Evidence Evidence based based Environmentally conscience planning and actionEnvironmentally conscience planning and action
A new model for a health and social service A new model for a health and social service system insystem in QuebecQuebec Canada Canadasystem insystem in QuebecQuebec, Canada, Canada
London, November 25th, 2008
David LevinePresident / CEOMontreal Regional Health Authority
The Reform of Health and Social ServicesTable of ContentsTable of Contents
Important datesImportant dates
The objectives of the reform
The guiding principles
A brief look at the reform
The Health and Social Services Centers
The local services networksThe local services networks
The impact of the reform on patients
The Reform of Health and Social ServicesTable of Contents ( ti d)Table of Contents (continued)
The impact of the reform on the organization of iservices
The Montreal Regional Health Authority – Role and ResponsibilityResponsibility
Integrated University Health Networks
Bill 83 on Health and Social Services
Bill 30 U i i tiBill 30 on Union organisation
A population based managed care model
The Reform of Health and Social ServicesImportant DatesImportant Dates
Rochon Commission 1987-1990: Regionalization – integration
Clair Commission 1998-2000: Primary care – chronic care management public based - role of public health
January 30, 2004 : Creation of the Agencies for the development of the health and social services networksand social services networks
February – April, 2004 : Public consultation in Montreal and in each Regional Health Authority
A il 30 2004 S b i i f th A ’ d ti t th Mi i t f April 30, 2004 : Submission of the Agency’s recommendation to the Ministry for the creation of the Health and Social Services Centers and the local networks based on health service utilization and public consultation (data examples)
June 15, 2004 : Approval by the Council of Ministers of the Agency’s proposition , pp y g y p pand the nomination of the members of the boards for 12 local Health and Social Service Networks
July 1, 2004 : Nomination by the new boards of their interim CEO
The Reform of Health and Social ServicesImportant Dates (continued)Important Dates (continued)
January – February 2005 : Selection appointment of the January – February, 2005 : Selection, appointment of the
networks Chief Executive Officers
2005 : Implementing the local networks2005 : Implementing the local networks
June, 2005: Montreal’s strategic vision
December, 2005 : Adoption of Bill 83
January, 2006: 10 Family Practice Groups
12 Medical Networks
January, 2006: Redesign of Primary Care Delivery
The Reform of Health and Social ServicesGlobal ObjectivesGlobal Objectives
Improve the health and well being of the population
Bring services to the population
Facilitate the use of servicesFacilitate the use of services
Take charge of vulnerable clientele
The Reform of Health and Social ServicesSpecific ObjectivesSpecific Objectives
Introduce a population based managed care model
Introduce a chronic care model
R t h iti t i tRoster each citizen to a primary care team
Develop corridors of care for seamless services
The Reform of Health and Social ServicesObjectivesObjectives
The Past The Present and Future
Responsibility for the individualFunctioning in silosA problem of continuity
Responsibility for the populationContinuous services without interruptionA problem of continuity
A problem of accessibilityRepetition of servicesHard to move from one level of care to another
pGeneral practitioners at the center of services in a multidisciplinary team functioning in a population based managed care model
to anotherManaging vulnerable patients based on a model of chronic care managementInformation systems linking y gdifferent health providers to the same medical fileResponsibility for the health and well being of a defined population
The Reform of Health and Social ServicesA Reorganisation of Service DeliveryA Reorganisation of Service Delivery
POPULATIONAL APPROACH:
Populational responsibility of the health and well being of the population
Access to health and social services
HIERARCHICAL PROVISION OF SERVICES:
Primary care responsibility
Responsibility of different level of care
Reference protocols and corridors of services included in the agreementsthe agreements
The Reform of Health and Social ServicesA Reorganisation of Service DeliveryA Reorganisation of Service Delivery
A new organization: Health and Social Services Centers A new organization: Health and Social Services Centers (HSSC)
A new concept of integrated services through the creation of local services networks
12 HSSC in Montreal, 95 across Quebec
Merger of hospitals, local community service center, Rehab centers, long term centers into a single institution
The Reform of Health and Social ServicesHealth and Social Services CentersHealth and Social Services Centers
12 / 95 HSSCPopulation : 1,9 million
Budget : 6 billion $
Institutions : 97
Installations : 350
Medical clinics : 400
Employees : 90 000Employees : 90 000
MD specialists: 3 293
General practitioners: 2 223
Nurses: 21 700
Other professionals: 8 000p
The Reform of Health and Social ServicesHealth and Social Services CentersHealth and Social Services Centers
(HSSC)
MANDATE:
Manage and evaluate the health and wellbeing of the
l tipopulation
Manage the use of services by the populationManage the use of services by the population
Manage the services offered by each HSSCManage the services offered by each HSSC
The Reform of Health and Social ServicesHealth and Social Services Centers
(HSSC)
RESPONSIBILITIES:
To define the local organizational and clinical projects in each HSSC according to the particular needs of the population
To mobilize and assure the collaboration of the professionals, institutions and partners in the local health network
To organize and coordinate all services offered at the local level
To manage the human, materiel, financial, informational and To manage the human, materiel, financial, informational and technological resources made available
To offer a portfolio of general and specialized services to their local population (coordination by service contracts)
The Reform of Health and Social ServicesHealth and Social Services CentersHealth and Social Services Centers
(HSSC)
RESPONSIBILITIES (continued)( )
To receive, evaluate and direct the population on their territory toward the services they require
To take charge, to accompany, to help vulnerable patients to manage their health care needs
To inform the population of their state of health and the services and programs available
To insure the participation of the population in the management of their own health and wellbeing and to measure the population’s satisfactionsatisfaction
The Reform of Health and Social ServicesLocal TerritoryLocal Territory
Social economy enterprises
PhysiciansCommunity pharmacies
Physicians(FMG, MN, medical clinics)
Health and Social Services Centres :grouping of one or several CLSCSs,
CHSLD, CHSGSs
Community organizationsYouth Centre
Non institutional resources
Rehabilitation centre Other sectors: education, municipal, justice, etc.
Hospitals that provide specialized services
The Reform of Health and Social ServicesImpact on PatientsImpact on Patients
PATIENTS WILL:
Know where to address their demands
Not have to repeat their history
Not have to repeat diagnostic testsNot have to repeat diagnostic tests
Not have to wait to move from one level of care to another
Be guided to the services they need through a managed care model
Have access to information concerning the quality of clinical services
Be able to make all appointments required through a unique agent
Be able to choose their primary care provider
In case of chronic illness, be contacted by their case manager for
the tests, treatments, follow up required by their situation, , p q y
The Reform of Health and Social ServicesThe Impact on the Organization of ServicesThe Impact on the Organization of ServicesFinancing by Program – Population Based
Gene
General Programs1. Public health2. Primary care
eral programs
Specific programs1. Elderly2. Physical handicap3 Intellectually and serious behavioural problems3 Intellectually and serious behavioural problems4. Youth in difficulty (0 à 17)5. Dependence6. Mental Health7. Acute care
Manag
1. Administration and support2. Management of equipment and infrastructure
gement program
ss
The Reform of Health and Social ServicesThe Impact on the Organization of Services (continued)The Impact on the Organization of Services (continued)
Primary care – the key to success
Family Practice Groups (FPG)
Medical Networks (MN)
Integrated medical network (IMN)
The Reform of Health and Social ServicesThe Impact on the Organization of Services (continued)The Impact on the Organization of Services (continued)
Family Practice Groups (FMG)y p ( )
Objective for Montreal 75 – 100 FMG and 300 FMG across Quebec
d ( )8 to 12 doctors (FTE)
Registered clientele on a voluntary basis
Complete spectrum of services including medical Complete spectrum of services including medical management of patients with or without appointment 7/7, 12h/weekday, 4h/weekends and holidays
70h/ k titi70h/week nurse practitioners
IS services
Up to 500 000 $ financial supportUp to 500 000 $ financial support
The Reform of Health and Social ServicesThe Impact on the Organization of Services (continued)The Impact on the Organization of Services (continued)
Medical Networks (MN)
Objective for Montreal: 30-40 MN, 1/50,000 population
An already existing clinic, a regrouping of clinics, the h i i i CLSC f il i i (FPG) physicians in a CLSC, a family practitioners group (FPG)
on a family practice unit
The complete spectrum of primary medical services:p p p y
- first line services including consultation with or without appointment
- open 365 days a year, 8 to 22h weekdays and 8 to 17h weekend and holidays, at least 50% of available physicians’ hours for consultation with appointment
The Reform of Health and Social ServicesThe Impact on the Organization of Services (continued)The Impact on the Organization of Services (continued)
Medical Networks (MN) (continued)Medical Networks (MN) (continued)
To provide medical on call 24/7 to vulnerable patients
Must insure a role of coordination and liaison with the
HSSC
Must help to find a treating physician for all
Must be able to provide access to diagnostic testing for
emergency cases
Up to $300,000 financial support
The Reform of Health and Social ServicesThe Impact on the Organization of Services The Impact on the Organization of Services
(continued)
Integrated medical network (IMN)
Merger of a FMG and a MN
15 equivalent full time family physicians15 equivalent full time family physicians
15 professionals
15 support staff15 support staff
2,000 patient panel per physician 30,000 per team
60 IMN in Montreal 1 9 M population60 IMN in Montreal 1.9 M population
Up to $1,500,000 financial support
The Reform of Health and Social ServicesIntegrated University Health Networks
(IUHN)
MANDATE ( ti d) :MANDATE (continued): :
One per faculty of medicine4 in Quebec: - McGill University
Uni e sité de Mont éal- Université de Montréal- Université de Laval- Université de Sherbrooke
I l d ll d i t d t hi h it l (1 IUHN) ll Includes all designated teaching hospitals (1 per IUHN), all affiliated teaching hospitals, all designated institutes, the faculty of medicine and the faculties of health sciences and the CEOs of the Regional Health Authority each IUHN is responsible for
Presided over alternately for 2 years period by each dean of Medicine or the Chief Executive Officer of the designated teaching hospital
The Reform of Health and Social ServicesIntegrated University Health NetworksIntegrated University Health Networks
(IUHN)MANDATE (continued):
Defining the corridors of specialised services for the Health and
Social Services Center across Quebec under their jurisdiction
Insuring medical coverage locally for the Health and Social
Services Centers under their jurisdiction
Defining along with the CEOs of the Regional Health Authority
the medical manpower plan for each region
Responsible for the evaluation of new technology
Each IUHN is under the responsibility of the Regional Health
A th itAuthority
The Reform of Health and Social ServicesNext Steps
BILL 83
Modifications of the law on Health and Social Services in support of the new model of organization of care
Adjusting the responsibilities of the Ministry, the Regional Health Authorities, the Health and Social Services Centers and the remaining specialised institutions
Establishing the integrated University Health Networks (IUHN)
Certification of private residences for the elderlyCertification of private residences for the elderly
Creating a complaints commissioner
New rules guiding the clinical data of patientsNew rules guiding the clinical data of patients
The Reform of Health and Social ServicesThe Montreal Vision – Our strategy for the The Montreal Vision – Our strategy for the
Implementation of the Reform
1) A population based managed care model
2) A multidisciplinary health and social service team 2) A multidisciplinary health and social service team
responsible for a rostered clientele
3) Empowering the population
4) Accountability
The Reform of Health and Social ServicesThe Montreal Vision – Our strategy for the
Implementation of the Reform
Why develop a population based care modelWhy develop a population based care model
Over half of KP’s total costs are incurred by 5 percent of members
80%
95%s
100%
incurred by 5 percent of members
53%
66%
80%
f tot
al c
osts
60%
80%
53%
ulat
ive
% o
f
40%
Cum
u
0%
20%
0%
Deciles (Members orderedfrom most to least costly)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
from most to least costly)Source : Kaiser Permanente
Where are Most of the Costs for C i f P l ti ?Caring for a Population?
Those w/one chronic condition
Those w/multiple chronic conditions
$$$21%
6%
31%
33%
People $$$
72%36%
Costs
Those w/no chronic conditions72%
Segments within the total
population
Costs associated with each segment
Source: Kaiser Permanente Northern California commercial membership, DxCG methodology, 2001.
Population-based care: Managing the whole population
Intensive ManagementLeverage available resources to optimize health status and coordination of care
Care ManagementEnhance self-care skills; provide clinical management using care paths and
t l
Self-care SupportR ti ith d i i t
protocols
Routine care with decision support technology and programs to assist members in developing/ improving self-care skills
Chronic Care Model
Chronic Care Protocol for each diseaseChronic Care Protocol for each disease
Support patients self management
Multidisciplinary team approachMultidisciplinary team approach
A seamless system
Decision toolsDecision tools
Information systems for developing registers and insuring follow-up
Involvement of community resources
Survey of operational practice built on the Chronic Care Model
Chronic Care ModelChronic Care Model•Which is the mostimportant practice?
–Leadership–Accountability
CommunityResources and
Policies
Health SystemOrganization of
Health Care
Accountability–Champions–Resources–Financial Incentives–Provider Feedback
SELF-MANAGEMENTSUPPORT
DELIVERY SYSTEMDESIGN
DECISIONSUPPORT
INFORMATIONSYSTEMS
–Program Evaluation–Patient Action Plans–Patient Education–Guideline Training–Provider Alerts
Informed Activated
Patient
Prepared, Proactive
Practice Team
ProductiveInteractions
–Provider Alerts–AMR–Defined Care Path–Risk Stratification–Registry
F I i Ch i Ill C
Clinical & Functional OutcomesClinical & Functional Outcomes
g y–Out reach and Follow-up–In reach–Care Coordination–Team-Based CareCultural CompetenceFrom Improving Chronic Illness Care
Ed Wagner, MD, Group Health Cooperative of Puget Sound–Cultural Competence
The Reform of Health and Social ServicesThe Montreal Vision – Our strategy for the The Montreal Vision – Our strategy for the
Implementation of the Reform
1) A population based managed care model
2) A multidisciplinary health and social service team
responsible for a rostered clientele
3) Empowering the population
4) Accountability
The Reform of Health and Social ServicesThe Montreal Vision – Our Strategy for the The Montreal Vision – Our Strategy for the
Implementation of the Reform
1) MANAGING CARE1) MANAGING CARE
Clinical components of a population based managed care model
– A population health evaluation protocolp p p
– An individual evaluation protocol
– Developing clinical protocols of care based of a Developing clinical protocols of care based of a chronic care model
– Organization of care
1. into a multidisciplinary teams responsible for a rostered population
2. corridors of service linking the providers of care into a seamless s stemseamless system
The Reform of Health and Social ServicesThe Montreal Vision – Our Strategy for the The Montreal Vision – Our Strategy for the
Implementation of the Reform (continued)
Structural Components of a population based managed Structural Components of a population based managed care model
- Restructuring nursing home careg g
- Restructuring rehab care
- Restructuring care for the intellectually handicapped
- Restructuring mental health care
- Restructuring laboratory servicesRestructuring laboratory services
Our Strategy for the Implementation of the Reformthe Reform
A Population Based Health Care Management Model
• Why develop multidisciplinary teams regrouping• Why develop multidisciplinary teams regrouping
general practitioners and professionals with a
responsibility for a rostered clientele.responsibility for a rostered clientele.
A Typical Medical Center(Kaiser background)(Kaiser - background)
Includes a hospital of 250-300 beds
Covers 250 000 – 275 000 membersCovers 250,000 275,000 members
3 Satellite Clinics (supports 20,000 – 30,000 members each)
Approximately 500 MDsApproximately 500 MDs
50/50 Primary Care / Specialty Care
3,000 – 4,000 deliveries
Centers for Excellence
A Typical Medical Center (Kaiser structure)(Kaiser structure)
International Medicine/Family Practice Module Structure
M d l L d (MD)Module Leader (MD)
Non MD Module Leader
6-7 MDs
1 Nurse Practitioner
7-8 Medical Assistants
1 LVN
0.5 RN (appointment and advice centralized)
1 Behaviourist
1 Health Educator
• Average panel size of 2,600
• Monthly module meeting of everyone
R l CME’ f MD /RN• Regular CME’s for MDs/RNs
The Reform of Health and Social ServicesThe Montreal Vision – Our Strategy for the The Montreal Vision – Our Strategy for the
Implementation of the Reform
2) THE MEDICAL CENTER
Populational ResponsibilityPopulational Responsibility
Integration of primary care physicians, specialists and health p ofessionals into f ll specialists and health professionals into fully integrated multidisciplinary teams
Access to medical technology
Use of a managed care model
The Reform of Health and Social ServicesThe Montreal Vision – Our Strategy for the The Montreal Vision – Our Strategy for the
Implementation of the Reform
2) THE MEDICAL CENTER (continued)
I f di l tiIssues of medical remuneration
Developing pilot projects
- Family practice groups
M di l t k - Medical networks
- Integrated medical networks
The Reform of Health and Social ServicesThe Montreal Vision – Our Strategy for the The Montreal Vision – Our Strategy for the
Implementation of the Reform
3) EMPOWERING THE POPULATION
Essential ingredients in developing populational g p g p presponsibility
Healthwise HandbookHealthwise Handbook
Education centers in each territory
Membership cards in your health center
The Reform of Health and Social ServicesThe Montreal Vision – Our Strategy for the The Montreal Vision – Our Strategy for the
Implementation of the Reform
4) ACCOUNTABILITY – EVALUATION OF CARE
Importance of accountabilityp y
Indicators of the health of the population
Indicators of clinical care (outcomes)
Indicators of qualityIndicators of quality
Indicators of efficiency and efficacy