Leading Better Value Care
Elizabeth Koff, Secretary, NSW Health
Improving the health of the community is a fundamental aspiration of any health service. This is against a backdrop of increasing technology, greater patient expectations and rising health costs. Adopting a comprehensive approach to better value healthcare in NSW will help us realise our aspiration. Our better value care strategy will assist us in creating a truly patient-centred system which continues to deliver and measure excellent health outcomes, controls expenditure and enhances experiences of receiving and giving care.
At the annual Leading Better Value Care Forum co-hosted by the Agency for Clinical Innovation (ACI) at the end of May, I was delighted to have the opportunity to engage with clinicians and staff from around the state and share insights on how we are travelling on the journey to better value care. The event attracted more than 200 people from across NSW Health, and it was pleasing to see the positivity from the districts working to improve the experiences and outcomes of care across all settings.
One question that arose was: What is happening in the health system that means we need to articulate better value as an overarching principle of how we deliver healthcare?
The reality is that healthcare worldwide is changing, along with the needs and expectations of patients, carers, clinicians and communities. We are acknowledging and building on the outstanding work of many people across NSW Health to meet these new challenges.
As health professionals know, delivering healthcare is increasingly complex and demanding. There are pressures from service delivery, chronic disease management, emergency department presentations, surgical waiting lists, new technology, the ageing of the population, and the list goes on.
Patients have greater expectations and understanding of what they would like to receive and what they expect from their health journey. The existing literature and the evidence show strongly that consumer driven healthcare will change the ways in which we deliver care.
In line with other industries around the world, digital enablement will also significantly alter the ways in which we will provide care.
Year on year expenditure on healthcare is increasing and demand continues to grow. The important question for us all is: ‘Is this sustainable in the long term?’
In NSW the health system accounts for over a quarter of the state’s annual budget, representing the biggest single expenditure for NSW. Ensuring the sustainability of our system lies at the heart of better value healthcare and as its collective stewards we hold this responsibility for the future.
A number of different initiatives support us in meeting these challenges by providing better outcomes for patients and better value for the health system.
The Leading Better Value Care Program is one of the core approaches supporting this system-wide shift. Since July 2017 we have set up new governance and reporting processes statewide, conducted more than 200 clinical audits and developed 100 local plans to reduce variation in clinical outcomes. By the end of this year there will be a Leading Better Value Care initiative in more than 100 NSW Health facilities.
The work that has been progressed in a system as large as NSW Health has been enabled by the work done by the ACI and the Clinical Excellence Commission (CEC). They have been partnering with local health districts (LHDs), who have embraced the program at all levels, and with clinicians’ support and engagement have been adapting models to local needs.
To make all of this happen, staff from NSW Health pillars have travelled 87,764km or roughly 2.19 times around the Earth.
A large part of the challenge for the NSW health system lies in our size and achieving scalability of initiatives to achieve impact. Knowing this, we began the Leading Better Value Care Program with eight Tranche One clinical initiatives. These were identified based on significant clinician work undertaken through ACI and CEC to determine the best practice models for care delivery. There was also an opportunity for all LHDs and networks to prioritise the clinical initiatives according to their local needs. Tranche One initiatives have provided a focus across the state to move the value-based healthcare agenda forward and help us continue to learn how to achieve outcomes and benefits for all the residents of NSW.
Using the strong foundational work by the ACI and the CEC, for Tranche Two we asked LHDs to nominate new initiatives to create the best impact for patients and our system. This is a systematic approach, embedding good practice and measuring care, experiences and health outcomes.
Putting the patient at the centre – be it as an individual or a specific patient cohort – is core and the most important thing we can do in all care settings.
It is recognised that we need to continue to partner with primary healthcare and other healthcare providers to attain the patient focus and outcomes that we aim for.
A strong evidence-base is essential. The evidence is well-defined in certain areas and we need to deliver healthcare in ways that accord with the evidence. Providing safe and quality patient care is all part of how we achieve better value care.
Similarly, measurement and evaluation of outcomes are essential to define how services will be provided, organised and funded.
In line with the principles of better value care, we need patient reported experiences and outcomes to be accurately reported and recorded. As our data and analytics become more sophisticated, this will help us to understand and deliver the best care for each individual. Using digital health and our analytics framework will be progressive steps in this process.
We have had a successful journey in program funding and counting the National Weighted Activity Units for inpatient care, community care, subacute care and mental healthcare – though this has focused on outputs. As we progress the agenda we will identify and seek other new opportunities to measure outcomes, incentivise and deliver better value care.
We recognise that there are challenges, particularly in rural and remote areas for example, and through events such as the Forum we are collectively learning and sharing ideas to address them.
I also acknowledge that at times it feels like yet another initiative is being rolled out and how do we manage this in our busy work lives. However, we have the foundations in place and we will deliver better value care by being vigilant and focused on what matters to both patients and clinicians.
Chief Executive Comment
Dr Jean-Frédéric Levesque
A value-based approach to deliver healthcare
Internationally, healthcare systems are exploring new ways to organise and finance healthcare to increase value for patients and societies. This comes in part from the realisation that simply increasing volumes of services, under the impetus of activity-based funding and performance reporting metrics, does not necessarily translate into better health and a better experience for patients. These funding models have been demonstrated to drive numbers of hospital visits, consultations and diagnostic and therapeutic procedures. As such, they drive productivity in healthcare but not necessarily appropriateness of care.
In addition, this drive to base the planning and delivery of healthcare from a value perspective also comes from the increasing realisation that clinician and patient assessments about what success looks like very often differ. While clinicians tend to focus on disease control and symptoms management, the issues for patients relate more to quality of life and how they can function in their daily lives. Value is not the same for everyone.
The state’s move to better value care is a welcomed focus on things that matter to patients and complements the clinicians’ more disease-focused approach. One does not go without the other and we need to identify ways for clinicians and patients to share decisions about what is appropriate care, weighing up the potential benefits and risks associated with healthcare.
The challenge is significant – no system has been able to completely resolve how to achieve value-based healthcare. But NSW starts from a strong foundation, with an established suite of evidence-based clinical approaches having been developed over the last decade and a system organisation that allows different partners – LHDs, the Ministry and pillars – to contribute to the approach in a concerted way.
For the ACI, the opportunity is unique. Through explicit processes of identification of what constitutes best practice, rigorous assessment of their health and financial benefits and the alignment of funding incentives, the state has embarked on the implementation at scale of various evidence-based interventions. While many systems have been successful at implementing pilots, few have succeeded to make them business as usual across entire systems.
This is why the focus on better value care, alongside other key priorities, such as increasing integration of care between the acute care sector, primary care and community-based services is so relevant for clinicians. Measuring Patient Reported Outcome Measures and funding new service models will give clinicians the opportunity to tailor care and treatment options according to what matters to patients.
The ACI has been active in supporting the implementation of seven clinical initiatives over the last year and will support the implementation of an additional two over the coming year. We will also be closely involved in the implementation of Patient Reported Measures in clinical settings, building on the pilots established in previous years. For clinicians involved in ACI activities, this means an increasing focus on implementation of new organisational models of care but also the continuation of work aimed at identifying best practice innovations of the future.
Ultimately, we will collectively create a system that maintains its productivity and efficiency, and ensures the delivery of appropriate care while providing services that matter to patients.
Aged Health Network Update
Caring for cognitive impairment now and into the future
The 2018 Care of Confused Hospitalised Older Persons (CHOPs) Knowledge Sharing Forum was live streamed to more than 100 participants across NSW, Queensland, Western Australia and South Australia.
The virtual event, held on 18 May, focused on caring for cognitive impairment now and into the future.
The program explored experiences of the implementation of the CHOPs key principles which are designed to improve experiences and outcomes of confused older people in hospital.
The objectives of the CHOPs program are to:
- sustain implementation at existing sites
- promote and support new sites wanting to implement CHOPs
- identify other models and resources that have been developed.
Professor Sue Kurrle, Clinical Director, Northern Sydney LHD, provided an update on improving outcomes for people with cognitive impairment in hospital. Anne Cumming from the Australian Commission on Safety and Quality in Health Care gave an overview of the Commission’s Cognitive Care Campaign including how it aligns with CHOPs.
A range of staff from across NSW presented on initiatives being undertaken across LHDs. The focus was on integrating the CHOPs key principles within a broader range of programs including the Cognitive Care Campaign, Delirium Clinical Care Standards and the National Standards.
2018 Falls Prevention Forum – Nutrition, Frailty and Falls
The ACI Aged Health and Nutrition Networks attended the Falls Prevention Forum in May to provide information and resources about nutrition, frailty and falls. Resources distributed at the event included information on CHOPs, Nutrition Standards for Adults, Therapeutic Diet Specifications for Adult Inpatients and Nutrition Standards for Consumers of Inpatient Mental Health Services in NSW.
Nutrition and Aged Health Network stand at the NSW Fall Prevention Forum. Photo: Kelli Flowers.
Intellectual Disability Network Update
Exploring mental health issues for people with intellectual disability
A roundtable held in March 2018 explored issues relating to the mental health of people with intellectual disability. The roundtable was hosted by the Department of Developmental Disability Neuropsychiatry (3DN), UNSW Medicine.
People with intellectual disability are 2-3 times more likely to have a mental illness compared to the general population. This is due to the complex effects of intellectual and developmental disability and other medical, social and psychological factors. There are about 400,000 people with intellectual disability in Australia.
The roundtable was officially opened by Minister for Health, the Hon. Brad Hazzard. Australian Disability Discrimination Commissioner Alastair McEwin presented at the event sharing insights and encouraging attendees to continue their work to support people with intellectual disability. Attendees had the opportunity to develop new priorities for action based on research findings from data linkage, policy audits and focus groups.
Professor Julian Trollor from 3DN presented a summary of research findings from the ACI supported partnership project, Improving Mental Health Outcomes for People with an Intellectual Disability. Professor Trollor is an Intellectual Disability Network member and chief investigator for the partnership project which aims to improve access to mental health services and the quality of mental health services for people with an intellectual disability. The partnership project will come to an end in December 2018 and is funded by the National Health and Medical Research Council under its Partnerships for Better Health Project.
A report on the roundtable will be available on the 3DN website. This document can be used to develop and apply an evidence-based approach to mental health service development, policy and reform.
Roundtable participants: Jim Simpson, Julian Trollor, Karen Fisher, Leanne Dowse, Alastair McEwin, Michael Sullivan and Tracey Szanto.
Transition Care Network Update
New transition services for South Western Sydney
South Western Sydney LHD (SWSLHD) has appointed a project officer to assist in the implementation of a model of transition care across the district. The new project officer, Katherine Kelly, is currently meeting with key stakeholders including ACI and Trapeze, mapping existing transition services and identifying service gaps. The inaugural SWSLHD Steering Committee Meeting was held on 27 April.
Redeveloping youth space at Westmead Hospital
An Adolescent and Young Adult Medicine Project User Group (PUG) has been established to work on the redevelopment of prime space at Westmead Hospital dedicated to adolescent and young adult services. The ACI Transition Care Network Coordinator and Support Worker for Western Sydney are members of the PUG. The new space is being designed in consultation with young people to ensure it is a youth friendly space that allows for future growth. The design phase has been completed and construction is planned for later this year.
Celebrating Youth Week 2018
The ACI Transition Care Network and Trapeze celebrated Youth Week 2018 by holding a joint information stall in the foyer of Sydney Children’s Hospital, Randwick on 17 April. The stall promoted Youth Week activities in the South Eastern Sydney LHD, promoted services and raised awareness of young people accessing local health services.
Two young consumers from the Sydney Children’s Hospitals Network Youth Advisory Council, Cooper and Regan Fenton, along with representatives from The Shack at Maroubra, helped out on the day.
An information stall was also held in the Hunter region where 35 young people and adults completed a short survey to determine the preferred and most effective modes of communication between transition care coordinators, clinicians, young people and carers. The majority of respondents indicated that they prefer to receive health information in person when they see their clinician or transition coordinator.
A surprising finding was that while most young people aged 12-15 have an email address, they only check their emails once a week or less. Young adults 16 years and older use email more frequently. The survey confirmed that not everyone has access to the internet.
Amanda Loughman, Nicole Simpson, Silvana Techera, Cooper Fenton, Regan Fenton, Danya Schonberger and Elly Lowery at the Youth Week stall at The Sydney Children’s Hospital, Randwick. Photo: Lynne Brodie.
Anaesthesia and Perioperative Care Network Update
Anaesthesia and Perioperative Care Network welcomes new Co-Chairs
The ACI Anaesthesia and Perioperative Care Network would like to welcome its new Co-Chairs, Dr Richard Halliwell, Dr Arpit Srivastava and Ms Deborah Burrows. The new Co-Chairs joined the network in April 2018.
Dr Halliwell is the Head of the Acute Pain Service, Deputy Director of Anaesthesia, and Head of Research Department of Anaesthesia at Westmead Hospital. He has a keen interest in pain management and is an active member of the Australia and New Zealand Collage of Anaesthetists.
Dr Srivastava is a specialist anaesthetist and currently Director of Cardiothoracic Anaesthesia at Royal North Shore Hospital. He is interested in quality improvement in perioperative medicine and has presented on this topic at regional and national meetings.
Ms Burrows is the District Perioperative Clinical Nurse Consultant in Southern NSW Local Health District. She has worked on many projects with the ACI and has a special interest in education and leadership.
This is an exciting time for the network as it develops a work plan for 2018-19 to realise its vision to:
- address equity of access and outcome issues and determine priority areas for anaesthesia and perioperative services across NSW, in collaboration with local health districts (LHDs) and specialty health networks (SHNs)
- support the delivery of effective patient care driven by patient, family and carer experiences.
Diabetes and Endocrine Network Update
Inpatient management of diabetes mellitus capability program launched
The NSW Diabetes Taskforce has launched a capability program to support junior medical officers (JMOs) and nursing staff to care for people living with diabetes while they are in hospital. This innovative program was developed to support the Leading Better Value Care (LBVC) program.
The capability program aims to improve the outcomes and experience of people living with diabetes while they are in hospital. In particular, it aims to improve the experience of those requiring insulin. Through engagement in the program, the Taskforce hopes to see a reduction in clinical variation and secondary complications due to poor glycaemic management.
The program includes three initiatives:
- The eLearning Program is a series of videos and learning modules that give information on the basics of blood glucose levels and insulin, preventing and managing hypoglycaemia, and safely prescribing and administering insulin. These modules are available via My Health Learning.
- The QStream Solution training app is designed to reinforce the learnings from the eLearning Program. Users’ skills are tested and progressively strengthened through gaming style components. The QStream Solution will be made available to JMOs who complete the modules.
- The Thinksulin app is a clinical decision support tool that will support JMOs to deliver best practice insulin management. The app is available now to download via the iOS App Store and Google Play store.
If you are interested in learning more about the capability program, or want to access further resources to promote the program, visit the Inpatient Management of Diabetes Mellitus Capability webpage.
The eLearning Program gives information on blood glucose levels and insulin, preventing and managing hypoglycaemia, and safely prescribing and administering insulin.
Bringing together rural and regional diabetes teams
The recent Inpatient Management of Diabetes Rural and Regional Workshop brought together project and clinical leads from regional and rural areas of NSW working on the LBVC initiative.
The workshop, held in Sydney on 23 April, provided an opportunity to support LHDs in implementing the inpatient management of diabetes mellitus initiative, recognising the unique challenges and barriers patients face in regional and rural areas.
An important part of the day included working with the ACI’s Centre for Healthcare Redesign to identify solutions that teams could work on to improve care locally. Teams made a commitment to share one piece of information each from their LHD with the group, via the LBVC Hub.
Attendees celebrated some of the successes achieved so far through the LBVC initiative in their LHDs. The Diabetes and Endocrine Network will continue to support opportunities to bring people together to share knowledge, experiences and innovation in diabetes management. Part of this includes the 2018 NSW Diabetes Forum, which will be held on Friday, 15 June. For more information contact Marina Davis, Network Manager, Diabetes and Endocrine, on firstname.lastname@example.org, or visit the Forum website.
Attendees at the Inpatient Management of Diabetes Rural and Regional Workshop. Photo: Marina Davis.
Mental Health Network Update
Meet the new look Mental Health Network Executive Committee
The ACI Mental Health Network recently appointed new members to the Mental Health Network Executive Committee. The committee provides governance for the network’s activities and is representative of the mental health sector.
The committee met for the first time in February for a planning session to revisit key priorities for the network and consider future projects to progress. Members from the committee pitched seven priority projects at the meeting. Members assessed and voted on the projects with the top three potential projects now being reviewed by network members who represent people with a lived experience of mental health issues, carers and clinicians. This will help guide the direction of the future work of the network.
Once the priority projects are determined, the broader network membership will be notified of the outcome and how they can be involved.
Mental Health Network Executive Committee. Photo: Sarah van de Scheur.
Rural Health Network Update
Improving quality of life for residents of multipurpose services facilities
Over the past year, 25 multipurpose services (MPS) sites have participated in the Living Well in MPS Collaborative to implement eight new Principles of Care designed to improve the quality of life for residents.
The aim of the new Principles was to deliver a more homelike environment for residents in MPS facilities, which provide a combination of hospital services and residential aged care in small regional and rural communities.
Over 12 months, more than 350 small-scale strategies were documented on the Plan, Do, Study, Act (PDSA) portal, implemented and embedded as business as usual. Examples of successful strategies include
- introducing social profiles that highlight residents’ likes, dislikes and interests
- implementing care plans based on lifestyle and routines rather than clinical need
- making facilities more homelike by introducing artwork, vegetable gardens and pets
- giving access to recreation and leisure activities involving the community
- replacing tray service with communal table dining and new menus
- using telehealth for dietetic reviews and mobility assessments
- improving access to aged care specific education for MPS staff.
In January 2018, a final evaluation was conducted on the statewide aggregated results. It was found that the project addressed the gaps in residential aged care assessment identified by the Australian Commission on Safety and Quality in Health Care.
Positive differences were documented for process and outcome measures collected. On self-assessments, improvements of 20-40% were achieved across all Principles of Care. The biggest improvements were for the ‘homelike environment’ principle which improved from 6% to 39% and the ‘recreation and leisure’ principle which improved from 7% to 21%. On outcome measures, residents’ physical wellbeing, comfort and relationships (between staff and residents) improved by 10%.
'The Living Well in MPS Collaborative has transformed aged care in our MPS facilities.' LHD Chief Executive.
A report, titled Living Well in Multipurpose Services: Principles in Practice, has been developed to outline the successful strategies. This report was incorporated into the Living Well in MPS Toolkit and is now being used by rural LHDs to spread these small but powerful ideas across NSW. The report, tools and templates are now available on the Living Well in MPS webpage.
MPS Advisory Committee. Photo: Sigrid Patterson.
The Telehealth Capability Interest Group is back
We are pleased to announce that the Telehealth Capability Interest Group (TCIG) is back.
The TCIG is a community of practice that aims to share telehealth initiatives and support clinicians to incorporate telehealth into their practice. Anyone using or interested in using telehealth to connect with their patients is invited to join. The first meeting of the new TCIG was be held on Thursday, 21 June 2018.
The TCIG was established to support clinicians to develop a successful and sustainable telehealth service across NSW. The meetings are designed to help you:
- share information and knowledge
- identify common issues at a state level
- network and build capacity
- identify excellence and promote innovative models
- learn more about the ACI Guidelines for the use of Telehealth for Clinical and Non Clinical settings in NSW.
If you want to learn more about telehealth or share your telehealth knowledge join the group now!
The TCIG will be held on the third Thursday of each month. Each meeting will feature two 20-minute presentations about innovative uses of telehealth in practice. If you have any questions, please get in touch with the ACI Telehealth team at email@example.com or on 0409 382 268.
Drug and Alcohol Network Update
Researching cognitive remediation for alcohol and other drug treatment programs
Up to 80%1 of people accessing treatment for substance use disorders have a degree of cognitive impairment, compared with around 16% of the general population.2
Cognitive impairment impacts a person’s ability to plan, organise, set goals, solve problems, make effective decisions and regulate emotions. People in alcohol and other drug (AOD) treatment programs need these capacities to benefit from treatment.
The goal of the Alcohol and Drug Cognitive Enhancement (ACE) Program is to provide all AOD services in NSW with access to resources that allow them to routinely screen for and accommodate clients with cognitive impairment. The project team has produced a new video that provides an introduction to the ACE Program.
To help achieve its goal the ACE Program is running an exciting cognitive remediation research study in residential treatment settings in NSW. The study intervention is aimed at improving brain executive functioning and treatment outcomes and ten residential sites have been selected to participate from July 2018.
This study seeks to replicate and validate previous trial results and use data collected to develop a suite of tools for services. It will also include a feasibility study to revise the intervention for use in an Aboriginal population.
An online communication platform called Basecamp is available for interested parties to share information, receive updates and ask questions about the ACE Program. You can request access to Basecamp by contacting Angela Wicks on firstname.lastname@example.org or 9464 4638.
For further information about the ACE program, contact Drug and Alcohol Network Manager Antoinette Sedwell on email@example.com or 9464 4634.
1 Marceau EM, Berry J, Lunn J, Kelly PJ, Solowij N. Cognitive remediation improves executive functions, self-regulation and quality of life in residents of a substance use disorder therapeutic community. Drug and Alcohol Dependence. 2017;178:150-8.
2 Marceau EM, Lunn J, Berry J, Kelly PJ, Solowij N. The Montreal Cognitive Assessment (MoCA) is sensitive to head injury and cognitive impairment in a residential alcohol and other drug therapeutic community. Journal of Substance Abuse Treatment. 2015;66:30-6.
Check out the new ACE Program video.
Research Strategy Project Officer
Successful ACI Research Grants for 2018 awarded
We are delighted to announce the recipients of the 2018 ACI Research Grants Scheme.
The scheme funds scientifically excellent translational research, where the research is aligned and consistent with the strategic priorities of the agency and will enable system-wide improvements.
A grant scheme review committee evaluated 54 high-calibre applications, each addressing a significant area of the NSW health system. This resulted in a very competitive selection process.
Congratulations to the researchers who were awarded a grant.
- Alcohol and Drug Cognitive Enhancement (ACE) Program study – Validation of tools for use within an Aboriginal population.
Lead: Antoinette Sedwell
- Implementing a new model of service delivery for knee and hip arthroplasty surgeries
Lead: Dr Richard Walker
- Implementing 'Structured Continence Assessment and Management' for inpatients (I-SCAMP) – SCAMPering across Northern NSW
Lead: Dr Di Marsden
- Investigating different methods of carbohydrate loading in elective colorectal surgery to improve post-operative outcomes
Lead: Trang Soriano
- Translating Eating as Treatment for Head and Neck Cancer (TREAT)
Lead: Dr Ben Britton
- Rural implementation of Best Evidence for Stroke Therapy (BEST)
Lead: Dr Melissa Nott
- Technology assisted early Allied Health Assistant home visits
Lead: Assoc. Prof Geoffrey Murray
- Improving emergency discharge care practices for older people with cognitive impairment returning to the community
Lead: Professor Margaret Fry
- Improving care for patients with low back pain in emergency departments: The SHaPED trial
Lead: Dr Gustavo De Carvalho Machado
- Severe Burn Injury Patient Reported Experiences (PRE) of their Treatment and Recovery at RNSH (SBIU)
Lead: Julia Kwiet