Understanding

the process to develop

a Model of Care
An ACI Framework
A practical guide on how to develop a Model of Care
at the Agency for Clinical Innovation.
Version 1.0, May 2013

AGENCY FOR CLINICAL INNOVATION

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Chatswood NSW 2067

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Chatswood NSW 2057
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SHPN: ACI 130216

ISBN: 978 1 74187 862 2

Further copies of this publication can be obtained from the

Agency for Clinical Innovation website at: www.aci.health.nsw.gov.au

Disclaimer: Content within this publication was accurate at the time of publication.
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indicated above, requires written permission from the Agency for Clinical Innovation.
© Agency for Clinical Innovation 2013

HS13-034
TABLE OF CONTENTS
INTRODUCTION......................................................................................................................... 2
Purpose...............................................................................................................................................................................2
Background.........................................................................................................................................................................2
Guiding principles...............................................................................................................................................................3
What is a MoC?..................................................................................................................................................................3
Developing an MoC............................................................................................................................................................3
The process.........................................................................................................................................................................4
Clinical program design and implementation (CPD&I) team support...................................................................................4
GEM e-Learning portal........................................................................................................................................................4

PHASE 1 – PROJECT INITIATION.................................................................................................. 6

1.1 Issue or opportunity identification.............................................................................................................................. 6
1.2 Create the initial high level case for change................................................................................................................ 6
1.3 Develop a project aim, objectives and scope............................................................................................................... 6
1.4 Generate sponsorship and engagement...................................................................................................................... 7
1.5 Develop a project governance structure...................................................................................................................... 7
1.6 Project management.................................................................................................................................................. 7

PHASE 2 – DIAGNOSTIC............................................................................................................. 8
2.1 Define the problem..................................................................................................................................................... 8
2.2 Understand the “as is”............................................................................................................................................... 8
2.3 Establish data and information sources....................................................................................................................... 8
2.4 Literature review of evidence-based practice and innovation....................................................................................... 9
2.5 Finalise the case for change........................................................................................................................................ 9
2.6 Identification and prioritisation of issues..................................................................................................................... 9
2.7 Examples of work already completed.......................................................................................................................... 9

PHASE 3 – SOLUTION DESIGN.................................................................................................. 10

3.1 Develop a vision for what services should look like.................................................................................................... 10
3.2 Overview of the solution design phase..................................................................................................................... 10
3.3 Current and future context....................................................................................................................................... 10
3.4 Designing solutions....................................................................................................................................................11
3.5 Prioritising solutions...................................................................................................................................................11
3.6 Testing the solutions..................................................................................................................................................11
3.7 Develop an evaluation framework............................................................................................................................. 12
3.8 Develop and document the MoC.............................................................................................................................. 12
3.9 Seek endorsement of the MoC from appropriate stakeholders and sponsors............................................................ 13
3.10 Plan for disinvestment............................................................................................................................................... 13
3.11 Examples of work already completed........................................................................................................................ 13

PHASE 4 – IMPLEMENTATION................................................................................................... 14
4.1 Define the change.................................................................................................................................................... 14
4.2 Self assessment/gap analysis..................................................................................................................................... 14
4.3 Develop the business case and seek endorsement.................................................................................................... 14
4.4 Generate sponsorship for implementation and governance structure........................................................................ 15
4.5 Build frontline capacity and engagement.................................................................................................................. 15
4.6 Communications plan............................................................................................................................................... 15
4.7 Implementation plans/reinforcement strategies......................................................................................................... 15

PHASE 5 – SUSTAINABILITY...................................................................................................... 16
5.1 Ongoing monitoring, continuing local focus and accountability................................................................................ 16
5.2 Review and optimise the MoC.................................................................................................................................. 16
5.3 Final evaluation......................................................................................................................................................... 16
5.4 Knowledge management......................................................................................................................................... 16

Understanding the process to develop a Model of Care in the ACI 1

 INTRODUCTION

Purpose
The aim of this document is to be a reference point for the Agency for Clinical Innovation (ACI) staff when
developing Models of Care (MoC). The document outlines the key processes required to develop a MoC. It is
acknowledged that developing a MoC will vary greatly depending on the size of the project and the subject area.
ACI staff will also bring different skills and expertise, all of which are needed to contribute to the development
of the model. This document offers guidance to assist the development of a MoC. Each project will have its own
unique elements and the guidance will need to be applied slightly differently to each. Some of the ACI human
resources that can assist with developing a MoC are outlined in this document. These guidelines are intended to act
as a reference or guide throughout this process.

Background
The ACI has an extensive network of clinicians and a wealth of clinical expertise. The vision of the ACI is to be
valued as the leader in the health system for designing and supporting the implementation of innovative models of
patient care.1 The concept behind the ACI Clinical Networks is that the knowledge needed and the best innovations
will come from front line clinicians working in the NSW Health system. This document provides a framework for
developing clinician’s ideas into an evidence based, implementable MoC. The process described in this document
should be managed by the ACI, but the ownership and creative process belongs to the networks and their
members. In this way, the end result will be owned by front line clinicians, creating a better product and making it
easier to implement.
Developing a MoC will require a wide range of skills, expertise and processes which include: clinical expertise,
2 Understanding the process to develop a Model of Care in the ACI
communication skills, financial, research, economic & data analysis, evaluation and project management skills. It
will be important to leverage these skills early in the development phase of the MoC. Within the ACI team there is
a wide skill set to enable the team to develop innovative MoC in collaboration with clinicians, patients, health care
partners and the community.
Many of the ACI Networks also work on developing clinical guidelines and although they are different to a MoC,
placing a greater focus on clinical practice rather than the delivery of health services, many of the principles in this
document will also be useful when producing them.

1 Agency For Clinical Innovation Strategic Plan (2012- 2015)

2 Understanding the process to develop a Model of Care in the ACI

Guiding principles
The guiding principles of a MoC are that it:
•  is patient centric
•  has localised flexibility and considers equity of access
•  supports integrated care
•  supports efficient utilisation of resources
•  supports safe, quality care for patients
•  has a robust and standardised set of outcome measures and evaluation processes
•  is innovative and considers new ways of organising and delivering care
•  sets the vision for services in the future

Factors for consideration when you are developing a MoC are that:
•  it is based on the best available evidence
•  it links to strategic plans and initiatives (local, national, state)
•  it is developed in collaboration with clinicians, managers, health care partners, the community, and with patients,
their carers, and or organisations that represent them
•  costing, funding and revenue opportunities for the MoC are identified, and assessed
•  it extends across the patient journey through different care providers
•  specialty and priority populations of patients have been considered

What is a MoC?
A “Model of Care” broadly defines the way health services are delivered. It outlines best practice care and services
for a person, population group or patient cohort as they progress through the stages of a condition, injury or event.
It aims to ensure people get the right care, at the right time, by the right team and in the right place2.

Developing a MoC
When designing a new MoC, the aim is to bring about improvements in service delivery through effecting change.
As such creating a MoC must be considered as a change management process. Development of a new MoC does
not finish when the model is defined, it must also encompass implementation and evaluation of the model and the
change management needed to make that happen.
Developing a MoC is a project and as such should follow a project management methodology. This document uses
the ‘Redesign Methodology’3 to manage the project of developing a MoC.

2 Government of Western Australia, Department of Health (2012) http://www.agedcare.health.wa.gov.au/home/moc.cfm

3 NSW Health (2012) http://www.health.nsw.gov.au/performance/redesign.asp

Understanding the process to develop a Model of Care in the ACI 3

 The process
The process for developing a MoC is illustrated in the flow chart (Diagram 1). The key steps are listed below and will
be described in detail.
Project Initiation: Identify services for review, begin to build a case for change, obtain sponsorship to proceed with
the program of work and set up project management mechanisms.
Diagnostic: Define the extent of the problem and understand the “root cause” to address the real problem.
Solution Design: Develop and select solutions. Create and document the MoC.
Implementation: Support the health system to deliver the changes needed to implement the MoC.
Sustainability: Optimise use of the MoC, monitor the results and evaluate the impact.

Clinical Program Design & Implementation (CPD&I)

Team Support
A snapshot of the support and expertise available to support the MoC Development within the Clinical Program
Design & Implementation (CPD&I) Team is given below:
The Clinical Redesign Implementation team can provide support, expertise and rigour in the development and
implementation of projects and MoC.
Rural Health and Telehealth team can provide expertise in rural health and telehealth to ensure that the needs of
rural and remote health services and communities are considered.
The Centre for Health Care Redesign can provide capability building for staff across the health system in the
area of skills for innovation, redesign and change management, which are key to the development, implementation
and evaluation of MoC.
4 Understanding the process to develop a Model of Care in the ACI
The Health Economics and Analysis team conduct economic, financial and service utilisation impact analyses
of the MoC to determine its viability and develop a business case, business proposal and/or resourcing strategy
to support the MoC. Included in this is consideration of the qualitative and quantitative costs and benefits of
implementing interventions.
Early engagement of the CPD&I teams in the development of a MoC is welcomed. This will support us to work
collaboratively to implement robust systems and processes in our MoC development.

GEM e-Learning Portal

The document is intended to be an outline guide on how to go through the process of creating a new MoC. If more
specific information on different tools and techniques is required then GEM4 is the NSW Health e-learning portal
that brings together the various tools and resources that support redesign and improvement methodologies outlined
in this document. It is accessible to all ACI and NSW Health staff.

4 https://gem.workstar.com.au/public/index.cfm?action=login&returnTo=/

4 Understanding the process to develop a Model of Care in the ACI

Diagram 1: Process Flow Chart for developing a Model of Care (MoC)
This document is used to illustrate the process for developing a Model of Care. It encompasses the work owned by
the project manager and the functions that the Clinical Redesign and Implementation Team assist with.

PROJECT DIAGNOSTIC SOLUTION IMPLEMENTATION SUSTAINABILITY

INITIATION Define the problem DESIGN Support the health Optimise use of the
Identify an area of – understand the Develop and select system to execute MoC, monitor the
need, build a case root cause to treat solutions. Create the changes needed results and evaluate
for change and the real problem and document to implement the the impact
obtain sponsorship and not just the the MoC MoC
symptoms Ongoing monitoring
to proceed with the Define the change The health economics and local accountability.
program of work clearly. team can prepare key
Define the problem
documents to support Review the impact of the
Issue or opportunity using a variety of tools:
Develop the business implementation MoC and adjust practices
arises: case. including:
• Consultation such to optimise use.
• Clinician/ACI as workshops, • Economic Appraisal
Network/Consumer Assist LHDs to conduct
interviews and brain Ensure disinvestment
identified innovation a self assessment/gap • Resourcing Strategy
storming occurs.
analysis. • Business Proposal
• Unwarranted clinical • ‘As is’ analysis – what
variation Seek endorsement Final evaluation of
does it look like now? The team can advise on
of the business case/ economic and clinical
• Priority area (Minister/ • Data review including implementation issues
resourcing strategy. outcomes.
DG/LHD/CEC demand analysis, such as quantifying
• Out of date MoC epidemiology and Generate local executive potential increases Knowledge
service utilisation sponsorship and create in service capacity; Management ‘sharing
Create the initial high a governance structure. quantifying potential our lessons’.
• Financial analysis of
level ‘case for change’ the cost of continuing avoidable future costs;
– quantify the extent of Build the capability of identifying the need
business as usual front line clinicians and
the issue and the cost for additional seeding
of continuing business • Review literature manager to change the
process/system. or recurrent funding;
as usual. and analyse any and identifying areas
innovation already in
Develop and agree Develop a of potential savings
this field
project aim, objectives Communication plan where services may be
and scope. Finalise case for and identify risks discontinued and
change. to implementation. resources redirected.
Generate Sponsorship:
Identification and Develop reinforcement
• ACI executive strategies for LHDs.
sponsorship/ prioritisation of issues.
prioritisation for the
Revisit aims and
program of work
objectives to ensure
• Seek direction project is on track.
from LHD clinicians,
managers and
stakeholders – is this
a piece of work they
will value?

Understanding the process to develop a Model of Care in the ACI 5

 PHASE 1 – PROJECT INITIATION

The aim of this phase is to develop a clear understanding of what your project is and how you plan to tackle all of
the issues that may arise.

1.1 Issue or opportunity identification

There may be many sources for starting to create a new MoC. These may include:
•  Clinician/ACI Network/Consumer identified innovation
•  Unwarranted clinical variation
•  Priority area (Minister/DG/LHD/CEC)
•  Out of date MoC
At this point, it may be considered that the best way to address this issue is through a new MoC. Alternatives may
be through new guidelines, procedures or an education program. Please refer to the definition of a MoC in the
introduction of this document, and feel free to discuss this with our team.

1.2 Create the initial high level case for change

This is creating the argument for change and describes what can be achieved through improving this area of
practice. This work is started during project initiation phase and should be in sufficient detail to convince sponsors
that further work in this area of practice is warranted. At this stage the rationale for action has to be created. This
will
6 be high level atthe
Understanding this stagetoand
process willabe
develop builtofupon
Model Care inand become more detailed during the diagnostic phase and will
the ACI
become the case for change.
The rationale for action should cover both qualitative and quantative information. Qualitative information may
include patient and clinician stories. Quantative information should define the size of the problem for example;
how many patients does it affect, how many lives could be improved and how much healthcare resource could be
diverted to better uses? This will also need to clearly define the patient cohort that the MoC is dealing with. Many
different factors can contribute to the case for change, such as is there identified unwarranted clinical variation? Is
this a priority area for the Local Health District, the Ministry of Health etc?
It needs to be made clear why this project should be prioritised to go forward.

1.3 Develop a Project Aim, Objectives and Scope

The project aim is a high level statement of what the project will achieve. It should be in line with the organisation’s
priorities. Where possible, develop your project aims and objectives with your project team and sponsors and get
“buy in” for them. Clear project aim and objectives will:
•  Ensure that everyone is working towards the same goal
•  Align expectations regarding the project
•  Define clearly what success looks like
The project objectives should outline the specific results and benefits to be achieved in order to reach the project
aim. They should include time frames in which the objectives are to be met (typically 12-24 months or less) and are
targets of defined, measurable achievement. The number of objectives required will depend, to a certain degree, on
your project aim and scope.

6 Understanding the process to develop a Model of Care in the ACI

A clear and concise definition of scope is central to the success of a project. Its purpose is to aid in establishing
realistic work plans, budgets, schedules, and expectations. This should clearly identify work that falls inside and
outside the defined scope and assists define project plans and manage expectations

1.4 Generate sponsorship and engagement

It is important to generate ACI executive sponsorship to ensure the project aligns with NSW Health and ACI
organisational priorities. If there are a number of projects competing for priority then the ACI sponsor/s should
be able to prioritise projects by aligning priorities with the ACI Strategic Plan.

The end users of any MoC will be clinicians and their patients. Throughout the development of the MoC, care
providers, patients/carers and or organisations that represent them should not only be consulted, but should part
of the team developing the MoC. Front line staff, patients/carers and or organisations that represent them will
have the best knowledge and innovative ideas for how services can be delivered. In addition, if clinicians are
involved in developing the MoC then they will have ownership of the changes to their services. Patients and their
carers and or organisations that represent them will provide valuable expertise, insight and experience into
current services and should be actively engaged in all the phases of the MoC development.

The earlier that clinicians and patients/carers and or organisations that can represent them are involved in the
project, the higher the likelihood of creating successful change will be. At this stage it should be established
whether this is a project that will have value for them. Do they consider it an area of priority? If it is not an area
of priority for front line staff and patients, should we be investing resources in this area?

1.5 Develop a project governance structure

The governance arrangements that are necessary will depend on the size of the project. This may include Network
co-chairs or the Network executive. Most projects will require a:
•  Working group – this should consist of relevant network clinicians, front line staff and managers, and should
cover appropriate stakeholders such as rural, indigenous, Culturally and Linguistically Diverse (CALD), consumers
etc. This group will participate in the diagnostic work, solution design and writing of the model.
•  Governance Committee – this committee may be a Network Executive, they will ensure that the project is on
track, is meeting its aims and objectives and is within budget. The members should have the seniority to be able
to solve problems that the project is facing through escalation to appropriate groups.

1.6 Project Management

The development of a MoC is a project, and as such should have appropriate project management mechanisms in
place throughout the project. These include:
•  Managing the scope and aims of the project to ensure that the project is on track
•  Developing and managing the project plan and timelines
•  Managing the team developing the MoC, ensuring that work is completed and deadlines are met
•  Creating and managing risk and issue logs
•  Creating a communication plan and managing stakeholder relationships.
For further detail on project management, there are modules available on GEM via the link provided on page 5.

Understanding the process to develop a Model of Care in the ACI 7

 PHASE 2 – DIAGNOSTIC

2.1 Define the problem

In the ‘Project Initiation’ phase an initial case for change was developed. The Diagnostic Phase will build on this
initial ‘case for change’. The initial problem identified will be the symptom of the problem – the diagnostic process
will enable you to understand the root cause of that problem.

2.2 Understand the ‘as is’

In order to understand how services can be improved, it is important to identify how services are currently being
delivered. It is important to consider issues of equity and access when considering a state wide model. Part of this
should include analysis of the cost of continuing business as usual, which provides analysis of resourcing and service
utilisation projections. For example, Australia has an aging population. If we continue to provide care as we do at
the moment, what will the increased costs of healthcare be in 20 years? The Health Economics and Analysis team
can assist with this work.

2.3 Establish data and information sources

Activities to do this may include:
•  Root Cause Analysis reports
8 Understanding the process to develop a Model of Care in the ACI
•  Process mapping
•  Patient journey mapping
•  Patient/carer/staff interviews
•  Staff/patient tagalongs
•  Process observation
•  Reviewing patient survey results
•  Wait list analysis
•  Economic or financial and resource analysis of the ‘as is’ state projected over an appropriate time frame
•  Issues identification, including analysis of service utilisation, epidemiology of the target patient group and
projection of health care needs
Depending on the size of the project, the diagnostic report may be written up into a paper that will be a supporting
document for the main MoC.
The context of Activity Based Funding and constraints in health funding mean that Models of Care should define
how existing healthcare resources can be better used to meet the needs of the population. For example, preventing
osteoarthritic hip re-fractures saves the cost of treating those patients in an acute setting, releasing the funding for
other uses. ABF data available enables us to compare the cost of the way we currently do business to the cost of
alternate proposed models and is a critical part of the diagnostic process.

8 Understanding the process to develop a Model of Care in the ACI

2.4 Literature review of evidence based practice
and innovation
Evidence Based Practice ensures that clinical practice is based on sound evidence. Critical evaluation of the relevant
literature for the model of care is an essential step in the development of evidence based models of care.
Critical analysis of the literature should provide information on best practice and how different healthcare providers
deliver care, which can then be compared to current practice. It may also provide information on change solutions
already tried and the outcomes and evaluation of the change. Analysis of current practice and innovation state wide,
nationally and internationally should also be considered.

2.5 Finalise the case for change

The information gathered in the diagnostic phase will complete the case for change that was started in project
initiation.

2.6 Identification and prioritisation of issues

The diagnostic work will have identified a number of issues or opportunities for improvement with the way that
services are currently provided. These should be brought together and prioritised according to the impact they
would have if the issues were solved. At this point, it is useful to revisit the aims and objectives for the project. This
will help identify whether the issues that you have identified are in line with your original objectives. If they are not,
then the group governing the project may decide to adjust the objectives or revisit the issues. It is also important to
revisit this in the solution design phase.

2.7 Examples of work already completed

Model of Care for the Osteoarthritis Chronic Care Program (OACCP) http://www.aci.health.nsw.gov.au/models-of-
care/musculoskeletal/osteoarthritis-chronic-care-program
NSW Rehabilitation Model of Care Diagnostic Report http://www.archi.net.au/documents/resources/models/rehab_
redesign/rehabilitation-diagnostic.pdf
Draft Model of Care for the NSW Paediatric Rheumatology Network http://www.aci.health.nsw.gov.au/__data/
assets/pdf_file/0005/172814/ACI-NSWPRN-final-draft-for_consultation-September-2012.pdf#zoom=100

Understanding the process to develop a Model of Care in the ACI 9

 PHASE 3- SOLUTION DESIGN

The aim of this phase of the Redesign methodology is to take the prioritised issues from the diagnostic phase and
develop a range of solutions that address the problem.

3.1 Develop a vision for what services should look like

Before attempting to develop the MoC, it is important to form an idea of what ideal service delivery will look like. It
is important to keep this in mind when examining the issues and potential solutions.

3.2 Overview of the solution design phase

T he diagnostic phase will have identified a list of issues with the way that
Review the issues identified
services are currently delivered. A full understanding of the extent of the issues
will assist in developing solutions.

Consult Key Partners

T hrough consultation with the health system, the project team should prioritise
Prioritise Issues
all of the defined issues in consultation with patients, carers and staff.

P roblem solving is the stage when thinking moves from analytical to creative,
Problem Solving
generating a large number of potential solutions.

Select & Prioritise Solutions

These solutions are then developed, tested and refined to form the
10 Understanding the process to develop a Model of Care in the ACI
final model.

3.3 Current and future context

Spending on healthcare as a proportion of Gross Domestic Product (GDP) is rising in most developed countries, as
is healthcare as a proportion of the federal and state government budget. With finite resources, this growth cannot
be sustained. In addition, increased cost of care per capita does not consistently correlate with better quality and
outcome measures.
The alternative to spending more health dollars is to find different ways of providing care. In the current
environment, we are unable to rely solely upon increased funding to support innovation, and therefore MoC must
include the reorganisation of current resources to support the change in practice. When designing solutions it
is important to consider factors that influence funding and resources. How will the proposed solution fit within
Activity Based Funding (ABF)? How is it diverting resources from current practice to the new model?
The MoC will need to interface with NSW Health systems, programs and economic environment, including ABF, eHealth
and telehealth. The ability to show how the model will fit within these will assist in gaining sponsorship for the project.
Planning for the future will help minimise any modifications that may be needed when new programs are installed.

10 Understanding the process to develop a Model of Care in the ACI

3.4 Designing solutions
This stage is progressing from the ‘as is’ to the ‘to be’. During the diagnostic phase we look at the current practice
and identify the issues. During the solution design phase alternatives are identified; this is the time when thinking
must move from analytical to creative to allow innovation. New ideas can be generated through literature reviews,
searches for best practice and conducting brainstorming workshops with representation from clinicians, consumers,
operational, data and managerial staff. This process should develop a large number of solutions which can then be
refined. During the solution design process:
•  Focus on quantity not quality. The quality will come later
•  Suspend judgement. Critical analysis comes later
•  Welcome unusual ideas.
•  Grow the initial idea. From one simple idea others can be developed and grown.

3.5 Prioritising solutions

Once a range of solutions have been identified, these should be prioritised. It is likely that a large number of ideas
have emerged, only some of which will be viable. The initial narrowing down is usually done by the working group.
At this point it is important to refer back to the aim and scope of the project, as well as the issues identified in the
diagnostic. Do the solutions proposed meet the aims of the project and are they within scope? Do they solve the
issues identified?

3.6 Testing the solutions

Once a small number of preferred solutions have been identified, they should be tested. It is recommended that
multiple solutions are tested widely to ensure that all options are explored and that the solutions address the issue to
be resolved. Testing of solutions enables them to be further understood and refined to enable the right solution or
solutions to be chosen. All the solutions can be tested with key representatives and consumers to see how well they
address the issues from the diagnostic phase. The first solution that is put forward may not be the most effective
in resolving the issues. The solutions can be tested in a desktop environment - they do not all have to be piloted. A
pilot at this point may be useful for certain MoC to gather further information on how successful an element of a
MoC would be.
A solution could also be tested through a pilot of the project. This will demonstrate whether it is successful, provide
data around its success and areas where small alterations may be beneficial.
The solutions will also need to be considered through an economic appraisal to identify the cost effectiveness of
different solutions. This may take the form of a Cost Benefit Analysis (CBA) which could be one of the inputs used
to inform whether or not to implement the change. The Health Economics and Analysis team can assist with this.
The complete economic appraisal is usually finalised once the MoC is near completion. However identifying potential
costs and benefits associated with different solutions or options can commence at this stage. These solutions are
assessed against the business as usual option developed in the Diagnostic Phase.
At this stage the solution(s) will be finalised and will form the proposed MoC.

Understanding the process to develop a Model of Care in the ACI 11

 3.7 Develop an evaluation framework
Evaluation is the systematic and objective assessment of the design, implementation and results of an on-going or
completed project, program, or policy. The aim of an evaluation is to determine the relevance and achievement of
objectives and the efficiency, effectiveness, impact, and sustainability of the model. There are two main kinds of
evaluation that can be undertaken:
•  A formative evaluation assesses initial and ongoing activities. It begins during project development and
continues throughout the project lifecycle. It is intended to monitor and improve processes and activities as they
are developed. Formative evaluation is usually undertaken when a MoC is being piloted.
•  A summative evaluation assesses quality and impact of an implemented project to see if it has achieved its
stated outcomes and occurs at the completion of a project.
Most MoCs will require an evaluation framework which the Health Economics and Analysis team can assist with
developing. The approach to evaluation is usually based on program logic and commences early in the development
of a MoC. Program logic is a useful tool for defining what should be measured and when. It is a tool that describes
the change process underlying an intervention, program or policy. It documents the connections between the critical
components in a project and identifies where evaluation is most important.
Program logics vary according to the project and complexity but in general, the components are:
Inputs – the resources that are used to implement a project. Typically this is staff, funding, support and equipment.
Activities – the activities are the actions undertaken by the project to achieve the desired goals. Examples of
activities are providing staff training, developing an awareness package, establishing a community council.
Outputs – the immediate results/products from an action and usually measured in numbers (but not always).
Examples include number of staff trained, number of awareness packages distributed, community council
established and number of meetings held.
Outcomes – the changes that occur showing movement towards the ultimate goals and objectives of a project.
Outcomes are desired accomplishments or changes and are defined by short, intermediate and long term. There is
no12hard
Understanding thetoprocess
and fast rule to develop
defining betweena Model of Care
these in the ACIshort refers to 2 years or less, intermediate up to 5 years
but usually
and long term 5 years or more – depending on the project.
The program logic facilitates effective evaluation by:
•  Determining what to evaluate, identifying what is important
•  Providing a theoretical framework when evidence is less robust
•  Assist in development of resourcing and disinvestment strategies
•  Identifying outcomes and other effects of change
•  Determining data collection sources, methods, selection of indicators and instrumentation
•  Providing a mechanism for gaining cooperation and acceptability from stakeholders for monitoring

3.8 Develop and document the MoC

Upon completion of the above steps, the MoC needs to be formally written up. The MoC should include a
diagrammatic representation of the model and how a patient would travel through the service.

12 Understanding the process to develop a Model of Care in the ACI

3.9 Seek endorsement of the MoC from appropriate
stakeholders and sponsors
Endorsement for the MoC should be a continued consultative process throughout the development of the model.
This process will maximise engagement and buy in from key partners and potential sponsors. This is a key point
where endorsement is required before proceeding.

3.10 Plan for disinvestment

As the new MoC is implemented it should be identified what (if anything) needs to discontinue as a result of the
service changes. This may be stopping the model or technologies that are currently used allowing resources to be
reallocated to other areas. It may also be important to the success of the new model, as if certain old practices
do not stop or change, they may interfere with the success of the new MoC. Resourcing strategies and economic
assessments of MoC will need to take disinvestment into account and consider resource reallocation options. This
may include avoided future costs, increased bed capacity as the result of care moving to different settings (acute
admitted to non-admitted) or it may mean resources such as people, space and time being allocated differently to
enable the new MoC to be successful.
The Health Economics and Analysis Team will provide guidance in relation to the preparation of a Resourcing
Strategy and a Business Proposal that will ensure that any investment, disinvestment and movement of resources are
clearly documented for the MoC.

3.11 Examples of work already completed

Model of Care for the Osteoarthritis Chronic Care Program (OACCP) http://www.aci.health.nsw.gov.au/models-of-
care/musculoskeletal/osteoarthritis-chronic-care-program
NSW Rehabilitation Model of Care http://www.archi.net.au/documents/resources/models/rehab_redesign/
rehabilitation-moc.pdf

Understanding the process to develop a Model of Care in the ACI 13

 PHASE 4 – IMPLEMENTATION

The aim of this phase of the methodology is to change current practice to the new MoC. The link must be made
between the system changes that will occur, and the behaviours changes that are needed to make this happen. This
phase of developing a MoC is the most resource intensive phase.

4.1 Define the change

Create a clear and commonly held definition of both the present state and the change:
•  What is the current situation (‘as is’/state of play)?
•  What is changing?
•  What behaviours need to change?
•  Why are we changing?
•  What are the consequences of not changing?
•  What are the measures of success?
The resulting objectives should be clearly documented, as you will use them as a building block for the rest of the
implementation plan. The evaluation framework required to support this should have already been collated in the
earlier phases.

4.2 Self assessment/gap analysis

14 Understanding the process to develop a Model of Care in the ACI
A gap analysis or self assessment tool in relation to the new MoC can be designed to assist sites to understand their
current practice and gaps in practice in relation to the new MoC. It should identify service checkpoints which are
designed to underpin each of the principles in the MoC. They enable LHDs to perform a self assessment against
each of the service checkpoints indicating if they are in place.

4.3 Develop the business case and seek endorsement

A Business Case and/or resourcing strategy to support the MoC may need to be developed prior to implementation.
The Business Case contains all of the evidence and critical information that is required to establish the compelling
case to allocate new or existing resources to a proposal and to provide the confidence that it can be delivered as
planned. The Health Economics and Analysis Team can assist with this process.
A business case template is currently being developed by the Health Economics and Analysis Team and will
be provided once finalised. This business case will demonstrate the case for change and all the implications of
introducing the new MoC. It can be used to seek endorsement from sponsors and stakeholders such as the LHDs.
It is also to be used for signing off any investment or realigning of resources, equipment that maybe required
implementing the new MoC.

14 Understanding the process to develop a Model of Care in the ACI

4.4 Generate sponsorship for implementation and
governance structure
Every project needs an executive ‘sponsor’, both at statewide and in every LHD where the change will be
implemented. An executive sponsor will provide strategic direction and access to resources. Sponsorship is a key
factor for ensuring fast and successful implementation of projects.
The project will need an ongoing governance structure in order to be successful. A governance structure will ensure
that the project remains on track and progress is monitored. It will also monitor the impact of the MoC and ensure
that the information is reported back. This will ensure that the MoC delivers what it is meant to.

4.5 Build frontline capacity and engagement

The changes to service delivery will be implemented by front line managers and staff. Assessing the skills and
capacity of these staff will identify what support they might need to implement the changes. The Centre for
Healthcare Redesign can provide building blocks to develop capability among staff to implement changes.

4.6 Communications plan

One of the key steps to ensuring success of the implementation of the project is communicating the right messages
to the right people. Communication is a tool to facilitate engagement and ownership of the project. Two way
communication channels must be facilitated to ensure that everyone is able to inform the project, listen and learn.
Mapping who needs to be involved in the change and how they can be meaningfully engaged in the process will
help facilitate local ownership of the change.

4.7 Implementation plans/reinforcement strategies

A statewide implementation plan should be developed. LHDs will develop their own implementation plans based on
the factors identified in their self assessment/gap analysis. This step in the implementation process will provide LHDs
with a plan for how to address each of their identified gaps. The plan is developed in consultation with partners
from the service using the MoC document as a reference. It is important that the approach used is appropriate to
the individual needs of the local environment.

Understanding the process to develop a Model of Care in the ACI 15

 PHASE 5 - SUSTAINABILITY

5.1 Ongoing monitoring, continuing local focus

and accountability
As discussed in previous sections, the evaluation framework for the MoC needs to be in place at project initiation.
This will ensure that monitoring systems are in place ready to start alongside the implementation of the MoC. This
empowers local services and clinicians to assure themselves that the model is working in the way that it was planned
to. It also enables there to be local ownership of the MoC so that local clinicians and managers will be aware of how
the MoC is being implemented in practice.
If there are small developments or changes within the service over time then alterations can be made to the MoC
without going through the entire process again. These changes would need to be included in the monitoring and
evaluation processes. However, if there is a significant development or change that impacts on how the MoC is
delivered then it would be necessary to go through the process from the beginning.
It is recommended that the MoC is reviewed after one year, and then every two years following.

5.2 Review and optimise the MoC

Once the monitoring system is in place, it will provide the tools necessary to continuously review the MoC and its
impact. It also provides people with the information they need to make the changes required to ensure that the
MoC is working as effectively as possible. It may also confirm that the system is working well and further changes
will not be required.

16 Understanding the process to develop a Model of Care in the ACI

5.3 Final evaluation

As noted previously, summative evaluation takes place at the end of a project and assesses on an ongoing basis
(quarterly, annually etc) whether a project has met its objectives. It is important to keep the final evaluation in mind
from the initiation of the project in order for it to be effectively done at the end. The Network that developed
the MoC would be the group responsible for regularly reviewing the MoC in an ongoing basis and ensuring that
planned future evaluation is undertaken and acted upon.
The Health Economics and Analysis Team will work on the evaluation providing support and analysis where required.
The team are able to undertake this piece of work for the project.

5.4 Knowledge management

It is crucial to continuing best practice and innovation that the knowledge and expertise gained through designing
and implementing a MoC is shared across the health system. This will enable creativity and success to create the
cycle of innovation continuing the principles of a successful MoC into other clinical areas.

16 Understanding the process to develop a Model of Care in the ACI

HS13-034