Proyecto Áncora & CESFAM San Alberto Hurtado

Some reflectionsAugust 2008

Thomas LeisewitzFamily Medicine DepartmentPontificia Universidad Católica de Chiletl@med.puc.cl

Background

Family & Community Medicine Programme: post-graduate training of family physicians from 1993

Collaborative work with Municipalities and Health Authority at SSMSO

Health policy initiatives: Family Health Centres 1997/98

Political willingness: management of public funds by private not-for-profit institutions

Health sector reform process based on primary care?: Family Health Centres

Family Health Centres

‘Registered’ population ‘Family Health Plan’ Teamwork Responsiveness

and accountability Information systems Local planning Outcome-orientation Coordination in the use

of resources

Proyecto Áncora. Aim

“Contribute to a significative change in primary care, delivering health care services and training professionals with a wide, efficient and human perspective, in a replicable way”

Proyecto Áncora. Objectives

Operation of 3 Health Centres Continuing evaluation of the model Encourage professionals’ and

students’ interest in primary care Diffussion of the experience Influence public policy decision-making

Proyecto Áncora. Challenge

…the implementation of a family health model in primary care through the management of public funding by a private not-for-profit organisation

…within the scope of the aim and objectives of the Ancora Project

Clinical model: some elements

The person at the centre The family as a fundamental referent The community and its role as a social support

network Keeping people healthy (Health Promotion) Continuity of care Personalised relationship with providers Responsiveness Teamwork Biopsychosocial approach

What we have… until now!

A team 22.703 people registered (22.076 validated) A building and equipment A budget An organisation of the main processes A proposal of implementation of the model

Our team 15 FTE doctors 5 FTE nurses 4 FTE midwives 2 FTE social workers 4 FTE clinical psychologists 1 FTE dietician 4 FTE dentists 9 FTE administrative staff 8 FTE clinical assistants 4 FTE dental assistants

The building

Some health indicators used for allocating resources

Coverage of preventive services Ultrasound for gall bladder disease Mammography for breast cancer

Chronic disease management BP control in hypertensive patients Blood glucose control in diabetic patients

Access to dental care Psychomotor development in children

Our budget

Per-capita value 2008: $ 2,826 Total per-capita funding 2008: M$ 536 University funding 2008: M$ 76 Total budget 2008: M$ 612

Expenditures

Expenditures

55% salaries 22% outsourced services: laboratory,

cleaning and security 15% pharmacy & others 4% electricity, water, heating, etc.

How are we organised? 2 sectors: multidisciplinary teams

delivering services for 10 000 people each

(green & blue) 1 clinical support team:

vaccination, pharmacy, laboratory,

diagnostic procedures,

special programmes

(eg respiratory diseases) 1 administrative support team:

call center, IT,

secretarial support, etc.

Work areas Family approach

Patients lists for each physician Families assigned to an specific team

Relationship with the community Diffusion and inscription Health promotion

Implementation of services included in the ‘Health Plan’ Process design and re-design and the relationship with ECR The teaching model (especially for 2008)

And what about evaluation?

Effectiveness

PrimaryCare global index

Costs

-Continuity-Access-Resolutividad-Preventive care –Health Promot-Participation-bps & family approaches

Centre 2

-Direct-Savings

-Appointments - Referals-Out-of-pocket payments -Patients’ waiting times

Centre 1

Evaluation. Methodology

Cost-Effectiveness analysis

Incremental Cost-Effectiveness RatioCosts (Centre 1- Centre 2)/ Effectiveness (Centre1 – Centre2) = Δ C / Δ E

EffectivenessCentre 1 Effectiveness

Centre 2

CostsCentre 1 Costs

Centre 2

Δ CostsΔ Effectiveness

Results. Effectiveness

Indicadores Objetivos Experiencia Aceptabilidad Total  

Total global ponderado

 

Dimension MTC Comp MTC Comp MTC Comp MTC Comp MTC Comp

Continuidad 0,1702 0,1699 0,1238 0,0837 0,2339 0,1562 0,5279 0,4098 0,0598 0,0464

Enfoque Prev y prom. 0,4200 0,3780 0,0909 0,0710 0,1322 0,1022 0,6432 0,5512 0,0837 0,0717

Resolutividad 0,3758 0,4008 0,1084 0,0616 0,1361 0,0861 0,6202 0,5484 0,1073 0,0949

Enfoque BPS y familiar 0,0217 0,1261 0,1936 0,1340 0,2512 0,1550 0,4665 0,4151 0,0339 0,0301

Accesibilidad 0,3004 0,2429     0,1231 0,0097 0,4235 0,2526 0,1669 0,0995

Participacion 0,5160 0,3090         0,5160 0,3090 0,0604 0,0362

Total                 0,5119 0,3788

0,1331ΔE =

ΔE = 0, 1317

Results. Direct costs

ΔE =

Tipo de Costo Item Origen MTC Comp.Delt

a%

             

  Médicos            

    gasto per cápita del centro   2652 2027 625 23,55%

      Gasto operacional del centro no docente 2594 1854    

      Gasto administración central 58 173    

    (gasto) per cápita del sistema   291 467 -176 -60,41%

      SAPU 115 148    

      Urgencia 170 307    

      Interconsultas no pertinentes 6 12    

    gasto de bolsillo   448 460 -12 -2,68%

      Medicamentos 81,9 173,1    

      Exámenes 191,1 151,5    

      Consultas 175,0 135,5    

  Tiempo            

    destinado a buscar cuidado   36 75 -39-

107,02%

      Pérdida de tiempo per cápita 36 75    

               

    TOTAL ($2006)   2960 2562 398 13,44%

             

Todas las cantidades son percapita mensuales          

Evaluation. Some conclusions The evaluated Ancora health center (MTC) was more

expensive and more effective than the comparator. The proposed effectiveness indicator seems

comprehensive, though the difficulties in understanding its practical implications.

Patient perspective stands as a key element for the proposed evaluation model, establishing significant differences between the analysed centres.

The difference in the estimated per-capita cost is smaller if a social perspective (modified) is adopted rather than just considering the operational expenditures.

Evaluation. Some conclusions The Ancora center saves money to the whole health

system, although it does not fully compensate the increased operational cost.

The effectiveness indicator is consistently higher for the Ancora health center, being unaffected by the different weights of the considered dimensions in a sensitivity analysis.

The family health model is complex, so do its evaluation. However, the richness of this evaluation model could give great information to health teams and managers for the betterment of the model.

Some reflections

After four years, we have realised that our main strength is the way how each team (and each individual professional) establish a relationship with its patients and families

The evaluation from the patients’ perspective has consistently been our best evaluated dimension

Some reflections

Financing Long-term feasibility (political willingness) Non-enveloped per-capita allocations versus

specific allocations by each programme (change during 2007)

Performance management Managing performance with a limited number of

indicators Is it possible to define a common set of

indicators for primary care organisations?

Some reflections

The Family Health Model What model do we want to implement? How should it be evaluated?

Information management in primary care the challenges of the electronic clinical

record (its full potential)