Looking backward to move forward - rsph.anu.edu.au · Solo providers Walk‐in clinics Group practices Network clinic Family health groups Health services organisations Local department

Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm

Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 1

Looking backward to move forward Insights from Canadian primary healthcare reform evaluations

Jean‐Frédéric Levesque, MD, PhD

Commonwealth Department of Health and Ageing

Canberra, ACT, Australia

March 28th 2012


Primary healthcare (PHC) in CanadaJean‐Frédéric Levesque, MD, PhD

The Barbara Starfield Plenary Measuring the Impact of Primary care

International Primary Care Reform Conference

Brisbane, Queensland, Australia

Primary healthcare (PHC) in Canada• 13 provincial and territorial health systems• A publicly‐funded and privately‐provided medical care

• Mostly fee‐for‐service reimbursement

• Mostly privately‐funded allied health and social services• 35‐40% of health expenditure is private – below 2% for medical

• A fairly homogeneous model of practice – the solo or smallMarch 7th 2012

• A fairly homogeneous model of practice – the solo or small medical group• Absence of rostering or registration of patients




Primary healthcare (PHC) in CanadaJean‐Frédéric Levesque, MD, PhD




Primary healthcare (PHC) in Canada• 20‐30% of patients not affiliated to a practice or doctor

• Increasing rates of orphan patients due to closing of clinics • Problems of access to primary care, mostly for younger males and children

• High rates of emergency department consultations

• Reduction of uptake of general practice as a medical

March 7th 2012

p g pspecialty

• Increasing number of patients followed by specialist for primary care

Regular doctor or regular place for medical care, countries and provinces, 2010

82 %

79 %

6 %

9 %

12 %

13 %

Ontario

Canada

79 %

83 %

85 %

88 %

94 %

95 %

72 %

12 %

13 %

4 %

3 %

3 %

4 %

12 %

9 %

4 %

11 %

8 %

16 %

Australia

New Zealand

France

Switzerland

Norway

Netherlands

Quebec

48 %

64 %

75 %

76 %

44 %

13 %

3 %

10 %

8 %

23 %

22 %

14 %

0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %

Sweden

United Kingdom

Germany

United States

Regular doctor No regular doctor but a regular place None



Emergency room visit was for a condition that could have been treated by the regular doctor, countries and provinces, 2010

49 %

46 %

51 %

54 %

Ontario

Canada

36 %

35 %

34 %

32 %

26 %

23 %

46 %

64 %

65 %

66 %

68 %

74 %

77 %

54 %

Netherlands

New Zealand

Australia

Norway

Germany

France

Quebec

49 %

42 %

41 %

39 %

51 %

58 %

59 %

61 %

0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %

United States

Switzerland

United Kingdom

Sweden

Yes No

Among respondents that had a hospital emergency room visit in the past 2 years

Waiting time (number of days) to see a specialist, countries and provinces, 2010

57.2

68.1

Ontario

Canada

34.2

27.2

20.5

14.3

13.4

82.6

United Kingdom

Netherlands

United States

Germany

Switzerland

Quebec

51.5

49.6

43.9

42.7

39.5

0 10 20 30 40 50 60 70 80 90

Sweden

Norway

France

Australia

New Zealand

Among respondents who were advised to see or decided to see a specialist in the past two years



Have been admitted to the hospital overnight in the past 2 years, countries and provinces, 2010

16 %

18 %

84 %

82 %

Ontario

Canada

20 %

20 %

19 %

16 %

12 %

8 %

20 %

80 %

80 %

81 %

84 %

88 %

92 %

80 %

Sweden

Switzerland

United States

Netherlands

United Kingdom

Germany

Quebec

24 %

22 %

22 %

21 %

76 %

78 %

78 %

79 %

0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %

France

New Zealand

Australia

Norway

Yes No

“Primary care traditionally seen as a distant observer ofa distant observer of reforms of hospital and community health centres”



Primary healthcare (PHC) reform is currently under






Primary healthcare (PHC) reform is currently under way in various Canadian provinces• Recognition of the central role of primary healthcare into healthcare systems’ performance

Emerging models and policies are at various levels

March 7th 2012of implementation across jurisdictions• A natural experiment of change in PHC

Patients roster, groups, multidisciplinary, blended funding, clinical governance, quality improvement, local coordination information systems

• There has been some evaluations of these• There has been some evaluations of these reforms, few cross provincial analyses– Lack of interprovincial studies;

– Variations in designs and measurement instruments;

– Few documentation of the impact of contexts on the implementation and impact of PHC reformsimplementation and impact of PHC reforms



Looking backward Our objectivesInsights from Canadian primary healthcare reform evaluations





Using qualitative deliberative synthesis techniques to better understand primary care reform and its impact on people,

March 7th 2012 providers, organisations and systems.Outlining the impact of context on policy

prescriptions.

A policy analyses of PHC reforms in ten provinces and three territories

• Examines primary health care reform efforts in Canada duringreform efforts in Canada during the last decade drawing on:– descriptive information from

published and grey literature

– and from a series of semi‐structured interviews with informed observers of PHC in CanadaCanada

(Hutchison, Levesque, Strumpf, Coyle 2011)



A deliberative synthesis of PHC reforms evaluations in five provinces

• Examines the impact of models and factors facilitating reform through:g g– Case studies of provincial reforms

– Deliberative synthesis involving reform evaluations researchers as well as decision‐makers

(Levesque, Burge, Haggerty, Hogg, Katz, Pineault, Wong 2012)

Various quantitative and qualitative evaluations

• Primary care reform evaluation in Nova Scotia (Burge and Lawson)( g )

• Studies of Family Medicine Groups implementation in Quebec (Haggerty, Pineault, Lamarche, Beaulieu, Levesque)

• Comparison of primary care models in Ontario (Hogg, Russell, Dharouge, Green)

• Assessment of chronic care in fourAssessment of chronic care in four intervention practices in Manitoba (Katz)

• Evaluation of primary care experiences in British Columbia (Wong and Watson)



Four measurement perspectives

1. Capturing contextual influences

2. Measuring the nature of reform efforts

3. Understanding the levers of reform

4. Evaluating impact of reforms

1. Capturing contextual influences

• A felt urgency for changef h hl h d ’ d f– Performance reports highlighting Canada’s deficits

– A tired and de‐motivated workforce

• A history of separate community health centres and primary care providers– Multi‐disciplinarity is outside of primary care and doctors have resisted working inside a community orientation

• A supportive socio‐political context– Recognition that primary care must be supported



“ A strong desire for change has been observed i i Ph i i i th iin many provinces. Physicians are seeing their workloads increase because of the shortage of human resources relative to the increased complexity of clinical cases. Many are now more receptive to changes.”

Satisfaction with practicing medicine, countries and provinces, 2009

24 %

21 %

53 %

55 %

23 %

24 %

Ontario

Canada

19 %

22 %

28 %

31 %

35 %

35 %

13 %

59 %

67 %

54 %

50 %

54 %

55 %

60 %

23 %

11 %

18 %

20 %

11 %

10 %

27 %

Italy

Netherlands

United Kingdom

Sweden

New Zealand

Norway

Québec

5 %

8 %

12 %

14 %

33 %

69 %

36 %

48 %

62 %

23 %

52 %

38 %

0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %

Germany

France

Australia

United States

Very satisfied Satisfied Somewhat dissatisfied/Very dissatisfied



Leaving medical practice within the next 5 years, countries and provinces, 2009

18 %

20 %

7 %

7 %

75 %

73 %

Ontario

Canada

14 %

16 %

17 %

17 %

18 %

29 %

19 %

7 %

15 %

3 %

8 %

4 %

28 %

4 %

80 %

70 %

80 %

75 %

78 %

43 %

78 %

Netherlands

United States

Italy

France

Germany

Sweden

Québec

7 %

9 %

11 %

13 %

15 %

13 %

4 %

12 %

78 %

78 %

85 %

75 %

0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %

New Zealand

Australia

Norway

United Kingdom

Yes, retiring Yes, leaving for other reasons No

Other health care providers in the practice, countries and provinces, 2009

55 %

55 %

45 %

45 %

Ontario

Canada

79 %

88 %

89 %

91 %

98 %

98 %

65 %

21 %

12 %

11 %

9 %

35 %

Germany

Australia

New Zealand

Netherlands

United Kingdom

Sweden

Québec

11 %

54 %

63 %

74 %

89 %

46 %

37 %

26 %

0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %

France

Italy

United States

Norway

Yes No



“ If the policy environment has historically b t l t d i dbeen neutral towards primary care and professionals generally opposed to the redesign of their practice, it is clear that the current socio‐political context has changed throughout the country.”

2. Measuring the nature of reform efforts

• Model‐based reformsOntario and Québec implementing a variety of practice– Ontario and Québec implementing a variety of practice models (organisational types)

– Some efforts at modifying reimbursement models

• Principle‐based reforms– Nova Scotia and British Columbia investing in quality improvement initiatives (best practice)

• System integration– Alberta, British Columbia and Québec implementing coordination organisations (networks and divisions)











Family medicine groups

F il h l h

Local integrated health networks

Cooperative clinics

Primary care divisionsLocal health centres

Family health teamsPrimary care networks

Community health centres

Solo providers

Cooperative clinics

Walk‐in clinics

Group practices

Network clinic

Family health groups

Community health centres

Health services organisations

Local department of general practice

Quality improvement initiative

3. Understanding the levers of reform

• Coercive policies and incentives– Provincial governments have been the main driversg

• Legislation supported expanded roles for other professionals• Best practice characteristics parts of contractual agreements

– Funding of reform is crucial• Too little thwarts efforts and demoralizes• Too much proves overwhelming and unsustainable

• Normative influences– There was a few case of active lobbying by professionaly g y p– Support and engagement of professional leaders was essential

• Mimetic influence– Presence of champion and an incremental process



“ Few changes have been imposed on providers d it i di f i tiand it is more a discourse of incentives or

demonstrations that is currently seen in many provinces. In many cases, the need to treat physicians as partners in reforms was identified as the key to success.”

“ ...in every province, the presence of certain h i i id hchampions among primary care providers has been crucial and they have often acted as role models for other physicians in order to generate the necessary uptake for new models or initiatives to grow.”



4.Impacts of reforms

• Most benefits of the reforms so far seem to have occurred with regards to: occurred with regards to: – patients’ affiliation with a usual source of care, – some benefits on the experience of care of patients, – higher workforce satisfaction

• Emerging evidence of the impact of new models on prevention and management of chronic diseases:– recognition of the value of oldermodels, such as CHCs, on

complex patients care– limited evidence of impact on quality of life and health

outcomes

5

6

General practice assessment survey scores by subdimensions across organisational types at baseline

2

3

4

0

1

Accessibility Reception Continuity Communication Nursing

Solo provider Private group practice Family medicine group/network clinic Local community health centre/Family medicine unit



(Commissaire à la santé et au bien‐être 2011)

(Commissaire à la santé et au bien‐être 2011)



Overall view of the health care system, Canada’s respondents (practice), 2009

29%

35%

67%

58%

3%

7%

Group practice

Solo practice

etting

32%

36%

34%

33%

34%

37%

39%

37%

64%

60%

64%

65%

59%

60%

58%

64%

4%

3%

3%

3%

7%

3%

3%

No

Yes

5 and more

2 to less than 5

Less than 2

Hospital / Other

Local com. health centre

Family medicine group

etwork of

practices

FTE doctors

Practice se

Improvement of the quality of medical care, Canada’s respondents (practice), 2009

6 %

21 %

%

46 %

33 %

33 %

G ti

Solo practice

g

33%

34%

31%

38%

62%

63%

65%

59%

5%

3%

4%

3%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

No

Yes

No

Yes

Other

providers

Electronic

records

N p

Works pretty well Fundamental changes are needed Need to be completely rebuilt

21 %

16 %

17 %

21 %

17 %

15 %

21 %

16 %

51 %

51 %

51 %

48 %

53 %

54 %

50 %

51 %

28 %

33 %

32 %

31 %

30 %

31 %

30 %

33 %

Yes

5 and more

2 to less than 5

Less than 2

Hospital / Other

Local com. health centre

Family medicine group

Group practice

ork of

tices

FTE doctors

Practice settin

Disease burden across types

SoloPrivate group

Family medicine group /

Local community

health centre / SpecialistSolo

Average elderly population

Better perceived health status

practice

Low elderly population

Better perceived health status

group / Network clinic


Worse perceived health status

health centre / Family medicine

unit

High elderly population


Specialist



Lower multimorbidity

Low home‐care reception

Lower multimorbidity

Low home‐care reception

Average multimorbidity

Average home‐care reception

High multimorbidity

High home‐care reception

High multimorbidity

High home‐care reception



(Provost et al. 2010)

P15. Asked how chronic condition affects life

P16. Contacted after a visit

P17. Encouraged to attend community programs

P18. Referred to health educator or counselor

P19. Explain visits with other doctors

P20. Asked about visits with other doctors

ng /

Follow‐up /

Coordination

Reported reception of chronic illness care, PACIC (n =776)

P6 Shown how what I did influenced my condition

P7. Asked to talk about goals in caring for condition

P8. Helped to set specific goals to improve eating and exercise

P9. Given a copy of treatment plan

P10. Encouraged to go to a specific group or class

P11. Asked questions about health habits

P12. Doctor or nurse thought about values, beliefs and traditions

P13. Helped to make a treatment plan

P14. Helped to plan ahead in hard times

gn

Goal Setting

Problem‐solvin

Contextual

Counselling

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

P1. Asked for my ideas when we made a treatment plan

P2. Given choices about treatment to think about

P3. Asked to talk about medicines problems

P4. Given a written list of things to improve my health

P5. Satisfied that my care was well organized

P6. Shown how what I did influenced my condition

Patient

Activation

Delivery

System Desig

/ Decision

Support

None of the time A little of the time Some of the Time Most of the time Always

v2

Slide 38

v2 J'ai noté "agrandir le stackbar...vous vous souvenez de quoi il s'agissait?"vlemieux, 28/04/2010



30

40

50

Average percentage gap with mean scores of PACIC subdimensions across organisational types (12 months)

‐10

0

10

20

‐30

‐20

Solo provider Private group practice Family medicine group/Network clinic

Local community health centre/Family medicine

unit

Specialist

Patient Activation Delivery System Design / Decision Support Goal Setting Problem‐solving / Contextual Counselling Follow‐up / Coordination

(Levesque et al. 2012)

Local community health t

Percentage of severe patients followed by specialists for their chronic illness (typology)

Group practice

Family medicine groups

centers

0 10 20 30 40 50 60 70 80 90 100

Solo provider

(Levesque et al. 2012)



Looking forward

• Canadian provinces and territories are experiencing an acceleration of primary careexperiencing an acceleration of primary care reforms

• Understanding their diversity and the levers that facilitate their implementation will help us better guide the continuation of reforms

• Change is happening where synergies betweenChange is happening where synergies between policy and professional leadership align

• It is starting to translate into population level impacts

Acknowledgements

Brian Hutchison

Erin Strumpf

Raynald Pineault

Bill Hogg

Jeannie Haggerty

Alan Katz

Fred Burge

Sabrina Wong

Dominique Grimard

And all the Forum participants

Looking backward to move forward - rsph.anu.edu.au · Solo providers Walk‐in clinics Group practices Network clinic Family health groups Health services organisations Local department

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