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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!