1. Breakfast with the Chiefs Strategic Levers for a High-performing Health System Equity issues in funding and delivery : The Montreal Experience Toronto - April 17 2007 David Levine President/CEO Montreal Regional Health Authority 2007

2. Developing a High-Performing Health System in Quebec 1. History 1970-2004 2. The Reform 2.1 Objectives 2.2 Guiding principles 2.3 Structural changes 3. Strategic Levers 3.1 A managed care model 3.2 Primary care teams 3.3 Empowerment 3.4 Performance measures 3.5 Management contracts 3.6 Equity funding 3.7 Purchasing accessibility 4. Conclusion

3. 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

4. Developing a High-Performing Health System in Quebec 2.The Reform 2.1 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

5. 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

6. 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

7. 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

8. 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

9. 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 enterprises Physicians (FMG, AMC, medical clinics) Youth Centre Rehabilitation centre Other sectors: education, municipal, justice, etc. Hospitals that provide specialized services

10. 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

11. From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Developing a High-Performing Health System in Quebec 3. Strategic Levers 3.5 Management contracts Minisitry with the Agency Agency with each institution

18. 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

19. 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

20. 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

21. 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