Creating a framework for change: transitioning to value-based healthcare in Queensland
Belinda Gavaghan A * , Jennifer Finch A and Katelyn Clarke AA
Abstract
Value-based healthcare has been described as the sustainable, equitable and transparent use of healthcare resources to achieve improved experiences and outcomes for people and communities. It is supported by all levels of government in Australia, with recent initiatives championing a shift away from traditional, clinician-centric care delivery to a more contemporary, value-based approach. To date, however, efforts in Queensland have focused on smaller scale siloed models of care and have not extended to the transformational change required to create equitable and sustainable healthcare delivery. The Queensland Health Allied Health Framework for Value-Based Health Care (the Framework) builds on contemporary frameworks with reference to the local context in Queensland and provides a structure and starting point for clinicians and managers to work together with consumers to transform services to focus on preventative health and wellbeing, shifting the focus of care to the community and sustainably improving the quality of care delivered. The Framework outlines key considerations for the design and implementation of new services, including understanding the care pathway, supporting an outcome driven workplace culture, measuring what matters and designing for outcomes. Several key lessons were learnt during the development of the Framework, including the importance of early and sustained consumer partnerships, of establishing a shared definition of value-based healthcare that enables integration across the care pathway and the need for leadership at all levels to actively support the change management process. While developed for Queensland public allied health services, the Framework is intended to be a system-wide tool relevant to all health professionals and services.
Keywords: allied health services, consumer engagement, health service innovation, value‐based healthcare.
Introduction
Australia’s health system is generally considered to be one of the best in the world, characterised by universal public coverage, high average life expectancy and low rates of infant mortality.1 Gains in health and care at the individual and population level, however, have come with increased costs from technological advancements, rising demands associated with an aging population and growing rates of chronic and complex disease.2–4 This cost burden contributes to inequity between the most and least advantaged members of the community and the application of Tudor Hart’s Inverse Care Law, where the availability of and access to high quality, comprehensive health care varies inversely with population need.5,6 Value-based healthcare (VBHC) has emerged over the past 20 years as one approach to increase the sustainability and efficiency of health services.7
VBHC is the ‘the equitable, sustainable and transparent use of the available resources to achieve better outcomes and experiences for every person’ (p. 8).8 When originally described by Porter and Teisberg, the VBHC approach changed the direction of competition between providers to the value they generated for patients and funders across the care journey.9,10 However, the implementation of such approaches have differed significantly, with VBHC frequently used as an umbrella term for a range of activities including quality improvement, disinvestment and cost-minimisation. Additionally, many health systems have experimented with Patient Reported Outcome Measures (PROMs) and value-based payment models, where fee-for-service models are replaced with an approach that ties reimbursement to cost and quality.11
All levels of government in Australia have indicated a strong commitment to VBHC. The National Health Reform Agreement 2020–2025 and the 2020 Addendum12 include an emphasis on the establishment of strong partnerships, improved local accountability and support for local planning, pooled funding and payment for outcomes. Despite this policy imperative, a widespread shift to VBHC in Australia, as in other comparable countries, has stalled due to regulatory and policy challenges, misaligned funding systems, interoperability of systems and platforms across settings and the complexity of implementing transformative change.10,11 Additionally, many of the components of VBHC, as described by Porter and Teisberg, are not feasible outside of the United States, and there is little evidence of the benefits of a one-size-fits-all approach to outcome-based payments.7,10 To date, efforts to shift away from traditional, conservative paradigms of healthcare delivery towards a value-based approach have tended to be siloed, with local pilot programs running in parallel to usual care.13
Allied health professionals are a diverse and multidisciplinary group of health practitioners who work to improve health outcomes and promote wellbeing across the full care journey, playing a significant and irreplaceable role in the management of chronic disease and multimorbidity.14 While some work has been done to identify how allied health professionals create and optimise value in the system, it has typically focused on isolated components of value, such as minimising errors in diagnosis, discontinuing low or no value interventions and demonstrating return on investment and cost efficiency, rather than the definition of value that also considers outcomes that matter to people and communities.14–16
In 2020, the Office of the Chief Allied Health Officer, Clinical Excellence Queensland, partnered with the Australian Healthcare and Hospitals Association (AHHA) to undertake a program of work to optimise opportunities from a system-level commitment to VBHC in Queensland and address challenges to the implementation of holistic cross-sector innovation. The program was also undertaken to shift the narrative and reconceptualise health as more than the absence of disease, utilising Singapore’s ‘Three Beyonds’ approach to VBHC transformation: ‘beyond healthcare to health, beyond hospital to community and beyond quality to value’ (p. 1098).17 While many frameworks, including the work of Porter, Teisberg and colleagues,9,18 theories of implementation science19 and recommendations for complex innovation20 exist to support VBHC, none were identified to be fit-for-purpose in their entirety for the local context in Queensland, nor for the knowledge, experience and identified need of the allied health workforce. The first phase of this program included the co-design of the Queensland Health Allied Health Framework for Value-Based Health Care (the Framework)21 with consumers and clinicians. The second phase involved implementing and evaluating the Framework within selected Queensland Health services.
Methods
The Framework was developed in partnership with AHHA and utilised an iterative approach (Fig. 1) to ensure collaborative engagement between consumers, clinicians, managers and health service executives.
Evidence review
A detailed literature review was undertaken to understand the current evidence base and identify existing frameworks and structures supporting VBHC design and implementation, both in Australia and internationally.
Ethics
This paper reports on the development of the Queensland Health Framework for Value-based Health Care. Approval from a Human Research Ethics Committee was not obtained for the development of the Framework. A risk assessment, however, was undertaken at the commencement of the project, including the identification of potential impacts on individuals and communities who participated in the consultation. The principles outlined in the Declaration of Helsinki were met and the project was undertaken with appropriate informed consent of participants.
Clinician and consumer engagement
Between July 2021 and April 2022, a total of eight workshops with two separate stakeholder reference groups, an allied health stakeholder group and a consumer group, were facilitated in parallel by acknowledged Australian experts actively involved in the advocacy and implementation of successful VBHC. The allied health stakeholder reference group was comprised of 25 clinicians, service leads and executives from a broad range of allied health professional backgrounds, from acute and community settings in metropolitan, regional and rural areas of Queensland. In addition to informing the development of the Framework, the purpose of the workshops was to create a shared understanding of VBHC and build the capacity and capability of participants to design and implement VBHC models and services. In parallel to the allied health stakeholder reference group, a second set of consultation workshops were held with a diverse group of seven consumer representatives from metropolitan, regional and rural areas, recruited through an expression of interest process facilitated by the peak consumer representative organisation in Queensland.
The same consultation process was used for both stakeholder groups. Workshop discussions included: an introduction to VBHC concepts and methodology; the enabling context, policy and institutional arrangements; data and resources to measure outcomes and costs; readiness for implementation and outcome-based payment options; and perspectives of consumers, clinicians and other stakeholders regarding the proposed Fframework. The five core elements of the Framework for Implementing Value-based Health Care by Teisberg and colleagues18 were utilised and included: understanding the shared needs of patients; designing solutions to improve health outcomes; integrating learning teams; measuring health outcomes and costs; and expanding partnerships. This became the ‘strawman proposal’ on which the Framework was developed.
Further consultation with the broader Queensland Health workforce was undertaken following the development of the draft Framework. A webinar for Queensland Health staff was held, with links to the recording promoted widely to the allied health workforce. An online survey was used to collect feedback from stakeholders on the comprehensiveness, utility and clarity of the draft Framework, as well as the integration of theoretical content and practical materials. Written submissions were also accepted, and presentations provided to allied health leadership groups, with additional feedback obtained during meetings and workshop sessions.
The final Framework
The finalised Framework outlines five key domains (Fig. 2) that should be considered throughout the VBHC design and implementation journey. Designed as a practical tool, the Framework includes key questions for each domain, considerations for partnerships at each stage and Australian case studies to showcase work currently underway and communicate contemporary, adaptable lessons to inform the development and implementation of VBHC models and services. The phased approach to development and consultation contributes to the Framework being reflective of the unique context of the public health service, as well as the needs of consumers and Queensland communities.
Findings
Several key lessons were learnt during the development of the Framework, as described below.
Consumers at the centre of care
A VBHC approach recognises the essential role of consumers in redesigning care to ensure the outcomes that matter to people and communities are at the centre of service delivery.9,18,22,23 Although there was widespread agreement on the importance of consumer partnerships, allied health stakeholders identified challenges in engaging with consumers and establishing consumer partnerships at the outset of the development of new models and services. Challenges included a lack of awareness of the importance and value of consumer co-design as well as practical strategies to engage with consumers. In line with contemporary practice, the Framework includes guidance and support for clinicians and health service managers to ensure consumer voices are at the centre of VBHC initiatives and reform opportunities from project inception.22,24
The role of consumers in the Framework co-design process
At the commencement of the stakeholder consultation process, the Office of the Chief Allied Health Officer perceived a potential imbalance between the voices of allied health and consumer stakeholders and subsequently implemented identical parallel consultation processes for the two stakeholder groups. The outcomes from both consultation processes were similar, as both groups identified common issues and requirements for the Framework. It was acknowledged that the separation of the two groups was not only unnecessary, but also a missed opportunity for the allied health stakeholder group to participate in a true co-design process, gain insight, experience and strategies to enable successful consumer engagement and further realise common understandings of the outcomes that matter to people and communities. In line with VBHC research and frameworks for implementation, this process reinforced the importance of placing the consumer at the centre of the redesign process, as well as at the centre of care delivery.7,8,18,24
Value is more than disinvestment and cost-cutting
All stakeholders identified the importance and benefits of VBHC at a conceptual level. However, allied health stakeholders identified challenges in applying a holistic definition of VBHC, and tended to rely on evidence-based practice, disinvestment or a reduction in unwarranted variation as their frame of reference. While all have been used successfully to increase cost-effectiveness of service delivery from a health service perspective, none represent the holistic change that is required to reorient services and improve value for consumers.7,18 Of the ‘Three Beyonds’, a move away from hospital-centric care to a more community and social focus was identified to be the most challenging, as it requires a shift in investment toward prevention and a focus on the care that matters most to people and communities.17
The focus on the Queensland public allied health service is recognised as a limitation of the Framework and process of development, reducing the opportunity to work in partnership with primary care services to take a holistic view across the care pathway. The separation between primary and acute care in Australia was consistently identified as a key challenge to the successful implementation of VBHC models and services. The Framework includes guidance for services to consider care across the patient journey, seeking opportunities for cross-service and cross-sector partnerships to enable the delivery of more coordinated and integrated care. Opportunities to shift funding to support the delivery of care where it has most impact should also be considered, as well as the standardised collection of outcome measures to inform care delivery and funding strategies.7,25
Leadership at all levels is required for cultural change
VBHC requires a cultural shift to reconceptualise health as more than the absence of disease.17 External facing organisational leadership is well recognised as one of the most important factors supporting cultural change and the implementation of innovative and challenging programs.23 Consistent with contemporary research, it was identified that successful and sustained implementation of VBHC initiatives in Queensland requires commitment, involvement and accountability from health service leaders, as well as a culture where the workforce feels valued, important and has permission to lead change.16,22,26
Diversity and breadth of experience is required for the successful delivery of VBHC
Teisberg and colleagues identified that VBHC requires care to be delivered by integrated multidisciplinary teams.18 Consultation with consumers and allied health stakeholders consistently identified the different roles played in the development and delivery of new models and services, the breadth of experiences that inform and encompass VBHC and the importance of shared accountability and sustained, genuine partnerships between consumers and healthcare providers. It is well recognised that individual service providers, teams and consumers bring strengths and pose challenges unique to their own community and consequently prioritise clinical services, health and other outcomes, drive value and integrate practice changes differently.27,28 Although the scope and pace of VBHC transformation will likely vary, it is anticipated that implementing the Framework through diverse multidisciplinary and cross-sectoral partnerships, communication and collaboration with consumers and communities, will assist in the dissemination of lessons, avoid duplication and enhance value in the health system.
A Framework for the broader health workforce
The Framework was developed for Queensland Health allied health professionals and recognises their unique role in supporting health and wellbeing across the life course.15 The diversity of allied health professions as well as the differing experiences, challenges and opportunities that encompass VBHC transformation mean that the Framework is applicable for all healthcare professions, services and settings. As the project was allied health-led, a strategic decision was made to take an allied health focus, however, the Framework is intended to be a system-wide tool relevant to all health professionals and services.
Conclusion
The Framework provides a reference guide for health services, together with consumers and communities, to discuss, develop, implement and sustain VBHC initiatives. It recognises the breadth of experiences and unique opportunities faced by different services and the importance of establishing strong consumer and cross-sector partnerships from the outset at the service design, and over the life of the implementation process. It also recognises the challenges in shifting away from traditional business and service models predominantly based on achieving volume and activity-based outcomes, and the need for strong leadership, effective communication and nuanced change management strategies and processes. The Framework is intended to be a dynamic and agile tool that reflects the need and meets the demand for more rapid evolution of healthcare delivery. While it recognises the unique position of allied health professionals to lead VBHC transformation, the Framework is relevant and applicable for all health professionals, services and settings. Consumers and communities are at the centre of health care, and VBHC is not about having everything in place at the outset of a new model or service, it is about starting where you can, working within your sphere of influence, creating and nurturing genuine partnerships and collaborating to make change over time.
Data availability
Data generated during the development of the Framework is available from the primary author.
Declaration of funding
Funding for this work was provided by the Office of the Chief Allied Health Officer, Clinical Excellence Queensland, Queensland Health.
Acknowledgements
The Office of the Chief Allied Health Officer recognises and sincerely thanks Kylie Woolcock, Emma Hoban, Suzzie Harvey and Naomi Sheridan from the Australian Healthcare and Hospitals Association for their generous and collaborative partnership, effort and expertise in the development, implementation and evaluation of the Queensland Health Allied Health Framework for Value-Based Health Care.
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