Leading Better Value Care is one of the programs accelerating the NSW Health move to value based healthcare. It is a statewide priority program that aims to improve the health outcomes and experiences of people with specific conditions or risk factors.

Leading Better Value Care involves collaboration across NSW Health, particularly between the Ministry of Health, the Agency for Clinical Innovation, the Clinical Excellence Commission, the Cancer Institute NSW and local health districts and networks.

The Leading Better Value Care program aims to:

• improve the experiences of providing care
• improve the efficiency and effectiveness of care
• take a systematic approach to embed evidence-based patient centred models or standards of care, which can be tailored at a local level.

Healthcare is changing and so are the needs and expectations of communities, patients and carers.

Healthcare systems are facing important challenges. These include an ageing population, rising prevalence of chronic disease, and new treatments and technologies that allow patients to live longer. These challenges place significant pressure on healthcare systems in terms of the cost of care and sustainability.

The vision for NSW Health is a sustainable health system that delivers outcomes that matter to patients and the community, is personalised, invests in wellness and is digitally enabled. Value-based healthcare will help us to achieve this vision.

In NSW, value-based healthcare means continually striving to deliver care that improves:

• health outcomes that matter to patients
• experiences of receiving care
• experiences of providing care
• effectiveness and efficiency of care.

Leading Better Value Care is one of the key statewide priority programs accelerating the move to value-based healthcare.

The Leading Better Value Care program involves scaling up and rolling out 13 evidence-based clinical initiatives across all 18 health districts and networks.

These shared initial clinical priorities are:

• Osteoarthritis chronic care program (ACI)
• Osteoporosis re-fracture prevention (ACI)
• Chronic heart failure (ACI)
• Chronic obstructive pulmonary disease (ACI)
• Inpatient management of diabetes mellitus (ACI)
• Diabetic high risk foot services (ACI)
• Falls in hospital (CEC)
• Renal supportive care (ACI)
• Hip fracture care (ACI)
• Chronic wound management (ACI)
• Bronchiolitis (ACI)
• Hypofractionated radiotherapy for early stage breast cancer (CINSW)
• Direct access colonoscopy for positive faecal occult blood test (CINSW).

The Agency for Clinical Innovation (ACI), the Clinical Excellence Commission (CEC) and the Cancer Institute NSW (CINSW) are supporting Local Health Districts and Specialty Health Networks in these initiatives.

The specific initiatives being supported by the pillars are outlined above.

The pillars

The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers to design and promote better healthcare for NSW. The ACI has expertise in service redesign and evaluation, specialist advice on healthcare innovation, initiatives including clinical guidelines and models of care, implementation support, knowledge sharing and continuous capability building.

The Clinical Excellence Commission (CEC) provides expertise and assurance of clinical quality and safety improvement across the NSW health system.

The Cancer Institute NSW (CINSW) provides strategic direction for cancer control in NSW. The CINSW is driven by the goals in the NSW Cancer Plan, and works in partnership with all involved in the cancer community to: reduce the incidence of cancer in the community; increase the survival rate for people diagnosed with cancer; improve the quality of life for people with cancer and their carers and  provide a source of expertise on cancer control for the government, health service providers, medical researchers and the general community.

The Leading Better Value Care program is about how we work in partnership to drive improvements in care across the health system.

The ACI supports local health districts and specialty health networks (LHDs and SHNs) with the implementation of clinical initiatives that address 10 of the 13 priorities through:

• expertise and advice specific to each clinical initiative
• provision of baseline data and recommendations
• access to tools, guides and implementation resources
• peer mentoring and collaboration opportunities
• capability development activities, so that local leaders and implementers can be more effective agents of change
• support for clinical redesign, so that improvements to clinical care are sustained
• expertise, advice and support for the implementation of patient reported outcome and experience measures (PRMs).

The CEC supports LHDs and SHNs to drive safety and quality improvements in the care of older people in hospital; specifically, helping to reduce falls and serious harm from falls through:

• a Quality Improvement Collaborative
• educational resources
• practice-based tools and guides
• standards and audit tools.

The CINSW is supporting LHDs and SHNs through the implementation of direct access colonoscopy (DAC) services for patients with a positive FOBT and triaging and prioritisation of colonoscopy wait lists. LHDs and SHNs will be supported to implement DAC through:

• providing a baseline data collection tool, information booklet and telephone support
• access to implementation resources
• providing capability development activities, to support local project leaders to design sustainable change across their service.

By bringing together leaders from primary, community and acute care settings, the ACI, CEC and CINSW can promote an integrated health system, and create appropriate platforms for LHDs and SHNs to share information, ideas, challenges and learnings.

No. The support available through the ACI, CEC and CINSW has been designed to assist sites with the implementation of clinical initiatives to address the shared priorities.

However, LHDs can determine the level of assistance required and how it can best be delivered to meet local needs.

The Ministry of Health and pillars will host some state-wide events to bring relevant parties together to provide updates and share progress.

Additionally, the LBVC Hub which can be used to post and discuss questions and issues and share information, resources and outcomes. See the LBVC Hub on the website for upcoming events: http://collaborate.aci.health.nsw.gov.au/login

The Leading Better Value Care program is a large-scale reform. The challenges vary across each clinical initiative and local sites. However, in general LHDs have reported the following barriers and challenges to date:

• the timeframe
• identifying the right people to drive change
• working within existing competing priorities
• putting a governance structure in place
• agreeing on the implementation methodology.

Some examples of tools or activities that have previously supported successful implementation among districts include:

• clear direction from the Chief Executive as the sponsor to indicate that this work is a priority of the organisation.
• local workshops with clinical leaders collaborating with local teams to develop services and problem solve
• a strong model of sponsorship
• establishment of a steering committee or using an existing relevant, successful steering committee
• peer mentoring to support communities of practice
• cross-sector support to share the load and understand each other’s issues/needs
• providing clinicians with their own data to support better decision making (e.g. clinical audits).

At a local level, the ACI, CEC or CINSW may be able to work with facility teams to plan the necessary improvement. The support offered is tailored to individual site needs – this may involve mentoring, guidance, facilitation and training throughout the project.

There are a number of ways to mobilise local resources. LHDs can:

• build upon existing links with the ACI’s clinical networks to share knowledge, resources and assist with implementation.
• use the implementation, project management and clinical initiative tools developed by the ACI and CEC to build localised resources. The ACI/CEC will work with LHDs to explore what may work best locally.
• redesign and improvement skills: Graduates of the CEC Clinical Leadership Program and/or the ACI Clinical Redesign School
• collaboration with teams working on each of the initiatives across NSW.

The Agency for Clinical Innovation (ACI) Centre for Healthcare Redesign can provide project management tools and guides to underpin a Project Management Office and assist in developing local capability. Implementation tools and links to additional ACI/CEC guides and resources are available on the Leading Better Value Care Hub.

If your Local Health District (LHD) has questions about Leading Better Value Care funding or measurement alignment, please direct these through your LHD Executive Sponsor so that they can be raised and discussed with the Health Reform Branch at the NSW Ministry of Health.

LHDs should consider early engagement and involvement with their Primary Health Network (PHN). This can assist with implementation and support of the clinical initiatives in the community setting. The involvement of primary care in the clinical initiatives will help ensure patients are receiving appropriate care across the care continuum, in turn supporting improved health outcomes and experiences of care.

Practical examples include, involving the PHNs:

• at the outset through membership in local steering groups.
• in the audit and feedback sessions that explore clinical variation in the hospital setting
• in the development of tools and gain community and primary care support.
• in communications about the implementation of LBVC within the LHD.

Not at this stage, although some aspects of the Leading Better Value Care Program can be built upon. For example:

Trials have been conducted in various communities across NSW involving the musculoskeletal models of care being implemented in general practices and other primary care settings. The local musculoskeletal service concept utilises some of the learnings from this work.

The Patient Reported Measures (PRMs) program has also worked with general practice and other primary healthcare settings to implement the routine collection and use of PRM (Outcome and Experience), and will continue to build upon this for the Leading Better Value Care.

Going forward there will be a focus on extending the Leading Better Value Care initiatives into the community, by working with primary and community health providers. This will support care across the patient journey, improve coordination and ensure care is provided in the most appropriate settings.

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There are some unique challenges faced by districts and health services in rural and remote areas. These include:

• a geographically dispersed organisation and population
• coordinating care across state boundaries (e.g. ACT/VIC/NSW)
• access to clinical resources
• engagement and buy-in from clinicians and key stakeholders located at distance from the program lead.

One way to overcome such challenges could be to take advantage of developing technological solutions (telehealth) where possible in the use of technology. Contact the ACI Telehealth Manager , speak to your Program Lead or contribute to the LBVC Hub discussion.

For more information about Leading Better Value Care, speak to your local program lead (if one is in place), refer to this website and/or the Hub collaboration space, or contact the ACI, CEC or CINSW.

The hub and pillar sites have information about specific events related to clinical initiatives.

The Leading Better Value Care program involves scaling up and rolling out 13 evidence-based clinical initiatives across all 18 health districts and networks.

These shared initial clinical priorities are:

• Osteoarthritis chronic care program (ACI)
• Osteoporosis re-fracture prevention (ACI)
• Chronic heart failure (ACI)
• Chronic obstructive pulmonary disease (ACI)
• Inpatient management of diabetes mellitus (ACI)
• Diabetic high risk foot services (ACI)
• Falls in hospital (CEC)
• Renal supportive care (ACI)
• Hip fracture care (ACI)
• Chronic wound management (ACI)
• Bronchiolitis (ACI)
• Hypofractionated radiotherapy for early stage breast cancer (CINSW)
• Direct access colonoscopy for positive faecal occult blood test (CINSW).

Patient reported measures (PRMs) are a direct account of a patient's personal experiences and progress towards their desired health outcomes. They are being systematically collected by NSW Health to improve quality, planning and understand the value our care adds to patients.

PRMs provide timely feedback to healthcare professionals and services about the outcomes and experiences that are important to patients. Collecting and using PRMs offers a more holistic approach to patients care and offers the opportunity to measure the impact of treatment and care where clinical measurement cannot.

For more information about PRMs, including types of measures, how they are collected and used, refer to the ACI website.

A rigorous measurement and evaluation process is applied to each of the Leading Better Value Care clinical initiatives. Progress is monitored across the state and outcomes are measured consistently to demonstrate the impact. Evaluation will enable:

• early learning from implementation
• adjustments to be made along the way
• a summative assessment to guide future policy and funding decisions.

Economic analysis, monitoring reports and formative and summative evaluations are prepared for each Leading Better Value Care clinical initiative. This data and information helps to inform how care is delivered at an individual, service and system level.

The Register of Outcomes, Value and Experience (ROVE) is a virtual registry that joins Leading Better Value Care administrative, clinical and patient reported measures data in one place.