OTC and EXTRA Alumni Event October 21, 2010 INTEGRATING SERVICES FOR FRAIL ELDERS: AN INTERNATIONAL COMPARISON Alejandra Dubois, Ph D (c) Population Health University of Ottawa
OUTLINE Team Members Acknowledgements Project Purpose The problem Research Questions Methods Contexts First Level of Comparison Discussion 2
A JOINT PROJECT: 3 UNIVERSITIES 3
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
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
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
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
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
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? RQ3 the appropriation of evaluation process interest by organisation? 9
METHODOLOGY Qualitative Methods: Interviews to key actors Review of documents Meetings observation Case Studies 10
CASE STUDIES Regional Geriatric and Community Intervention Program (GEM) 2 réseaux gérontologiques Aging in Place 11
12 THE CONTEXT OF LHIN CHAMPLAIN
THE 14 LHIN TERRITORIES Champlain LHIN Source: Champlain LHIN web site (http://www.champlainlhin.on.ca/map.aspx) 13
MANDATE - - 1.1 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
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
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
SIX STRATEGIC DIRECTIONS 2007 2010 LHIN CHAMPLAIN Better access to treatment closer to home Addictions and mental health Elderly with complex and chronic conditions Chronic disease prevention and management Primary health services for healthy communities E-health (i.e. an electronic health record) 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 18
19 THE CONTEXT OF PACA REGION
DEMOGRAPHICS The PACA Region 4,870,000 inhabitants ( 65 years 18%) Density: 155 per km2 The Bouche-du-Rhône Département 1,960,000 inhabitants Density: 385 per km2 Marseille the main town, 840,000 inhabitants ( 65 years 18%) 20
THE ORGANIZATION OF HEALTH AND SOCIAL SECTORS IN FRANCE (SIMPLIFIED VIEW) (SINCE APRIL 2010, URCAM AND ARH ARE MERGED UNDER THE SAME REGIONAL AGENCY, NAMED ARS) National level Ministries (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 21
THE ORGANIZATION OF HEALTH AND SOCIAL SECTORS IN FRANCE (SIMPLIFIED VIEW) The main national policies for elderly people - Fostering aging at home (regulations in favor of the home-based services) - Favoring better coordination of services among providers (gerontologic networks, partnerships between hospitals, nursing homes, GPs, etc) - Favoring better coordination around patient with Alzheimer disease (MAIA) The main local orientations for elderly people (Urcam, ARH) - Supporting experimentations and improvements in the implementation of national policies - Fostering the development of networks based on territories (not on pathologies) - Greater attention to network performance (in the context of financial constraints) 22
THE ORGANIZATION OF HEALTH AND SOCIAL SECTORS IN FRANCE (SIMPLIFIED VIEW) The main local orientations for elderly people (Conseil Général) - Financial difficulties in managing the départemental social policy of elderly people (the allocation of APA Personnalized Allocation for Autonomy) The main challenges in articulating the various competences - The space of competences of Urcam/ARH and of Conseil Général are not equivalent - Urcam and ARH are administrative bodies, under the authority of the State the Conseil Général is a elected body 23
24 FIRST LEVEL OF COMPARISON
COMPARING GENERAL CONTEXTS CHAMPLAIN MARSEILLE Public Policy Aging at Home (AAH) Not equivalent single policy but a set of policy orientations Organization of services Regionalized (14 LHINs in Ontario) Urcam / ARH: Deconcentrated (22 regions 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 CNSA (national public body): allocate funds for experimentation of MAIA Population Champlain : 1,116,000 (70% in Ottawa) Marseille 840,000 Density Champlain : 62 per km2 PACA region: 155 per km2 25
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 26
SOME INTERMEDIATE RESULTS About Governance at the meso level - Differences in public policy cycle - in the case of LHIN/Ontario: a lot of projects / experimentations seem to be funded but very few ones are pursued => 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 (which seems to result from an addition of projects and national orientations)? - in both cases: the user is not included in the public policy cycle => how to recognize the users as a competent 27 stakeholder?
SOME INTERMEDIATE RESULTS To what extent coordination / integration is supported by the meso level? - Main differences: - in France: coordination-oriented reforms => a very large number of authorities -in Ontario/LHIN: integration-oriented reforms => a more simplified model? - in France: experimentations and orientations towards coordination based on national or regional regulations or policy orientations - in Ontario/LHIN: weak formalization; the LHIN way of doing may be one first example of change for more 28 formalized and planed innovation
SOME INTERMEDIATE RESULTS (CONT.) About Innovation at the meso level - Ontario/LHIN: recent radical change by the LHIN regarding approach to innovation - France/PACA:. Ongoing move towards better coordination and simplification of decision process between health sector and 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 sectors. A recurrent challenge: innovations are often evaluated on the basis of current (and not innovating) criteria 29
SOME INTERMEDIATE RESULTS (CONT.) About governance of coordination / integration -In France / Marseille: - 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 collaborative governance in France) 30
31 QUESTIONS AND DISCUSSION