David Levine President/CEO Montreal Regional Health Authority 2007

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

2. Developing a High-Performing Health System in Quebec • History 1970-2004 • The Reform 2.1 Objectives 2.2 Guiding principles 2.3 Structural changes • 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 • Conclusion

3. Developing a High-Performing Health System in Quebec • 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 • 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 Social economy enterprises Physicians (FMG, AMC, medical clinics) Community pharmacies Health and Social ServicesCentres : grouping of one or several CLSCSs, CHSLD, CHSGSs Community organizations Youth Centre Noninstitutional resources Rehabilitation centre Other sectors: education, municipal, justice, etc. Hospitals that provide specialized services

10. Developing a High-Performing Health System in Quebec • 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. 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 From Improving Chronic Illness Care Ed Wagner, MD, Group Health Cooperative of Puget Sound

12. Developing a High-Performing Health System in Quebec • 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 • 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 • 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 • Strategic Levers 3.3Empowerment • On the determinants of health • On healthy living • On disease management

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

18. Developing a High-Performing Health System in Quebec • 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 • 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 • Conclusion – The key ingredients • A population based managed care model • Multidisciplinary primary health care teams • Competition for provision of services • Management contracts

21. Thank You 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