's response. Which is why PROMs are perfect instruments for hospital care managers who may follow high risk patients through their acute hospitalization and transitions of care, and sometimes through Transitional Care extending 30,60 or 90 days. Patients must be engaged and informed about the purpose and value of completing another form so make it as easy as possible.

There are several modes of reaching patients where its convenient for them.  It can be a paper form that the patient can complete at home or a questionnaire used as part of a telephonic or in-person interview.  More and more, organizations are using electronic data capture with a tablet, smart phone, or web.  Every tool has rigorous instructions on how they are administered to avoid bias, increase compliance, and promote consistency across sites, patients, and visits. 

Another rule of thumb is to make it fast...For example, the KOOS questionnaire has 42 questions related to knee injury and osteoarthritis which is a heavy load for most patients.  Beyond 24-30 questions, patients simply stop answering.  So find the most actionable, relevant PROM for a condition, and ask once per year, perhaps twice, if the patient has surgery. 

And finally, the biggest determinent of whether a patient answers a PROM is whether her physician bothered to look at her answers the last time the questionnaire was completed.  If a patient sees the physician referring to a survey, research reports that response rates will be high.  But ignoring the effort the patient put in, will cabosh the entire project.  For example, at Brigham and Women's Hospital, radiation oncologists use a PROM to ask about side effects of treatment and then use the information when considering a dose adjustment.  Collection rates by this group are 100% because the patient perceives value in answering the questions.    

Outcome reporting is essential for every hospital case management program especially as they extend scope of services into the community with Transitional Care programs and Population Health. We suggest using a PROM platform to capture data directly from patients and embed the results into the EHR. Not only will this reduce clerical burden, the information can be used for screening purposes and can be referenced in clinical notes reducing documentation burden.  

The list of validated PROMs is extensive and should be part of any transformtion of your care coordination program. While hospital execs are grappling with how to make PROMs an integral part of the care we provide, the challenge is to "use outcomes to understand, and then to meaningfully transform, what we do to provide the highest value care to our patients."