Part of creating a successful integrated care model is to ensure that we personalise our approach as much as possible. This extends to personalising the outcomes that we measure for different people. Both commissioners and providers will need to think about how to personalise the outcomes that they measure. This will ensure that individual needs are addressed, rather than being lost in a system that only measures outcomes on a population level.
Personalising outcomes means focusing on the individual goals of people, rather than simply on their clinical outcomes. A vital part of doing this is using a personalised, individual care plan that lays out the clinical needs of an individual next to the goals and aspirations of that person regarding his or her care. This idea is further detailed in Chapter 6: How do we innovate a new model of care working with users and carers?
WORKING GROUP OPINION
The Population and Outcomes working group had a long discussion of how to personalise outcomes. They discussed the importance of highlighting the fact that different people will think of success in their care in different ways. In order to truly capture whether people are achieving the outcomes and goals that they want to, clinicians and care professionals must engage individually with the people for whom they care and discuss with them their personal aspirations.
The working group decided that it was necessary for care professionals who are coordinating care, whether this be a care coordinator, a GP or someone else, to have in-depth individual conversations with their patients about what constitutes personal success for them and their family.
Below, we set out a series of steps that commissioners and providers can practically use to ensure that they personalise their outcome measurements.
1. Commissioners set quality-of-life outcome goals that facilitate personalisation.
Commissioners set broad outcomes that they will track that include a set of personalised outcomes. This can include things like "Individuals are empowered by their care to remain independent” or "Individuals feel that their care supports them to achieve their personal aspirations.”
2. Individual care professionals and individuals work together to set personal goals.
Providers have in-depth conversations during care planning with individuals that capture personal goals and aspirations in the care plan.
3. Individuals are supported to track the achievement of personal goals.
Providers regularly check-in with people about whether they are achieving their personal goals, and have discussions about what could be improved.
Check and challenge
How can your organisation personalise outcomes and metrics to ensure you are person-centric?