Proyecto Áncora & CESFAM
San Alberto Hurtado
Some reflections
August 2008
Thomas Leisewitz
Family Medicine Department
Pontificia Universidad Católica de Chile
tl@med.puc.cl
Background
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Family & Community Medicine Programme: postgraduate 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
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‘Registered’ population
‘Family Health Plan’
Teamwork
Responsiveness
and accountability
Information systems
Local planning
Outcome-orientation
Coordination in the use
of resources
Proyecto Áncora. Aim
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“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
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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
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…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
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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!
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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
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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
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Coverage of preventive services
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Ultrasound for
gall bladder disease
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Mammography
for breast cancer
Chronic disease management
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BP control in
hypertensive patients
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Blood glucose control
in diabetic patients
Access to dental care
Psychomotor development
in children
Our budget
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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
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55% salaries
22% outsourced services: laboratory,
cleaning and security
15% pharmacy & others
4% electricity, water, heating, etc.
How are we organised?
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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
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Family approach
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Patients lists for each physician
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Families assigned to
an specific team
Relationship with the community
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Diffusion and inscription
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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?
Evaluation. Methodology
Primary
Care
global
index
-Continuity
-Access
-Resolutividad
-Preventive care
–Health Promot
-Participation
-bps & family
approaches
-Direct
-Savings
-Appointments
- Referals
-Out-of-pocket payments
-Patients’ waiting times
Effectiveness
Costs
Centre 1
Centre 2
Cost-Effectiveness analysis
Δ Effectiveness
Effectiveness
Centre 1
Effectiveness
Centre 2
Δ Costs
Costs
Centre 1
Costs
Centre 2
Incremental Cost-Effectiveness Ratio
Costs (Centre 1- Centre 2)/ Effectiveness (Centre1 – Centre2) = Δ C / Δ E
Results. Effectiveness
Total global
ponderado
Indicadores
Objetivos
Experiencia
Aceptabilidad
Total
Dimension
MTC
Comp
MTC
Comp
MTC
MTC
Comp
MTC
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
0,5119
0,3788
Comp
Total
ΔE =
ΔE = 0, 1317
Comp
0,1331
Results. Direct costs
Tipo de Costo
Item
Origen
MTC
Comp.
Delta
%
Médicos
gasto per cápita del centro
625
23,55%
-176
-60,41%
-12
-2,68%
-39
-107,02%
ΔE =398
13,44%
2652
2027
2594
1854
58
173
291
467
SAPU
115
148
Urgencia
170
307
6
12
448
460
81,9
173,1
Exámenes
191,1
151,5
Consultas
175,0
135,5
36
75
36
75
2960
2562
Gasto operacional del centro no
docente
Gasto administración central
(gasto) per cápita del sistema
Interconsultas no pertinentes
gasto de bolsillo
Medicamentos
Tiempo
destinado a buscar cuidado
Pérdida de tiempo per cápita
TOTAL ($2006)
Todas las cantidades son percapita mensuales
Evaluation. Some conclusions
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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
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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
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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
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Financing
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Long-term feasibility (political willingness)
Non-enveloped per-capita allocations versus
specific allocations by each programme (change
during 2007)
Performance management
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Managing performance with a limited number of
indicators
Is it possible to define a common set of
indicators for primary care organisations?
Some reflections
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The Family Health Model
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What model do we want to implement?
How should it be evaluated?
Information management in primary
care
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the challenges of the electronic clinical
record (its full potential)