Breakfast with the Chiefs

Strategic Levers for a High-performing Health System

Equity issues in funding and delivery :

The Montreal Experience

Toronto - April 17 2007David LevinePresident/CEOMontreal Regional Health Authority

2007

Developing a High-Performing Health System in Quebec

1. History 1970-20042. The Reform

2.1 Objectives2.2 Guiding principles2.3 Structural changes

3. Strategic Levers3.1 A managed care model3.2 Primary care teams3.3 Empowerment3.4 Performance measures

3.5 Management contracts3.6 Equity funding3.7 Purchasing accessibility

4. Conclusion

Developing a High-Performing Health System in Quebec

1. History 1970-2004

• 5 Canadian principles respected• Responsibility for the individual• Functioning in silos• A problem of continuity• A problem of accessibility• Repetition of services• Hard to move from one level of care to

another• Performance undefined• Payment not linked to performance

Developing a High-Performing Health System in Quebec

2. The Reform2.1 Objectives

• Improve the health and will being of the population (specific mandates)

• Bring services to the population (equitable distribution of services)

• Facilitate the use of services (accessibility, continuity)

• Manage care for vulnerable clientele

Developing a High-Performing Health System in Quebec

2.2 Guiding principal Populational responsibility

• Defined population• Responsible for the health well-being of that

population• Responsible for the individuals health and well-being

Hierarchical provision of services• Regrouping primary care responsibility• Clearly refining secondary and tertiary services• Reference protocols and corridors of services

Developing a High-Performing Health System in Quebec

2.3 Structural changes

• A new organization: Health and Social Services Centers (HSSC)

• A new concept of integrated services through the creation of local services networks

• Merger of hospitals, local community service center, long term care centers into a single institution

• 12 HSSC in Montreal, 95 across Quebec

Developing a High-Performing Health System in Quebec

Population : 1,9 million

Budget : 5,2 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

Developing a High-Performing Health System in Quebec

Mandate of a Health and Social Service Center

• Manage and evaluate the health and well being of the population

• Manage the use of services by the population

• Manage the services offered by each HSSC

• Develope a local network of care

Developing a High-Performing Health System in Quebec

Local territory

Health and Social Services Centres :

grouping of one or several CLSCSs, CHSLD, CHSGSs

Community pharmacies

Community organizations

Non institutional resources

Social economy enterprisesPhysicians

(FMG, AMC, medical clinics)

Youth Centre

Rehabilitation centre Other sectors:

education, municipal, justice, etc.

Hospitals that provide

specialized services

Developing a High-Performing Health System in Quebec

3. Strategic Levers

3.1 Managed care Chronic care model

• Chronic care protocal for each disease• Support patients self management• Multidisciplinary team approach• A seamless system• Decision tools• Information systems for developing

registers ans insuring follow-up• Involvement of community resources

From Improving Chronic Illness CareEd Wagner, MD, Group Health Cooperative of Puget Sound

Informed Activated Patient

Prepared, Proactive

Practice Team

CommunityResources and

Policies

Clinical & Functional OutcomesClinical & Functional Outcomes

ProductiveInteractions

Health SystemOrganization of

Health Care

Chronic Care ModelChronic Care Model

SELF-MANAGEMENT

SUPPORT

DELIVERY SYSTEM

DESIGN

DECISION

SUPPORT

INFORMATION

SYSTEMS

Survey of operational practice built on the Chronic Care Model

•Which is the most important practice?

–Leadership–Accountability–Champions–Resources–Financial Incentives–Provider Feedback–Program Evaluation–Patient Action Plans–Patient Education–Guideline Training–Provider Alerts–AMR–Defined Care Path–Risk Stratification–Registry–Outreach and Follow-up–Inreach–Care Coordination–Team-Based Care–Cultural Competence

Developing a High-Performing Health System in Quebec

3. Strategic Levers

3.1 Managed care Clinical components of a population based

managed care model• A population health evaluation protocol• An individual evaluation protocol• Developing clinical protocols of care based of a

chronic care model• Organization of care

- Into a multidisciplinary teams responsible

for a rostered population- Corridors of service linking the providers

of care into a seamless system

Developing a High-Performing Health System in Quebec

3. Strategic Levers

3.1 Managed care Restructuring care for a population

based care model• Restructuring nursing home care• Restructuring rehab care• Restructuring care for the intellectually

handicaped• Restructuring mental health care• Restructuring laboratory services

Developing a High-Performing Health System in Quebec

3. Strategic Levers

3.2 A Primary care teams• Populational responsibility – Rostered

clientel• Integration of primary care physicians

specialists and health professionals into folly integrated multidisciplinary teams

• Access to medical technology• Use of a manage care model

Developing a High-Performing Health System in Quebec

3. Strategic Levers

3.3 Empowerment

• On the determinants of health• On healthy living• On disease management

Developing a High-Performing Health System in Quebec

3. Strategic Levers

3.4 Performance measurement

• Evaluation of population health• Evaluation of clinical performance of primary

care teams (England quality outcome frame work)

• Quality control of secondary and tertiary care• Measurement of efficiency add efficacy

Developing a High-Performing Health System in Quebec

3. Strategic Levers

3.5 Management contracts

• Minisitry with the Agency• Agency with each institution

Developing a High-Performing Health System in Quebec

3. Strategic Levers

3.6 Principals of equity funding

• Regional equity 221 $ million• Terretorial equity – Program funding

- Population based adjusted for age, sex, income, education, cost of services, needs evaluation, geography, state of health

- Redistribution of services : - dialysis - chemotherapy - rehab - mental health

Developing a High-Performing Health System in Quebec

3. Strategic Levers

3.7 Puchasing acessibility

• Primary care acessibility- Family practice groups and integrated

primary care teams - Hours of operation add coverage

- Affiliated medical centers

• Chirurgical acessibility• Diagnostic services• Regrouping lab services• Purchasing radiology services• Purchasing volume

Developing a High-Performing Health System in Quebec

4. Conclusion – The key ingredients

• A population based managed care model

• Multidisciplinary primary health care teams

• Competition for provision of services

• Management contracts

ISBN 2-89510-223-6

Dépôt légal – Bibliothèque nationale du Québec, 2005

This document is available:

- At Service des technologies et de la diffusion de l’information

Phone (514) 286-6500

- On the Website of the Agency: www.santemontreal.qc.ca