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David Levine: Environmentally conscience planning

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  • 1. Evidence based Environmentally conscience planning and action A new model for a health and social service system in Quebec, Canada Quebec, London, November 25th, 2008David LevinePresident / CEOMontreal Regional Health Authority
  • 2. The Reform of Health and Social Services Table of ContentsImportant datesThe objectives of the reformThe guiding principlesA brief look at the reformThe Health and Social Services CentersThe local services networksThe impact of the reform on patients
  • 3. The Reform of Health and Social Services Table of Contents ( ti d) (continued)The impact of the reform on the organization ofservices iThe Montreal Regional Health Authority – Role andResponsibilityIntegrated University Health NetworksBill 83 on Health and Social ServicesBill 30 on U i Union organisation i tiA population based managed care model
  • 4. The Reform of Health and Social Services Important DatesRochon Commission 1987-1990: Regionalization – integrationClair Commission 1998-2000: Primary care – chronic care management publicbased - role of public healthJanuary 30, 2004 : Creation of the Agencies for the development of the healthand social services networksFebruary – April, 2004 : Public consultation in Montreal and in each RegionalHealth AuthorityApril 30,A il 30 2004 : S b i i Submission of the Agency’s recommendation to the Ministry for f th A ’ d ti t th Mi i t fthe creation of the Health and Social Services Centers and the local networksbased 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 SocialService NetworksJuly 1, 2004 : Nomination by the new boards of their interim CEO
  • 5. The Reform of Health and Social Services Important Dates (continued)January – February 2005 : Selection appointment of the February, Selection,networks Chief Executive Officers2005 : Implementing the local networksJune, 2005: Montreal’s strategic visionDecember, 2005 : Adoption of Bill 83January, 2006: 10 Family Practice Groups 12 Medical NetworksJanuary, 2006: Redesign of Primary Care Delivery
  • 6. The Reform of Health and Social Services Global ObjectivesImprove the health and well being of the populationBring services to the populationFacilitate the use of servicesTake charge of vulnerable clientele
  • 7. The Reform of Health and Social Services Specific ObjectivesIntroduce a population based managed care modelIntroduce a chronic care modelRosterR t each citizen t a primary care team h iti to i tDevelop corridors of care for seamless services
  • 8. The Reform of Health and Social Services Objectives The Past The Present and FutureResponsibility for the individual Responsibility for the populationFunctioning in silos Continuous services withoutA problem of continuity interruption pA problem of accessibility General practitioners at the centerRepetition of services of services in a multidisciplinary team functioning in a populationHard to move from one level of care based managed care modelto another Managing vulnerable patients based on a model of chronic care management Information systems linking y g different health providers to the same medical file Responsibility for the health and well being of a defined population
  • 9. The Reform of Health and Social Services A Reorganisation of Service DeliveryPOPULATIONAL APPROACH: Populational responsibility of the health and well being of the population Access to health and social servicesHIERARCHICAL PROVISION OF SERVICES: Primary care responsibility Responsibility of different level of care Reference protocols and corridors of services included in the agreements
  • 10. The Reform of Health and Social Services A Reorganisation of Service DeliveryA new organization: Health and Social Services Centers(HSSC)A new concept of integrated services through the creation oflocal services networks12 HSSC in Montreal, 95 across QuebecMerger of hospitals, local community service center, Rehabcenters, long term centers into a single institution
  • 11. The Reform of Health and Social Services Health and Social Services Centers 12 / 95 HSSC Population : 1,9 million Budget : 6 billion $ Institutions : 97 Installations : 350 Medical clinics : 400 Employees : 90 000 MD specialists: 3 293 General practitioners: 2 223 Nurses: 21 700 Other professionals: 8 000 p
  • 12. The Reform of Health and Social Services Health and Social Services Centers (HSSC)MANDATE: Manage and evaluate the health and wellbeing of the population l ti Manage the use of services by the population Manage the services offered by each HSSC
  • 13. The Reform of Health and Social Services Health 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 technological resources made available To offer a portfolio of general and specialized services to their local population (coordination by service contracts)
  • 14. The Reform of Health and Social Services Health 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 satisfaction
  • 15. The Reform of Health and Social Services Local Territory Social economy enterprises Physicians (FMG, MN, medical clinics) Community pharmacies Health and Social Services Centres : Community organizationsYouth Centre grouping of one or several CLSCSs, CHSLD, CHSGSs Non institutional resources Rehabilitation centre Other sectors: Hospitals that provide education, municipal, justice, etc. specialized services
  • 16. The Reform of Health and Social Services Impact on PatientsPATIENTS WILL: Know where to address their demands Not have to repeat their history Not 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
  • 17. The Reform of Health and Social Services The Impact on the Organization of Services Financing by Program – Population Based General Programs 1. Public health 2. Primary care Gene programs eral Specific programs 1. Elderly 2. Physical handicap 3 Intellectually and serious behavioural problems 4. Youth in difficulty (0 à 17) 5. Dependence 6. Mental Health Manag 7. Acute care gement programs 1. Administration and support 2. Management of equipment and infrastructure s
  • 18. The Reform of Health and Social ServicesThe Impact on the Organization of Services (continued) Primary care – the key to success Family Practice Groups (FPG) Medical Networks (MN) Integrated medical network (IMN)
  • 19. The Reform of Health and Social ServicesThe Impact on the Organization of Services (continued) Family Practice Groups (FMG) y p ( ) Objective for Montreal 75 – 100 FMG and 300 FMG across Quebec 8 to 12 d doctors ( (FTE) ) Registered clientele on a voluntary basis Complete spectrum of services including medical management of patients with or without appointment 7/7, 12h/weekday, 4h/weekends and holidays 70h/week nurse practitioners 70h/ k titi IS services Up to 500 000 $ financial support
  • 20. The Reform of Health and Social ServicesThe 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 physicians i a CLSC a f h i i in CLSC, family practitioners group (FPG) il ii on a family practice unit The complete spectrum of p p p primary medical services: 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
  • 21. The Reform of Health and Social ServicesThe Impact on the Organization of Services (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
  • 22. The Reform of Health and Social 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 physicians 15 professionals 15 support staff 2,000 patient panel per physician 30,000 per team 60 IMN in Montreal 1 9 M population 1.9 Up to $1,500,000 financial support
  • 23. The Reform of Health and Social Services Integrated University Health Networks (IUHN)MANDATE ( ti (continued): : d) One per faculty of medicine 4 in Quebec: - McGill University - Uni e sité de Mont éal Université Montréal - Université de Laval - Université de Sherbrooke Includes ll designated t I l d all d i t d teaching h hi hospitals (1 per IUHN) all it l IUHN), ll 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
  • 24. The Reform of Health and Social Services Integrated 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 Authority A th it
  • 25. The Reform of Health and Social Services Next StepsBILL 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 elderly Creating a complaints commissioner New rules guiding the clinical data of patients
  • 26. The Reform of Health and Social Services The Montreal Vision – Our strategy for the Implementation of the Reform1) A population based managed care model2) A multidisciplinary health and social service team responsible for a rostered clientele3) Empowering the population4) Accountability
  • 27. The Reform of Health and Social Services The Montreal Vision – Our strategy for the Implementation of the ReformWhy develop a population based care model
  • 28. Over half of KP’s total costs are incurred by 5 percent of members 100% 95% ulative % of total costs s 80% 80% 66% 60% 53% f 40%Cumu 20% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Deciles (Members ordered from most to least costly) Source : Kaiser Permanente
  • 29. Where are Most of the Costs for Caring for a Population? C i f P l ti ? 6% Those w/multiple chronic conditions 33% 21% Those w/one chronic condition 31%People $$$ 36% 72% Those w/no chronic conditions Segments within Costs the total associated with population each segment Source: Kaiser Permanente Northern California commercial membership, DxCG methodology, 2001.
  • 30. Population-based care:Managing the whole population Intensive Management Leverage available resources to optimize health status and coordination of care Care Management Enhance self-care skills; provide clinical management using care paths and protocols t l Self-care Support Routine R ti care with d i i support ith decision t technology and programs to assist members in developing/ improving self- care skills
  • 31. Chronic Care ModelChronic Care Protocol for each diseaseSupport patients self managementMultidisciplinary team approachA seamless systemDecision toolsInformation systems for developing registers and insuringfollow-upInvolvement of community resources
  • 32. Survey of operational practice built on the Chronic Care Model •Which is the most Chronic Care Model important practice? –Leadership Accountability –Accountability Community Health System –Champions –Resources Resources and Organization of –Financial Incentives Policies Health Care –Provider Feedback SELF-MANAGEMENT DELIVERY SYSTEM DECISION INFORMATION –Program Evaluation SUPPORT DESIGN SUPPORT SYSTEMS –Patient Action Plans –Patient Education –Guideline Training –Provider Alerts Informed Prepared, –AMR Productive Activated Interactions Proactive –Defined Care Path Patient Practice Team –Risk Stratification g y –Registry –Out reach and Follow-up Clinical & Functional Outcomes –In reach –Care Coordination –Team-Based CareFrom Improving Chronic IllF I i Ch i Illness C Care –Cultural Competence CulturalEd Wagner, MD, Group Health Cooperative of Puget Sound
  • 33. The Reform of Health and Social Services The Montreal Vision – Our strategy for the Implementation of the Reform1) A population based managed care model2) A multidisciplinary health and social service team responsible for a rostered clientele3) Empowering the population4) Accountability
  • 34. The Reform of Health and Social Services The Montreal Vision – Our Strategy for the Implementation of the Reform1) MANAGING CARE Clinical components of a population based managed care model – A population health evaluation p p p protocol – An individual evaluation protocol – 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 system s stem
  • 35. The Reform of Health and Social Services The Montreal Vision – Our Strategy for the Implementation of the Reform (continued) Structural Components of a population based managed care model - Restructuring nursing home care g g - Restructuring rehab care - Restructuring care for the intellectually handicapped - Restructuring mental health care - Restructuring laboratory services
  • 36. Our Strategy for the Implementation of the Reform A Population Based Health Care Management Model• Why develop multidisciplinary teams regrouping general practitioners and professionals with a responsibility for a rostered clientele.
  • 37. A Typical Medical Center (Kaiser - background)Includes a hospital of 250-300 bedsCovers 250,000 – 275 000 members 250 000 275,0003 Satellite Clinics (supports 20,000 – 30,000 members each)Approximately 500 MDs50/50 Primary Care / Specialty Care3,000 – 4,000 deliveriesCenters for Excellence
  • 38. A Typical Medical Center (Kaiser structure)International Medicine/Family Practice Module Structure Module L d M d l 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 • Regular CME’s for MDs/RNs R l CME’ f MD /RN
  • 39. The Reform of Health and Social Services The Montreal Vision – Our Strategy for the Implementation of the Reform2) THE MEDICAL CENTER Populational Responsibility Integration of primary care physicians, specialists and health professionals into fully p ofessionals f ll integrated multidisciplinary teams Access to medical technology Use of a managed care model
  • 40. The Reform of Health and Social Services The Montreal Vision – Our Strategy for the Implementation of the Reform2) THE MEDICAL CENTER (continued) Issues of medical remuneration I f di l ti Developing pilot projects - Family practice groups - Medical M di l networks t k - Integrated medical networks
  • 41. The Reform of Health and Social Services The Montreal Vision – Our Strategy for the Implementation of the Reform3) EMPOWERING THE POPULATION Essential ingredients in developing p p g p g populational responsibility Healthwise Handbook Education centers in each territory Membership cards in your health center
  • 42. The Reform of Health and Social Services The Montreal Vision – Our Strategy for the Implementation of the Reform4) ACCOUNTABILITY – EVALUATION OF CARE Importance of accountability p y Indicators of the health of the population Indicators of clinical care (outcomes) Indicators of quality Indicators of efficiency and efficacy
  • 43. Dépôt légal – Bibliothèque nationale du Québec, 2005This document is available:- At Service des technologies et de la diffusion de l’information Phone (514) 286-5604- On the Website of the Agency: www.santemontreal.qc.ca