2011 CAHSPR Conference May 11, 2011

Transcription

1 2011 CAHSPR Conference May 11, 2011 COMPARING INTEGRATED CARE SYSTEMS FOR ELDERS: THE EXPERIENCES OF MARSEILLE AND CHAMPLAIN Alejandra Dubois, Ph D (c) Population Health University of Ottawa

2 OUTLINE Team Members Acknowledgements Project Purpose The problem Research Questions Methods Contexts First Level of Comparison Results 2

3 A JOINT PROJECT: 3 UNIVERSITIES 3

4 TEAM MEMBERS From University of Ottawa Douglas E. Angus, Professor, MHA Program/MGSS Telfer School of Management Project PI Alejandra Dubois, Ph D (c) Population Health Research Assistant From Laval University Michèle St-Pierre, Ph.D. Professeur agrégé Université Laval Faculté des sciences de l'administration Département de management 4

5 TEAM MEMBERS (CONT.) From EUROMED (Marseille) Corinne Grenier, Professeur, HDR, sciences de gestion Directrice scientifique Pôle Santé / Social Chercheur rattaché au Laboratoire Cergam (équipe IMPGT), U. Aix Marseille III Francois Gambarelli, Ph D student, sciences de gestion Centre d Etudes et de Recherche en Gestion d Aix-Marseille, Laboratoire CERGAM Research Assistant 5

6 ACKNOWLEDGEMENTS Project Funded by the Social Sciences and Humanities Research Council of Canada (SSHRC) Doctoral Research Award in the Area of Public Health Research granted by the Canadian Institutes of Health Research (CIHR) 6

7 PROJECT PURPOSE To compare the models of governance, integration and coordination of heath services being offered in two different regional communities: The Champlain region in Ontario (Canada) and the Marseille region (France). 7

8 THE PROBLEM % elderly will continue to increase 10-15% of seniors have multiple chronic health problems) 25% or more seniors will require some supports Inappropriate use of resources (hospitals, nursing home-beds) Lack of community supports 8

9 RESEARCH QUESTIONS What is the role of the Regional Agency (LHIN or ARS) in facilitating / constraining : RQ1 the coordination and integration of actors and of services around the elderly patient? RQ2 the innovation of services around elderly people and developed by one organisation? 9

10 METHODOLOGY Qualitative Methods Research field from September, 2009 to June, 2010 (data validation in March-April 2011) Interviews to key actors (9 in Marseille and 4 in Ottawa) Review of documents (regulations, reports, minutes of meetings, et) Meetings observation Data analysis with N Vivo Case Studies 10

11 CASE STUDIES (MESO AND MICRO LEVELS) LHIN Champlain ARS = ARH + URCAM GEM (Regional Geriatric and Community Intervention Program ) Aging in Place 2 réseaux gérontologiques 11

12 THE CONTEXT OF LHIN CHAMPLAIN 12

13 THE 14 LHINs TERRITORIES Champlain LHIN Source: Champlain LHIN web site ( 13

14 MANDATE million population ( 10% of Ontario) - - The Champlain LHIN does not directly provide services; its mandate is to plan, coordinate and fund (trough MOLTCH budget) health care services in the following seven areas: 1. Hospitals 2. Community Care Access Centre (CCAC or home care) 3. Addictions Services 4. Mental Health Services 5. Community Support Services (such as Meals on Wheels) 6. Community Health Centres (CHCs) 7. Long-term Care Homes 14

15 SERVICES EXCLUDED FROM LHIN BUDGET: provincial drug programs, including senior drug programs physician fees (except salaries of physicians being employed at the CHCs) provincial health administration costs public health programs municipal expenditures on health care, which includes all land ambulance services in Ontario since 1988 (MOHLTC website, 2010) private expenditures such as drugs (other than the ones being provided within institutions), private therapeutic interventions, and dental services costs independent health facilities, such as private nursing homes 15

16 THE NEED FOR A NETWORK Despite its limited financial leverage, the LHIN mandate is to develop a network, integrate services and build partnerships based on a large array of sectors that influence health status of their community. 16

17 THE AGING AT HOME STRATEGY Purpose: To provide seniors and their caregivers with an integrated continuum of community-based services to enable them to stay healthy and live more independently in their own homes. Its goals are aimed at: Ensuring that seniors homes support them Supportive social environments Senior-centered care that is easy to access Identifying innovative solutions to keep seniors healthy 17

18 18 THE CONTEXT OF PACA REGION

19 FRANCE (SIMPLIFIED VIEW) (SINCE APRIL 2010, URCAM AND ARH ARE MERGED UNDER THE SAME REGIONAL AGENCY, NAMED ARS) National level Ministrie s (Health, Finance) Ministry of Social Affairs Union Nationale des Caisses d Assurance Maladie Regional level ARH URCAM Conseil Régional Conseil Départemental Local level Hospitals, facilities for elders Healthcare Networks GP, speciaslists CLIC, social services of CG Cities and social services 19

20 COMPARING CONTEXTS 20

21 COMPARING GENERAL CONTEXTS CHAMPLAIN MARSEILLE Population Champlain : 1,116,000 (70% in Ottawa) Marseille 840,000 Density Champlain : 62 per km2 PACA region: 155 per km2 Public Policy Aging at Home (AAH) Not equivalent single policy but a set of policy orientations Organization Regionalized URCAM / ARH: Deconcentrated (22 regions of services (14 LHINs in Ontario) in France) Conseil régional and Conseil général: regionalized Financing Structure LHIN Champlain allocates funds received in-trust from MHLTC ARS (URCAM-ARH PACA) allocates funds for networks and some experimentations, regulates hospitals and socio-medico facilities Conseil Général: APA 21 CNSA (national public body): allocate funds for experimentation of MAIA

22 LEVEL OF ANALYSIS CHAMPLAIN MARSEILLE MACRO Provincial (Ontario ) National (France ) MESO The LHIN The URCAM and the ARH of PACA The Conseil régional of PACA The Conseil Général of Bouches-du-Rhône Sub regional 6 political ridings No health subregions MICRO (Case studies) 2 pilot projects among 28 financed by AAH 9 health territories in PACA, including Bouches du Rhone Nord, which splits in 3 territoires de niveau de proximité : Marseille Aubargne-La Ciotat Martigues 2 gerontologic networks in Marseilles 1 MAIA 22

23 The role of the Regional Agencies (a) CHAMPLAIN LHIN set up in 2007 MARSEILLE URCAM / ARH set up in 1996 ARH: under the authority of the Ministry of Health URCAM: under the authority of UNCAM (at the national level under parliamentary control) DRASS set up in 1996 Now: the ARS regional agency 23

24 The role of the Regional Agencies (b) CHAMPLAIN Trough AAH, the LHIN is in charge of managing (and evaluating) a portfolio of projects aimed involving public and private services delivered to elderly people living at home. But in a context of already integrated local services MARSEILLE. The regional agencies are in charge of planning (and evaluating) activities in line with the national and regional policies and orientations. One main planning tool: SROS (Schéma Régional d Organisation des Soins). Main organizational tools: cooperation between hospitals (and other health organizations), networks between GP (and specialized doctors) and health organisations Public policies: mainly population-oriented policies. Public policies: mainly pathologiesoriented policies 24

25 The role of the Regional Agencies (c) CHAMPLAIN More traditionally oriented towards a regulation model In a context of less fragmented local services MARSEILLE More traditionally oriented towards a planning model Encouraging then making quasi- compulsory coordination among local actors A very recent move toward integration and territory-oriented model for better coordination A recent move for better institutionalisation of networks as the loci for articulation between the various policies 25

26 RESULTS About Governance at the meso level Differences in public policy cycle - in the case of LHIN/Ontario: a lot of projects / experimentations were initially funded but priorities shifted overtime how to innovate? - in the case of France/ PACA: a lot of projects /experimentations are funded and, especially when included in national of regional public orientations, they are pursed how to simplify the system? - in both cases: the user is not included in the public policy cycle how to recognize the users as a competent stakeholder? 26

27 RESULTS To what extent coordination / integration is supported by the meso level? Main differences: o in France: coordination-oriented reforms => lots of authorities experimentations based on national or regional regulations or policy orientations o in Ontario/LHIN: integration-oriented reforms => a more simplified model? weak formalization 27

28 RESULTS (CONT.) About Innovation at the meso level - Ontario/LHIN: recent radical change by the LHIN regarding approach to innovation - France/PACA:. continuous move towards better coordination and simplification of decision process between the health sector and the social/medico-social sector. the innovations funded by the micro or meso levels are launched in accordance with regional orientation plans of the health and social sector. One main challenge: innovations are often evaluated on the basis of current (and not innovating) criteria 28

29 RESULTS (CONT.) About governance of coordination / integration -In France / Marseilles: - changes towards coordination are difficult to implement, even under mandatory regulations - the various boards of governance of networks do not work very well (not a strong culture of governance in France) - in Ontario / LHIN: collaborative governance models in the rise 29

30 QUESTIONS AND DISCUSSION 30