Why It Matters
A new measurement framework gives communities, nonprofits, health care systems, and the federal government a common "language" to use to improve population health together.
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How Do You Measure Health?

By Julia Nagy | Tuesday, June 4, 2019

Photo by William Warby | Unsplash

Take a moment to imagine a ladder with steps numbered from zero at the bottom to ten at the top. The top of the ladder represents the best possible life for you. The bottom of the ladder represents the worst possible life for you.

Could you say where on the ladder you stand right now? Could you say where you think you’ll stand in five years? Since you are familiar with your own life — including your physical and mental health and financial situation — the answer is likely yes.

In fact, these two simple questions — called Cantril’s Self-Anchoring Striving Scale — can help you understand the health and well-being of your panel of patients or your town or community. Unlike pay for performance measures — such as morbidity, mortality, and cost — these are some of the most evidence-based questions you can ask. They are the basis of the Gallup World Poll, a collection of nationally representative surveys conducted in over 150 countries around the globe.

Cantril’s Ladder is one example of the kind of multisector measures relevant to health care and stakeholders including education, criminal justice, and business offered by the newly launched Well-being in the Nation (WIN) Measurement Framework. Developed in collaboration with the National Committee on Vital and Health Statistics, the federal interagency group directed by the US Secretary of Health and Human Services to identify measures for population and community health, WIN establishes a living library of powerful, evidence-based measures for population health and social determinants. Over the last 18 months, 100 Million Healthier Lives (a multi-partner effort convened by IHI) facilitated this work with the input of more than 100 expert contributors. These measures can be used to understand the overall well-being of people and communities as well as specific outcomes (from mental health to high school graduation rates). They can also be used to advance equity and promote collaboration. Many of the indicators, including Cantril’s Ladder, were chosen because they can indicate improvement in as little as six months.

The WIN Measurement Framework builds on other community-level health measurement platforms in several ways. Like County Health Rankings & Roadmaps and the US News & World Report Healthiest Communities rankings, the WIN framework looks beyond health behaviors and outcomes. WIN offers a set of nine “Core Measures” related to the well-being of people, the well-being of places, and equity. In addition, there are a powerful set of “Leading Indicators,” measures grouped by social determinants such as community vitality, housing, transportation, and environment. Finally, there is a “Flexible Expanded Set” of measures — including access to broadband internet and perceptions of everyday racism — that seem to have significant impact on health and life outcomes, don’t (yet) qualify as a Leading Indicator, but may in the future be added or removed as the evidence or data availability changes.

With more than half of its Core Measures focused on measuring inequities, the WIN framework demonstrates a greater emphasis on equity than most other frameworks. To ensure that development of the framework itself was equitable, participants from across sectors contributed measures during multiple rounds of participation. Most powerfully, WIN prioritizes measures that rely on individuals to define what matters to them in the context of their lives. Research based on over 10 years of data indicates that people’s perceptions of their lives are some of the most powerful predictors of morbidity, mortality, and cost.

A group of public and private partners — including the Well Being Trust, the American Heart Association, Kaiser Permanente, the Health Partners Institute, the National Council on Aging, US News & World Report, Delaware Substance Abuse and Mental Health, and 100 Million Healthier Lives — have committed to adopting measures in the WIN framework. This group represents the first large-scale, public-private collaborative across the US of implementation partners committed to learning together about how to drive the improvement of the health, well-being, and equity of people and communities. They also invite others to join them in the effort.

How to Use the WIN Framework

Various health and community system stakeholders can use the WIN framework in different ways. Here are some possibilities:

  • Clinic directors might use the framework to learn that their community has a higher than average proportion of individuals who worried in the last year that they would run out of money to buy food.
  • Care teams, payers, or ACOs could use the Cantril’s Ladder questions to risk stratify a population to prioritize care management resources.
  • Hospitals can use the WIN measures as part of their community health needs assessment process.
  • Employers could use the WIN framework to understand how the strengths or weaknesses of housing and transportation in their community affects their employees.
  • Researchers and improvers can use it to understand the impact of population and community health interventions over time.
  • Veterans’ advocates can use the WIN Framework to assess both housing and health needs.
  • Patients and community residents can use measures to set life goals.

Go to the Well-being in the Nation Measurement Framework website to download the full report with all the measures. Use interactive maps and charts to see how WIN measures would work on the national, state, and county levels. Get guides to using WIN measures in your population or community. Learn more about the evolution of the WIN measurement framework.

Julia Nagy is an IHI project coordinator.

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