The NSW Leading Better Value Care Program (the Program) focusses on delivering better care for patients using a patient experience and health outcomes approach.

The Program is focussed on what patients, clinicians and the public health system value: improving the health of individuals and communities, doing it safely, doing it efficiently and optimising the use of health system resources.

Led by the NSW Ministry of Health (the Ministry), and supported through the Agency for Clinical Innovation (ACI), the Clinical Excellence Commission (CEC) and the Cancer Institute NSW (CINSW), the Program is about improving the experience of care for everyone. The Program builds on previous and current efforts of clinicians, and aims to achieve better health for patients, a better experience of receiving and delivering care and a better use of the financial resources invested.

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.

There are also variations in how care is being provided to patients; often the care provided does not reflect holistic patient needs or expectations. Clinicians are not always providing care that reflects accepted standards. Increasing complexity and multidisciplinary nature of healthcare delivery, means that health services must adapt.

The NSW health system is refocussing away from the traditional approach of measuring value in terms of volume/output (in relation to costs), to measuring value in terms of the Institute for Healthcare Improvement’s Triple Aim of health outcomes, experience of care and efficient and effective care (in relation to costs). The aim is to provide health services that are patient focused, evidence based, safe, high quality, effective and efficient.

The Leading Better Value Care Program has created shared priorities across the NSW health system involving clinicians, pillars, Local Health Districts, Specialty Health Networks and the NSW Ministry of Health.

The Leading Better Value Care Program (the Program) involves scaling up and rolling out evidence-based clinical initiatives that are not currently standardised across NSW but have been demonstrated to be effective.

There are 13 shared initial clinical priorities under the Program. These priorities include people:

1. With osteoarthritis
2. At risk of osteoporotic re-fracture
3. With chronic heart failure in hospital
4. With chronic obstructive pulmonary disease in hospital
5. With diabetes in hospital
6. At risk of diabetes related foot complications
7. Over 70 years of age at high risk of falls in hospital
8. With renal disease to access supportive care
9. Infants with bronchiolitis who need hospital treatment
10. With a broken hip
11. With a wound that is not healing well
12. Who need to have a colonoscopy
13. Who need radiotherapy in the early stages of breast cancer

The Agency for Clinical Innovation, the Clinical Excellence Commission and the Cancer Institute NSW are supporting Local Health Districts and Specialty Health Networks in their implementation.

The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers to design and promote better healthcare for NSW. The ACI have 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 ACI, CEC, CINSW and the NSW Ministry of Health (the Ministry) work in partnership with Local Health Districts (LHDs) and Specialty Health Networks (SHNs) to support the implementation of clinical initiatives that address the 13 priorities under the Leading Better Value Care Program (the Program).

The ACI, CEC and CINSW provide customised support to LHDs and SHNs that is both centralised and local. Where possible various delivery methods, including face to face and video conferencing/webinars, are used.

The ACI supports 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 will lead and support LHDs and SHNs to implement the LBVC Tranche 2 initiative, Direct Access Colonoscopy (DAC). This initiative will primarily focus on increasing access to colonoscopy services after a positive Faecal Occult Blood Test (FOBT) through the:

• implementation of direct access colonoscopy services for patients with a positive FOBT; and
• triaging and prioritisation of colonoscopy wait lists

An Implementation Working Group comprised of clinicians and other key stakeholders has been established to support the localisation of Direct Access services for public patients across NSW. Where possible various delivery methods, including face to face and video conferencing/webinars, will be used. The Implementation Working group, 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 through a shared platform (The HUB)
• Providing capability development activities, to support local project leaders to design sustainable change across their service

Clinical Reference Groups will be established when required and for a defined period of time with the purpose of providing clinical advice and expertise for the design, implementation and evaluation of the DAC project.

The ACI will lead the evaluation of the priorities, assessing their effect on patient outcomes and healthcare costs. Evaluation will enable:

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

The Leading Better Value Care Program (the Program) is about how we work in partnership to drive improvements in care across the health system.  The NSW Ministry of Health, the Agency for Clinical Innovation (ACI), the Clinical Excellence Commission (CEC) and the Cancer Institute NSW (CINSW) acknowledge that health services and clinical staff face many competing priorities. Thus, the Program needs to be efficient and reduce the burden on Local Health Districts (LHDs) and Specialty Health Networks (SHNs).

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 Agency for Clinical Innovation and Clinical Excellence Commission has been designed to assist Local Health Districts (LHDs) with the implementation of clinical initiatives to address the shared eight priorities. However, LHDs can determine the level of assistance required and how it can best be delivered to meet local needs.

The Agency for Clinical Innovation and Clinical Excellence Commission will host a number of state wide events to bring Local Health Districts together to provide updates and share progress. An LBVC Website has been established to ensure consistent messaging. Additionally there is an LBVC Collaborative 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: www.eih.health.nsw.gov.au/lbvc

Local Health Districts (LHDs) have reported the following barriers and challenges to date:

• The Leading Better Value Care Program is a large scale reform to be delivered in a tight time frame
• 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 Local Health 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/needsProviding clinicians with their own data to support better decision making (e.g. clinical audits)

The Agency for Clinical Innovation and the Clinical Excellence Commission encourage LHDs to visit the LBVC Hub to share successes with colleagues: www.eih.health.nsw.gov.au/lbvc

There are a number of ways to mobilise local resources:

• Local Health Districts (LHDs) can build upon existing links with the Agency for Clinical Innovation (ACI) clinical networks to share knowledge, resources and assist with implementation.
• Use the implementation, project management and clinical initiative tools developed by the ACI and Clinical Excellence Commission (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
• The online collaboration space, ‘Leading Better Value Care Hub’, will provide Local Health Districts (LHDs) with essential links to teams working on each of the initiatives across NSW.

Yes, there are a number of Local Health Districts (LHDs) using or developing a Program Management Office (PMO) to support the Leading Better Value Care Program (the Program). This includes an identified Program Lead, who will provide support from a system perspective. A PMO is a key source of documentation, guidance and metrics on the structured and organised way to support the Program. Other LHDs are using existing clinical networks as the structure to implement the Program rather than establish a PMO.

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 Program funding, the next phase of LBVC, e.g. tranche 2, arrangements 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.

Local Health Districts (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 Program.

The Agency for Clinical Innovation and Clinical Excellence Commission recognises some of the unique challenges faced by Local Health Districts (LHDs) and health services in rural and remote areas. These include:

• A geographically dispersed organisation and population
• Coordinating care is difficult in situations that include cross 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

To overcome such challenges might be to take advantage of developing technological solutions where possible in the use of technology. The ACI tele-health program is available to assist LHDs to establish solutions to bridge these challenges.

Patient Reported Measures (PRMs) form an essential component to measuring health outcomes as part of the Leading Better Value Care Program because the evidence around the routine collection, relevance and use of Patient Reported Measures (PRMs) is overwhelmingly positive.

Start by providing information and evidence about the practical use of PRMs. For example, recommend that they begin by asking patients to complete their questionnaire before treatment or consultation (it should not take patients long to do). The completed questionnaire can then form part of a collaborative discussion in consultation between the patient and the clinician, reviewing their answers, and possible need to address any identified issues. Additionally, while technology enables the measurement of physical, physiological or biochemical data of a person, it is not able to provide all the information about a particular treatment, condition or disease (Deshpande, 2011).

Once used as part of routine clinical care, clinicians and managers will understand how PRMs can guide and support their clinical care.

The Agency for Clinical Innovation (ACI) Health Outcomes Team (Patient Reported Measures Program) is available to provide capability training, workshops and implementation support.

Resources on the ACI PRM are available from: www.aci.health.nsw.gov.au/make-it-happen/prms

Sites that have already implemented Patient Reported Measures (PRMs) have reported that using them helps to identify and triage what matters to patients, have discussions regarding their concerns and plan their care and treatment accordingly.

Some patients will require follow up or referrals to other services; however this will not always be the case.

Using existing resources such as Health Pathways, referral pathways or empowering patients (and their families/carers) with exiting self-management guides has been an effective approach to-date. All sites are encouraged to have local discussions about appropriate referral pathways.

Patient Reported Measures (PRMs) can be captured electronically through personal computers, tablet devices or smart-phones, enabling patients (or their families/carers) to self-report on experiences and outcomes.

The Patient Reported Measures Program uses existing stand-alone software to enable the routine collection and use of PRMs electronically amongst their proof-of-concept sites.

The Agency for Clinical Innovation (ACI) Health Outcomes Team, together with eHealth NSW, are currently progressing with an integrated PRM IT solution, to enhance the routine collection and use of PRMs as part of the Leading Better Value Care Program (the Program).

The Health Outcomes Team (Patient Reported Measures Program) is currently working across the clinical priorities to determine the appropriate and logical collection and use of PROMs.

The PROMIS 29 (generic Quality of Life tool) is being recommended across care settings and clinical priority areas as the core PROM; it is important to note that the clinical initiatives may each have their own condition-specific PROMs.

While it is important that measures are collected and compared over time to determine if the patient health outcome has been achieved, the collection and use of PROMS may vary depending upon clinical condition and care setting.

Use of the PROMIS 29 (generic Quality of Life tool) doesn’t stop you using your quality of life tool or any other assessment. PROMIS 29 covers numerous needs of all people with health conditions and will guide your focus. For example, if PROMIS 29 indicates an individual may be depressed, you can then use a validated depression tool to support your discussions and care planning with the patient.

Clinicians have found the use of a quality of life tool to add value to their patient care and treatment. It can increase the clinician’s awareness of the patient’s quality of life and enable them provide more holistic care by capturing what is most important to the patient.

Patients also like self-reporting on what matters most to them. It allows the patient to assess their life as a whole and identify what they want to discuss with their healthcare team. In some cases, it can also provide them the words or permission they need to have these discussions.

Resources on the ACI PRM are available from: www.aci.health.nsw.gov.au/make-it-happen/prms

The Agency for Clinical Innovation (ACI) and Clinical Excellence Commission (CEC) have established a website to keep Local Health District (LHD) sponsors, leads and clinicians informed about current information and services relating to the implementation of Program initiatives. Check back here regularly for the most up to date information. www.eih.health.nsw.gov.au/lbvc

On the website homepage there is a link to the Leading Better Value Care Program Hub, a web based collaboration space for Local Health District (LHDs) project teams. Here local staff can register and collaborate across initiatives sites and districts, and share learnings, templates and resources. LHDs can find practical examples of tools from previous successful implementations. For example peer mentoring to support communities of practice, local workshops with clinical leaders collaborating with local teams to develop services and problem solve. Additionally the hub contains a calendar of the Program events and meetings.