Outcomes & Value part 1- whose outcome is it?

​I have always been interested in outcomes and the measurement of change in the people I work with. In fact, I spent quite a few months writing several thousand words on this very subject for my master’s dissertation and the phrase “I love a spreadsheet me” has often been whispered in my presence. Enough said on that subject though.

Looking back on this got me thinking about measuring change – How do we ensure that the people we are working with are fairly represented? How can we make sure that any change is meaningful? How do we demonstrate value and evidence progress?

So, who’s outcome is it?

This is an important question to think about when we consider the significant effort and (all too often) sacrifice that has been made to engage and participate in interventions and activities that are designed to stimulate change. There are “costs” associated with this – emotional, physical, social, psychological, environmental, spiritual, financial etc. etc. We need to remind ourselves of this and not lose sight of the person behind the numbers and graphs – balancing the quantitative snapshot with the qualitative detail of peoples lived experience of change.
​
It’s not difficult to translate what we do with people, as case managers, therapists, doctors, solicitors… into numbers to demonstrate that a change has occurred between two-time frames and there are plenty of tools to enable us to do this – 

'Mrs S can now wash, dress and toilet themselves with moderate instead of full assistance',

'Mr B can achieve 60° instead of 30° active elbow flexion'…
​

​​We get a nice graph, everyone’s happy…or are they? Whilst this allows us to compare progress between individuals, professionals, and services, does it compare progress within the person? Does it really articulate what is important on an individual level?
​
Being able to communicate change in a meaningful way that makes sense to a wide audience is a skill that is refined over time and developed through discussion and active listening. We don’t always get it right and can lose sight of the person behind the statistics if we are too focused on the numbers and providing data. That’s why we need to gather a variety of information that serves multiple purposes.

As an example, I worked with a young man with a brain injury – James, and his Physio to become stronger and fitter with the aim of him being able to ride his bicycle with his school friend in the local park – his aspiration. He wasn’t very motivated to do activities outside his Physio session and Dad found it difficult to encourage him after school. He did not like tech or gadgets to measure his progress between sessions, he did like taking things apart and putting them back together again.

So… we looked at some bicycles in the right price range, with the right set-up. James chose the one he liked the best and we cut up a picture of it, so it had lots of parts and kept another picture of the whole bicycle as the background. For each part of the bicycle, we assigned a set of exercises and targets. Each time he completed the exercises to within the set targets, he chose the relevant part of his bicycle and stuck this over the top of the background. When he had rebuilt the whole bicycle back together again, we went out and bought the bicycle, and bicycle helmet. We then made a map of the park using a mixture of photographs we took as part of outdoor mobility sessions and drawings that James made. We made a set of mini bicycle stickers and each time he got so far round the park, he put a sticker on the map.
​
James got fitter and stronger, more confident at riding his bicycle until eventually he was able to go on his first bicycle ride around the park with his friend. 

​James, put his bicycle back together and was able to do an activity he enjoyed with the person he enjoyed spending time with. He told everyone about his new bike and how he was now cycling with his friend (as well as how much better he felt, how much less pain he was in and how much better he slept – if you asked him and his Dad!)
The physio was able to demonstrate improvements in range of movement, strength, and balance by being creative with standardised outcome measures which were woven into fun activities.

The case manager was able to demonstrate how James was achieving one of his aspirations through participating in Physiotherapy, how he was able to access equipment that continued to contribute to improving and maintaining his physical, social, and mental health as well as preserving social contact and engagement in age-appropriate activities. He was doing better at school - he was able to concentrate more and had an activity that he could talk about and do with others of his own age.

Change could be demonstrated in terms of what James can now do compared with before. We were not just enabling him to achieve improved range of movement in his affected right arm and leg joints, we were enabling him to achieve so much more. We were demonstrating the change made through outcomes and outputs.

Why does it matter that we differentiate between outcomes versus outputs?

Outcomes personalise the “what's desired” and makes it meaningful. Putting the “what” into context for that individual and not just counting the action or the activity, it is about the personal, individual difference that it makes. It's about focusing on what that person does in their widest sense and context and celebrating how close they come to be being able to achieve or exceed in this. It's important to make sure that the things that the person wants to achieve are made very clear and change is viewed through the lens of the intervention or input that's provided to that person. “How does doing X, or providing Y enable P to achieve the thing they have said they want to be able to do, or be able to do differently?”
 
An output is more like counting or quantifying a specific action or activity; service or product provided without necessarily looking at the wider purpose it achieves. For example, consistently providing P with 15 hours of support a week at home is an output. Whereas 15 hours of support a week at home enables P to go out to work 3 days a week and improve their mental health so they are no longer needing to take antidepressant medication.
 
Outputs feed into outcomes and outcomes provide context and meaning – the “so what” which leads onto “what next, and next, and next….”  Outputs are the pieces of the puzzle, and the outcome is parts of or the whole puzzle.
 
Demonstrating Value

Value is a personal, individualised concept and will mean different things to different people. That is why it can be quite difficult to quantify where several parties are involved, and they are often seeking different examples to demonstrate that value has been provided.
 
In order to achieve this, we need to understand what the expectations are. Sometimes these will be less achievable or less realistic – that does not mean that attempts should not be made to work towards them as there is nothing better than being proved wrong.  Often it is about compromise in such situations and aiming to understand the importance behind expectations and the meaning placed on the aspiration. This then helps in being able to think creatively and proactively about what value means to the different parties and what their needs are from the information we provide.
 
This also links back to being clear and distinguishing between outputs and outcomes as well as devising a clear plan to work towards the desired achievements. This plan needs to articulate what the person will be doing differently rather than a list of actions or tasks that have been completed.
 
Seeking feedback on the information provided will also ensure that there is not a mismatch between what was expected versus what was provided.
 
At Social Return, we provide regular updates and ask for feedback to continually maintain high standards of communication and transparency in our case management activities. We like to be challenged and consider this an important part of our role to achieve the best outcomes for the people we work with.
 
If you would like to find out more about outcomes and value, please contact me on the below details. 
​

Rachel Charles
Case Manager
Social Return Case Management.
[email protected] ​