david levine: environmentally conscience planning

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


(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)


(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)


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


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


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


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


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


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


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



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



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



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



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

Dépôt légal – Bibliothèque nationale du Québec, 2005Dépôt légal Bibliothèque nationale du Québec, 2005

This 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

david levine: environmentally conscience planning

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