proyecto Áncora & cesfam san alberto hurtado some reflections august 2008 thomas leisewitz...
Post on 18-Dec-2015
214 Views
Preview:
TRANSCRIPT
Proyecto Áncora & CESFAM San Alberto Hurtado
Some reflectionsAugust 2008
Thomas LeisewitzFamily Medicine DepartmentPontificia Universidad Católica de Chiletl@med.puc.cl
Background
Family & Community Medicine Programme: post-graduate training of family physicians from 1993
Collaborative work with Municipalities and Health Authority at SSMSO
Health policy initiatives: Family Health Centres 1997/98
Political willingness: management of public funds by private not-for-profit institutions
Health sector reform process based on primary care?: Family Health Centres
Family Health Centres
‘Registered’ population ‘Family Health Plan’ Teamwork Responsiveness
and accountability Information systems Local planning Outcome-orientation Coordination in the use
of resources
Proyecto Áncora. Aim
“Contribute to a significative change in primary care, delivering health care services and training professionals with a wide, efficient and human perspective, in a replicable way”
Proyecto Áncora. Objectives
Operation of 3 Health Centres Continuing evaluation of the model Encourage professionals’ and
students’ interest in primary care Diffussion of the experience Influence public policy decision-making
Proyecto Áncora. Challenge
…the implementation of a family health model in primary care through the management of public funding by a private not-for-profit organisation
…within the scope of the aim and objectives of the Ancora Project
Clinical model: some elements
The person at the centre The family as a fundamental referent The community and its role as a social support
network Keeping people healthy (Health Promotion) Continuity of care Personalised relationship with providers Responsiveness Teamwork Biopsychosocial approach
What we have… until now!
A team 22.703 people registered (22.076 validated) A building and equipment A budget An organisation of the main processes A proposal of implementation of the model
Our team 15 FTE doctors 5 FTE nurses 4 FTE midwives 2 FTE social workers 4 FTE clinical psychologists 1 FTE dietician 4 FTE dentists 9 FTE administrative staff 8 FTE clinical assistants 4 FTE dental assistants
Some health indicators used for allocating resources
Coverage of preventive services Ultrasound for gall bladder disease Mammography for breast cancer
Chronic disease management BP control in hypertensive patients Blood glucose control in diabetic patients
Access to dental care Psychomotor development in children
Our budget
Per-capita value 2008: $ 2,826 Total per-capita funding 2008: M$ 536 University funding 2008: M$ 76 Total budget 2008: M$ 612
Expenditures
55% salaries 22% outsourced services: laboratory,
cleaning and security 15% pharmacy & others 4% electricity, water, heating, etc.
How are we organised? 2 sectors: multidisciplinary teams
delivering services for 10 000 people each
(green & blue) 1 clinical support team:
vaccination, pharmacy, laboratory,
diagnostic procedures,
special programmes
(eg respiratory diseases) 1 administrative support team:
call center, IT,
secretarial support, etc.
Work areas Family approach
Patients lists for each physician Families assigned to an specific team
Relationship with the community Diffusion and inscription Health promotion
Implementation of services included in the ‘Health Plan’ Process design and re-design and the relationship with ECR The teaching model (especially for 2008)
Effectiveness
PrimaryCare global index
Costs
-Continuity-Access-Resolutividad-Preventive care –Health Promot-Participation-bps & family approaches
Centre 2
-Direct-Savings
-Appointments - Referals-Out-of-pocket payments -Patients’ waiting times
Centre 1
Evaluation. Methodology
Cost-Effectiveness analysis
Incremental Cost-Effectiveness RatioCosts (Centre 1- Centre 2)/ Effectiveness (Centre1 – Centre2) = Δ C / Δ E
EffectivenessCentre 1 Effectiveness
Centre 2
CostsCentre 1 Costs
Centre 2
Δ CostsΔ Effectiveness
Results. Effectiveness
Indicadores Objetivos Experiencia Aceptabilidad Total
Total global ponderado
Dimension MTC Comp MTC Comp MTC Comp MTC Comp MTC Comp
Continuidad 0,1702 0,1699 0,1238 0,0837 0,2339 0,1562 0,5279 0,4098 0,0598 0,0464
Enfoque Prev y prom. 0,4200 0,3780 0,0909 0,0710 0,1322 0,1022 0,6432 0,5512 0,0837 0,0717
Resolutividad 0,3758 0,4008 0,1084 0,0616 0,1361 0,0861 0,6202 0,5484 0,1073 0,0949
Enfoque BPS y familiar 0,0217 0,1261 0,1936 0,1340 0,2512 0,1550 0,4665 0,4151 0,0339 0,0301
Accesibilidad 0,3004 0,2429 0,1231 0,0097 0,4235 0,2526 0,1669 0,0995
Participacion 0,5160 0,3090 0,5160 0,3090 0,0604 0,0362
Total 0,5119 0,3788
0,1331ΔE =
ΔE = 0, 1317
Results. Direct costs
ΔE =
Tipo de Costo Item Origen MTC Comp.Delt
a%
Médicos
gasto per cápita del centro 2652 2027 625 23,55%
Gasto operacional del centro no docente 2594 1854
Gasto administración central 58 173
(gasto) per cápita del sistema 291 467 -176 -60,41%
SAPU 115 148
Urgencia 170 307
Interconsultas no pertinentes 6 12
gasto de bolsillo 448 460 -12 -2,68%
Medicamentos 81,9 173,1
Exámenes 191,1 151,5
Consultas 175,0 135,5
Tiempo
destinado a buscar cuidado 36 75 -39-
107,02%
Pérdida de tiempo per cápita 36 75
TOTAL ($2006) 2960 2562 398 13,44%
Todas las cantidades son percapita mensuales
Evaluation. Some conclusions The evaluated Ancora health center (MTC) was more
expensive and more effective than the comparator. The proposed effectiveness indicator seems
comprehensive, though the difficulties in understanding its practical implications.
Patient perspective stands as a key element for the proposed evaluation model, establishing significant differences between the analysed centres.
The difference in the estimated per-capita cost is smaller if a social perspective (modified) is adopted rather than just considering the operational expenditures.
Evaluation. Some conclusions The Ancora center saves money to the whole health
system, although it does not fully compensate the increased operational cost.
The effectiveness indicator is consistently higher for the Ancora health center, being unaffected by the different weights of the considered dimensions in a sensitivity analysis.
The family health model is complex, so do its evaluation. However, the richness of this evaluation model could give great information to health teams and managers for the betterment of the model.
Some reflections
After four years, we have realised that our main strength is the way how each team (and each individual professional) establish a relationship with its patients and families
The evaluation from the patients’ perspective has consistently been our best evaluated dimension
Some reflections
Financing Long-term feasibility (political willingness) Non-enveloped per-capita allocations versus
specific allocations by each programme (change during 2007)
Performance management Managing performance with a limited number of
indicators Is it possible to define a common set of
indicators for primary care organisations?
top related