Experience in Other Provinces: Ontario Stroke Analysis

Quebec Stroke Summit

October 7, 2008

Mary LewisDirector Government Relations and Health Partnerships, Heart and Stroke Foundation of Ontario

Mission: To continuously improve stroke prevention, care,

recovery and re-integration.

History

Guiding Principles:•Comprehensive•Integrated•Evidence-based•Province-wide

Patient and FamilyPatient and FamilyHealth care teamHealth care team

Best Practice across the Continuum of Care

Fewer strokes. Better Outcomes.

Ontario Stroke System

Stroke recognition

Prevention

PrehospitalEmergency Acute

RehabCommunity

& LTC

Transition

Foundation of the Ontario Stroke System

Clinical,Process

Standards

Research&

Education

EvaluationMonitoring,

& CQICommunication

Integration:System change

Funding Directed To:

9 Regional Stroke Centres 2 Enhanced District Stroke Centres

= 11 Regional Teams 16 District Stroke Centres 24 Secondary Prevention Clinics $1.4 Million for Research/Best

Practices $4.6 Million for Health Promotion

Medical DirectorRegional ManagerEducation CoordinatorRehab CoordinatorCommunity & LTC CoordinatorAllied Health OutreachAdmin support

CNSBehaviour ModificationAdmin/Coordinator

Ontario Stroke SystemBest Practice across the Continuum of

Care

Stroke recognition

Prevention

PrehospitalEmergency Acute

Rehab

Community& LTC

Transition

•Public awareness•Links: public health, primary care•Healthy living – smoke-free living, physical activity, healthy eating•Blood pressure management•Risk factor management•TIA management•Secondary prevention clinics

•Regional acute stroke protocols – medical redirects for access to tPA•Telestroke•Organised emergency care•Acute Care pathways, early rehab•Acute stroke units•Dysphagia management

•Rehab pilot projects•Triage to rehabilitation•Standards for rehab•Access to rehab•Telerehab•Enhanced community based rehabilitation•Community re-integration•Education in LTC

•Infrastructure•Research

•Best practice guidelines

•Clinical process standards•Education

•Interprofessional care &

expertise•Evaluation & CQI

Enablers for Success Broad engagement Shared vision – finding common ground Dedicated change agent/infrastructure Champions Networks and partnerships Evidence based practice guidelines Knowledge translation focus Sharing of resources, tools, processes

(care pathways, algorithms, agreements, protocols)

“Healthy” competition

Lesson Learned in Achieving an Integrated Care System

The process is just as important as the content

Engage all stakeholders from the beginning and keep it collaborative, multidisciplinary

You are implementing a system change that needs both champions and full-time “change managers”

Use evidence (best practice) to drive changes You need to measure and monitor the impact of your system changes

Lewis M, Trypuc J, Lindsay P, O’Callaghan C, Dishaw A.

Healthcare Quarterly 9:50-59, 2006

OSS Successes: Regional Stroke Centres

2003-042005-

06p

value

Arrival <2.5 hrs from symptom onset

36% 42% <0.001

Access to t-pa (eligible patients)

24% 29%

Admission to Stroke Unit 24% 62% <0.001

Dysphagia Screening 40% 58% <0.001

Referrals to SPC from ER 48% 63.5% <0.001

Stroke registry of the CSN

OSS Successes: Provincial

2003-042005-

06p

value

Readmission Rates (1yr)TIA 14.6% 10.8%

<0.001Ischemic 13.0% 9.6%

Carotid Intervention Median Wait Time

66 days 24 days <0.001

In-hospital Mortality Rates(Adjusted for age and gender)

10.4% 9.1%

One-year Mortality Rates (for admitted pts) (Adjusted for age and gender)

24.2% 22.1% <0.001

Provincial CIHI DAD data

Evaluation: Summary of Successes Volumes

OSS diversion of patients to more specialized stroke centres

Volume of stroke admissions stable or decreased despite the projections of increased #’s of stroke with the aging population.

ED: increased access to tPA Prevention

Improved wait times for CEA/CAS Decreased one year re-visit rates for ON and for SEO Decreasing mortality rates

Inpatient acute care Reduction in complications ALOS stable In-hospital mortality rates decreasing

Other Successes

Capacity building Partnerships Emergence of the Canadian Stroke

Strategy Cross Continuum Approach New organisational design

Evaluation: Summary of Areas to Improve Greater number of younger people are

experiencing stroke (19-65 year olds) Wait times for CEA much higher for DSCs and

community hospitals than RSCs. Public awareness: 60% of pts at RSCs are not

arriving in time to be eligible for tPA Access to inpt rehab is limited for severe

stroke and varies across the province Limited and inequitable access to ambulatory

and community based interprofessional rehab services

Limited public funding for help with pyschosocial issues

OSS Rehab Challenges

2003-042005-

06

Admission rates to inpatient rehabilitation

21% 21%

Days from stroke onset to inpatient rehab admission mean (median)

21 (13) 18 (11)

Admission FIM Score mean (median) 75 (77) 78 (80)

Change in FIM mean (median)22 (21) 22 (21)

Provincial CIHI NRS data

Recent Rehab Successes

Uptake from rehabilitation pilot projects

One region: Specialized stroke community rehab teams

Action plans for implementation of rehab consensus panel standards

Making it Better Provincial/Regional evaluation and

performance improvement Align research with system priorities Align provincial and regional initiatives Align initiatives with LHIN priorities – e.g.

CDPM Leverage e-health Greater focus on rehabilitation and community re-integration

Current Challenges Finding the balance: provincial standards/

coordination vs regional implementation – will the provincial focus be lost?

Will LHINs ensure accountability for regional roles? – Lack of clarity re accountability.

How will inequities be addressed? How do we balance disease specific issues

with chronic disease approaches? Mismatch/inequities in the evidence base

Patient and Family Health Care Patient and Family Health Care TeamTeam

Future DirectionsFewer strokes. Better Outcomes.

5 Provincial Strategic Directions•Credible Advisor to Improve Stroke Prevention & Care•Leadership and Coordination •Evaluation to Support Continuous Improvement•Innovation and Knowledge•Best Practices across the Care Continuum

Stroke recognition

Prevention

Prehospital

Emergency Acute

Rehab

Community& LTC

Transition

For more info, visit:www.heartandstroke.ca/

profed

Thank you!