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, 2008
David Levine
President / CEO
Montreal Regional Health Authority

2. The Reform of Health and Social Services
Table of Contents
Important dates
The objectives of the reform
The guiding principles
A brief look at the reform
The Health and Social Services Centers
The local services networks
The 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 of
services
i
The Montreal Regional Health Authority – Role and
Responsibility
Integrated University Health Networks
Bill 83 on Health and Social Services
Bill 30 on U i
Union organisation
i ti
A population based managed care model

4. The Reform of Health and Social Services
Important 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 networks
February – April, 2004 : Public consultation in Montreal and in each Regional
Health Authority
April 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 f
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 p
and 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

5. The Reform of Health and Social Services
Important Dates (continued)
January – February 2005 : Selection appointment of the
February, Selection,
networks Chief Executive Officers
2005 : 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

6. The Reform of Health and Social Services
Global Objectives
Improve the health and well being of the population
Bring services to the population
Facilitate the use of services
Take charge of vulnerable clientele

7. The Reform of Health and Social Services
Specific Objectives
Introduce a population based managed care model
Introduce a chronic care model
Roster
R t each citizen t a primary care team
h iti to i t
Develop corridors of care for seamless services

8. The Reform of Health and Social Services
Objectives
The Past The Present and Future
Responsibility for the individual Responsibility for the population
Functioning in silos Continuous services without
A problem of continuity interruption
p
A problem of accessibility General practitioners at the center
Repetition of services of services in a multidisciplinary
team functioning in a population
Hard to move from one level of care based managed care model
to 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 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 agreements

10. The Reform of Health and Social Services
A Reorganisation of Service Delivery
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

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 organizations
Youth 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 Patients
PATIENTS 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 Services
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)

19. The Reform of Health and Social Services
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
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 Services
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
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 Services
The 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 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 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 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

27. The Reform of Health and Social Services
The Montreal Vision – Our strategy for the
Implementation of the Reform
Why 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 Model
Chronic Care Protocol for each disease
Support patients self management
Multidisciplinary team approach
A seamless system
Decision tools
Information systems for developing registers and insuring
follow-up
Involvement 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 Care
From Improving Chronic Ill
F I i Ch i Illness C Care –Cultural Competence
Cultural
Ed 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 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

34. The Reform of Health and Social Services
The Montreal Vision – Our Strategy for the
Implementation of the Reform
1) 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 beds
Covers 250,000 – 275 000 members
250 000 275,000
3 Satellite Clinics (supports 20,000 – 30,000 members each)
Approximately 500 MDs
50/50 Primary Care / Specialty Care
3,000 – 4,000 deliveries
Centers 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 Reform
2) 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 Reform
2) 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 Reform
3) 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 Reform
4) 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, 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