Ontario Stroke Network Forum Quality Based Procedures Update Stroke QBP Deborah Hammons Chief Executive Officer Central East LHIN January 9, 2015

Champlain, Mississauga-Halton and South West LHINs have pursued stroke QBP IDEAS projects (timely transfer, rehab intensity, stroke centre identification) Waterloo Wellington LHIN worked with Stroke Network to flow all stroke patients to designated acute and rehab stroke centres with standardized care pathways that include outpatient rehabilitation – now meeting QBP LOS targets with reduced ALC. North Simcoe Muskoka LHIN - engagement forums identified three acute stroke centres for stroke unit care. Community based and outpatient day rehab programs being planned. Central East LHIN working on funding reallocations in relation to acute stroke unit care. (Guests at our Sept Regional meeting) HNHB, Toronto Central LHINS have led LHIN-wide system integration work e.g. “Stroke Patient Flow” including identification of stroke centres and standardized transparent systems for referral to rehab. NE, ESC, SW, M-H, HNHB, Champlain, CW, CE, WW, NSM, Central LHINS: formal reviews of rehabilitation services for recommended rehab system change Successes in LHIN QBP Implementation to Date 2

Some of the key issues for and barriers towards successful implementation of the stroke best practices Recommendations include, but not limited to: A transitional approach to funding is recommended to enable building of capacity in the community Each LHIN will need to consider consolidation of stroke care in a fewer number of hospitals in their region Transportation services will need to be in place to support access to rehab services The location of Telestroke sites will need to be considered Collaboration will need to occur between “stand-alone” rehab facilities and referring sites to facilitate timely transfer Barriers include, but not limited to: If changes in length of stay and discharge into community are not achieved, it may be difficult to increase the number of patients seen in stroke units To provide 7 day-per-week admission to inpatient rehab, access to pharmacy, dietary and medical coverage, among others, will need to be available Human resource shortages Implementation of Best Practices 3

 Early adopters followed the OSN guidelines and had already started the implementation of best practices for stroke  Key enablers for implementation included the OSN Recommendations and Guidelines and QBP Stroke Clinical Handbook  Most of the hospitals had a dedicated stroke unit; some are planning to reallocate stroke beds and work collaboratively with their referral and community partners  Most had a dedicated team of health professionals (i.e. MD, Nurse, OT, PT, SLP, dietician, SW) and had organized QBP governance structures (e.g. Steering Committee) with cross-membership from physician leadership, clinical teams, decision support teams etc. 4 Comments from Health Service Providers (1)

 Some indicators for stroke are arbitrary and may not show improvement in stroke outcomes  Need to link quality of patient experience with stroke QBP  Need to reinvest in primary and secondary prevention  Stroke assessment requires resource intensive assessment; consultation should be recognized  Concerns over impact on funding and operations especially as it relates to patients with multiple comorbidities 5 Comments from Health Service Providers (2)

 Standardized language across the organization re best practices  Improvements in coding, data collection and quality (i.e. regular chart audits decreased number of unspecified strokes, physician documentation improved)  Use of Order Sets advantageous  Key performance indicators were developed and teams were educated (i.e. use of dashboard or scorecard, discussed at rounds)  Referral to stroke prevention clinics from ED  Greater emphasis in working to understand variations in practice 6 Some Specific Quality/Process Improvements

 Challenges with Computed Tomography Angiography (CTA) utilization  Difficulty referring patients to rehab with low AlphaFIM® scores, with complex or cognitive deficits  Swallowing assessments and Dysphagia screening  Over occupancy in stroke unit, patient have to be bed spaced in a non- stroke bed  Access to rehab: Difficulty accessing rehab for patients with cognitive deficits, risk for falls, etc.  Workload for Allied Health therapists 7 Some Specific Barriers/Challenges (1)

 Challenges for the hospitals administering tPA  May have to transfer patients farther from their home; Difficulties with managing severe strokes with cognitive/physical impairments  Tendency to have higher % of ALC due to limited availability of inpatient rehabilitation or long-term care beds; Also, working closely with CCAC to facilitate discharges (e.g. HomeFirst); bed management is an issue  In some hospitals, there is a lack of follow-up care (i.e. stroke prevention, outpatient services)  Coding challenges and different definitions of stroke exist (i.e. CIHI versus OSN versus QBP) 8 Some Specific Barriers/Challenges (2)

 Equitable access to timely rehabilitation services  Limited community services particularly in remote communities 9 Overarching QBP Implementation Challenges

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