Table 1
Outcomes and associated indicators.
| PHC PLUS EXPECTED CHANGE (OUTCOME) | INDICATOR | DATA SOURCE |
|---|---|---|
| Change in health outcomes of patients | ||
| Improvement in the health outcomes of patients enrolled in the PHC Plus model, as reported by patients | % of PHC Plus registered chronic patients who reported an improvement in their PROM score from baseline to the end of the PHC Plus implementation period | PROM tools for 3 selected chronic care conditions for which tools exist |
| Average % reduction in care cascade gaps for the 5 most prominent PHC Plus services for which temporal change could be managed | Care cascade constructs using NHF and PHC facilities datasets | |
| Improvement in the ability and confidence of patients enrolled in the PHC Plus model to manage the patient’s condition | % of PHC Plus registered chronic patients who reported an improvement in their health literacy score (HLS) from baseline to the end of the PHC Plus implementation period | HLS tool for use in integrated chronic care |
| Lower hospitalization rate/acute conditions rate of patients enrolled in the PHC Plus model | Number of hospitalizations and acute conditions for any of the 11 chronic care conditions per 100 000 PHC Plus registered chronic patients, in the last 12 months | PHC Plus IT system, routine data transferred to NHF (electronic patient records) |
| Change in patient experience with chronic care | ||
| Patients receive a more coordinated range of chronic care services with less fragmentation, as reported through patient-reported experience measures | % of PHC Plus registered chronic patients who reported an improvement in their PREM score from baseline to the end of the PHC Plus implementation period | PREM tool customized for purpose of integrated chronic care model |
| Average number of health services per patient | PHC Plus IT system, routine data transferred to NHF (electronic patient records) | |
| % of PHC Plus registered chronic patients who receive all minimum health services recommended to them | PHC Plus IT system, routine data transferred to NHF (electronic patient records) | |
| Patients have shorter waiting times and report that they can more easily navigate their way through the system | Average waiting time per service received (across each of the 11 chronic diseases) | PHC Plus IT system, routine data transferred to NHF (electronic patient records) |
| Family members are actively involved in patient’s healthcare | % of PHC Plus registered chronic patients who report that they receive targeted support from family members | PREM tool customized for purpose of integrated chronic care model |
| Reduce fragmentation in the provision of chronic care and lower costs | ||
| Lower cost per-patient contact of health service received | Cost per contact-visit in the PHC pilot facilities | PHC Plus IT system, routine data transferred to NHF (electronic patient records) |
| Fewer duplicate laboratory tests | % of registered PHC Plus registered chronic patients who receive a duplicate laboratory test in the last 12 months | PHC Plus IT system, routine data (electronic patient records) |
| Better coordinated care with IT tools to strengthen integration and coordination at the patients, healthcare provider and payer level functioning | % of PHCs who order laboratory tests and receive results electronically | PHC Plus IT system, routine data (electronic patient records) |
| % of times that specialists could access a patient’s electronic record at a location other than the one where the patient was registered, using the Integrated Patient Information System | PHC Plus IT system, routine data (electronic patient records) | |
| % of PHCs who have participated in electronic ordering and receiving results imaging tests performed outside the institution | PHC Plus IT system, routine data (electronic patient records) | |
| Extended screening, prophylactic, and chronic care services | Average number of contact visits to provide expanded scope of services per 1000 population in catchment area, by type of service | PHC Plus IT system, routine data (electronic patient records) |