Improving oral service delivery and outcomes using the principles of VBHC.
Background: Public dental health care system in Victoria (Australia) operates under a fee-for-service funding model which incentivises volume rather than patient outcomes. People who access public dental system are generally more disadvantaged and have poorer oral health outcomes compared to the general population.
To address inequities in access to care and improve health outcomes for people, Dental Health Services Victoria (DHSV), the lead public oral health agency in Victoria, implemented a novel, co-designed, patient-centred Value Based Health Care (VBHC) framework. In designing our VBHC initiative, we used learnings from strategy experts Professor Michael Porter and Elizabeth Teisberg. We adapted Porter and Lee’s VBHC model and contextualised it to the public dental health environment in Australia. Each patient within our VBHC initiative is risk assessed and appropriate care pathways are organised around specific dental conditions. Patient Reported outcomes Measures (PROMs) are captured using ICHOM oral health standard set and patient experience is captured through Patient Reported Experience Measures (PREMS).
Methods: A mixed-method evaluation examined service delivery, clinical and experiential outcomes from patient, staff, and stakeholder perspectives. Participatory action research was used to bring together qualitative narrative-based research and service design methods. Experience-based co-design approach was used to enable staff and consumers to co-design services. Appreciative Inquiry approach was employed to understand patient experience of accessing care and what a holistic, patient-centered understanding of value looks like. A range of patient evaluation tools (experience mapping, empathy mapping) are used to build rapport with patients and families, understand value from patient’s perspective, capture patient experience and evoke patient stories. Value-stream mapping was undertaken using lean methodology with patients, clinicians, and key stakeholders to understand the current state of dental services and map the future, and ideal state.
Results: Our VBHC model of care resulted in the implementation of discrete projects to identify variation, measure costs and outcomes, improve consumer experience, improve culture and capability, harness information technology and communication, and investigate blended funding models that supported VBHC.
Compared to the standard general care clinic, VBHC model showed 44% lower failure to attend rate and 36% higher preventive service utilisation. Higher proportion of clinicians worked to their top scope of practice within a multi-disciplinary team. Approximately 80% of services previously provided by dentists were shifted to oral health therapists and dental assistants, thereby releasing the capacity of dentists to undertake complex treatments.
Significant improvement in patient reported experience and outcome measures were noted. However, interviews showed that multiple understanding and perspectives of ‘value’ existed. Between 2019 and Jan 2021, a total of 15,402 PREMs responses were received from patients. Patients agreed or strongly agreed that: the care they received met their needs (87%); received clear answers to their questions (93%); left their visit knowing what is next (91%); felt they were taken care of during their visit (94%) and felt involved in their treatment and care (94%). Approximately, 72% of the patients felt that the quality of treatment they received was excellent and 20% felt it was good.
Conclusion: Our VBHC initiative offers the highest recognition of what patient’s value while defining health and care outcomes and how this can be achieved within a fee-for-service environment with limited available resources.