An Auditor’s Perspective on Healthcare Sergei Pekh MBA, CPA, CMA Audit Principal Doug McKenzie CA, LLB Audit Principal
Who Are We • Alberta legislature’s independent audit office • audit provincial departments and crown corps • “clients” include MLAs and Albertans • financial audits • systems (or value for money) audits: systems to ensure economy and efficiency processes to measure and report effectiveness • ~150 staff in Edmonton and Calgary, plus agents • 2015-16 budget = $27M 2
Three Examples • chronic disease management • mental health services • seniors care common themes: – continuity of care over time and across continuum – integration of AHS and primary care – information sharing 3
Why We Audited CDM • affects all of us – individuals, family, friends, community • prevalence high and increasing • cost to public healthcare = $ billions • medicine has developed systems to manage chronic disease effectively: 1) p atient’s medical home (continuity, care team) 2) clinical practice guidelines (e.g., diabetes care) 3) patient engagement in care planning 4
CDM - Main Conclusions • CDM is critical to health of Albertans and sustainability of public healthcare • significant opportunities exist to improve CDM in Alberta • improvement will take time, but dramatic action must be taken now 5
What is CDM? • patients need continuity of care: – a family doctor – a care plan that is actively managed – a care team • good information systems to support physicians, care teams and patients • patient engagement 6
Our Hope Today — Encouragement • LPNs are key providers and members of the patient’s team • across the system, we see improvements driven from the ground up (vs. top down) • support efforts to improve outcomes measurement and evidence-based practice 7
High Priority Chronic Diseases “Long -lasting condition, usually progressive, and cannot be cured ” • Hypertension • Diabetes • Heart failure • COPD Ministry Priorities • Heart disease • Asthma • Depression • Obesity 8
High Priority Chronic Diseases “Long -lasting condition, usually progressive, and cannot be cured ” • Hypertension • Diabetes • Heart failure • COPD • Heart disease • Asthma • Depression • Obesity 9
Affects All of Us • ~25% of Albertans will develop diabetes • > 90% will have high BP by age 80 • > 20% will have a mental illness at some point • 1/5 women and 1/6 men will have a stroke • cost to Alberta’s public healthcare system is $ billions/year 10
Annual Cost 735,000 patients w hypertension, diabetes, COPD, heart disease: 1.8M hospital days (60%) = $2.9B ALOS 11.8 days (~2½ x avg ) 6M GP visits (34%) = $385M 4M specialist visits (38%) = $645M > 10M prescriptions = $470M 575K ER visits (27%) = $105M 11
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Drivers • Growing population • Aging • Unhealthy lifestyle factors lack of exercise poor diet smoking excessive alcohol consumption 13
Rising Burden Albertans' Life Expectancy at Birth 90 80 70 60 Disabled years Age 50 Disability-free years 40 30 20 10 0 1957 1985 2000 Year 14
The “M” in CDM 15
What We Examined Whether Ministry of Health has systems to: • manage the business of providing healthcare to individuals with CD • actively link all Albertans with a family physician and care team • plan and evaluate CDM delivered by AHS and Primary Care Networks • support CD patients through care plans • support CDM with IT, including: – EMRs in physician offices and AHS, and – personal health records 16
What We Did Not Audit • social determinants of health (income, education, housing) • social/economic impacts (pain & suffering, productivity) • health promotion and prevention programs provided to all • CD services by specialists, hospitals, home care, long-term care or referral processes between them and family physicians • the work of any specific individual physician or provider 17
Findings - Department “Alberta’s Primary Health Care Strategy describes the key elements of CDM. However, the department does not currently have a structured approach or business model to deliver CDM services at the level of a high-performing healthcare system .” The ministry has: • not set clear expectations for CDM services (e.g., care plans and care teams) • no system to determine CDM demand or see it is met • does not have formal processes to obtain assurance physicians or AHS provide CDM in accordance with good practice • does not have adequate systems to evaluate CDM effectiveness • privacy concerns re sharing patient info but can overcome them 18
Findings — GPs & PCNs • ministry has no process to know if CD patients have a family physician – many PCN physicians have identified their patients but most have not – ~490,000 Albertans do not (>16,000 with CD) • no requirement for PCN physicians to identify CD patients or patients with risk factors (e.g., pre-diabetes) • ministry has not determined optimal size and distribution of care teams • 750 GPs not in a PCN ( > 520,000 patients /84,000 w CD) 19
Findings – Care Plans • no expectations set for physician care plans – what it should contain – how it should be implemented – program coverage • < 20% of individuals with chronic disease have a care plan, and the number of patients without a care plan is increasing as the incidence of chronic disease rises • no ongoing process to evaluate and improve care plan effectiveness (data exists – e.g., AHS inpatient and lab) • many GPs lack information systems to manage care plans effectively • AHS does not obtain process to obtain patient’s care plan or inform GP if it considers changes are necessary 20
Care Plans Long-term Care Plans? Physician Pharmacist Care Plans Care Plans 16,975 70,700 128,725 21
Care Plans Long-term Care Plans? Physician Pharmacist Care Plans Care Plans 16,975 70,700 128,725 Physio Care Plans? 22
Care Plans Long-term Care Plans? Physician Pharmacist Care Plans Care Plans 16,975 70,700 128,725 Physio Care Plans? 23
Care Plans Long-term Care Plans? Physician Pharmacist Care Plans Care Plans 16,975 70,700 128,725 Mental Health Care Plans? Physio Care Plans? 24
Findings — IT AHS shares its hospital, lab, and DI data through Netcare X > 12 different EMR systems and none communicate with others X clusters of EMR excellence are emerging but most GPs do not currently use their systems to manage care plans , maintain a chronic disease registry, or measure and report CDM effectiveness X the ministry and other providers have no access to GP EMRs X the ministry does not currently provide Albertans access to their personal health information 25
Public Mental Health System 26
Mental Health — Findings no follow through on mental health strategies no integrated case management – still work in silos fragmented care planning lack of care pathways no operating model to support care teams family physicians and AHS operate separately IT systems remain incompatible and outdated CIS is still 10 years out – can patients wait? performance measurement and HoNOS thoughts on privacy and information sharing 27
Mental Health — Findings housing supports needed as part of integrated care no meaningful change at the front line from 2008 supply/demand gap analysis not done no waitlist management (with few exceptions) lack of standardized assessment tool n o coordinated placement mechanisms… even for spaces AHS funds directly community placement for ALC patients in hospitals is a problem – what about patients treated in the community? many entities are involved in housing — why should AHS take the lead? 28
Long-term Care • continuing care = home care, assisted living and long-term care • we focused on long-term care • 170 LTC facilities with 14,370 beds • facilities receive: – $910M from AHS for healthcare services – $285M from residents for accommodation services • care plans 29
Resident Care 30
LTC Facility Oversight 31
LTC Facility Oversight No single program or function is responsible to manage overall performance of individual facilities, including authority to act on poor performance. Data to do so exists. No process to identify high risk facilities, and no standard set of proactive compliance tools to escalate action based on risk. 32
What Needs To Be Done skills, resourcefulness and dedication of providers many good practices in Alberta Leadership and action is needed at the system level: • the orchestra needs a conductor • recognize vested interest and instill sense of purpose • patient-centered and population-focused • long-term commitment beyond annual fiscal cycles and 4-year political terms You are vital as care providers and ministry allies in reshaping and revitalizing healthcare, including CDM. 33
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