Experience in Other Provinces: Ontario Stroke Analysis Quebec Stroke Summit October 7, 2008 Mary Lewis Director 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 Family Health care team Best Practice across the Continuum of Care Fewer strokes. Better Outcomes. Ontario Stroke System Stroke recognition Prevention Prehospital Emergency Acute Rehab Community & LTC Transition Foundation of the Ontario Stroke System Clinical, Process Standards Research & Education Evaluation Monitoring, & CQI Communication 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 Director Regional Manager Education Coordinator Rehab Coordinator Community & LTC Coordinator Allied Health Outreach Admin support CNS Behaviour Modification Admin/Coordinator

Ontario Stroke System Best Practice across the Continuum of Care Stroke recognition Prevention Prehospital Emergency 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 p 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 p value Readmission Rates (1yr) TIA 14.6%10.8% <0.001 Ischemic 13.0%9.6% Carotid Intervention Median Wait Time 66 days24 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 Admission rates to inpatient rehabilitation 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) 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 Team Future Directions Fewer 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: Thank you!