Improving Access to Quality

Stroke Care in

Waterloo/Wellington

Tammy Tebbutt

May 11th, 2013

Why is this happening?

We want to make rehabilitation better for

patients across Waterloo and Wellington

•The stroke stream is part of a broader rehabilitation review

•There are three other aspects to this review, covering

– Musculo-skeletal care

– Care for the frail elderly

– Cardio-pulmonary care

•This involves hospitals and health providers from across

Waterloo and Wellington

Stroke is a system of care

We need to prevent strokes, treat them as

quickly as possible, provide timely access to

rehabilitation and help people as they go home.

What is/isn’t working now?

We have great providers who

do their very best for patients.

The stroke system in Waterloo

and Wellington has too many

pieces in too many places.

•There aren’t consistent ways of caring for people

•There isn’t a way to give patients access to the best specialists

all the time, no matter where they live.

•We can do better, and improve outcomes for patients.

What do we propose?

To develop a stroke system that has better

results for patients and families

•Access to specialized, timely stroke care for all stroke patients

in Waterloo and Wellington

•Concentrate stroke beds to make sure patients have the best

access to the care they need (critical mass)

•Develop designated stroke units with dedicated stroke staff

receiving the latest training to give patients the best results

•Partnerships with the Community Care Access Centre and

other community stakeholders to help patients when they

recover at home

Preventing strokes and acting faster

•We need families/friends to recognize the signs and

symptoms of stroke, recognize this is a medical

emergency and call 9-1-1 right away:

�Sudden weakness

�Trouble speaking

�Vision problems

�Headache

�Dizziness

•EMS can get patients to care faster, and ensure faster

access to clot-busting drugs (when appropriate)

Changing the care system for the better

• Care in an emergency will remain the same. People will

continue to go directly to Grand River Hospital in Kitchener for

assessment for clot-busting medications. We continue to

review whether other sites should be equipped to provide this

therapy.

• Inpatient acute and rehabilitation stroke unit care will be

consolidated to create critical mass

• We are finalizing and refining where the services will be

located

• Working with CCAC to develop a model of care for better

community care when patients return home

New Model of Stroke System of Care in

Waterloo/Wellington LHINRecommended by WW Rehab Council

waterloo_map.lnk

Acute Stroke Care• 2 Geographically Defined Stroke Units with dedicated staff

Inpatient Rehabilitation•3 Geographically Defined Stroke Rehab Units with dedicated staff

This is a big change. Why is this better?

Ontario Stroke Reference Panel has put forth province-wide recommendations for :

•Specialized Stroke Units

•Early admission to rehabilitation

•Intensity of therapy

•7 day a week admission – 7 day a week therapy

•Access for severe stroke

•Outpatient rehabilitation

Putting specialized resources in a few

large sites allows us to provide better

care.

Critical mass: bigger is better for patients

Stroke Expert Panel recent recommendations

(Feb 2013)

“to achieve the critical mass of expertise and

stroke unit admissions, each LHIN will need to

consider consolidation of stroke care in a few

number of hospitals in their region. Thus,

stroke-related bed days will be moved from

smaller centres to those with stroke units.”

Faster access to rehabilitation:

better outcomes for patients

Day 5 for ischemic stroke, Day 7 for hemorrhagic

Time is brain for acute stroke; but time is

function for rehab!

What changes we can make now?

• Applying a consistent “banding” approach… making sure we clearly identify stroke patients for their needs, so we can act on those needs faster

• Hiring a stroke navigator in May to assist with seamless, timely transitions

• Putting in place best practice clinical pathways to standardize care provided across the continuum of care

Stroke Navigator

• Anticipate the needs of stroke patients within

the system

• Ensure appropriate referral and placement of

stroke patients

• Ensure capacity and flow across the

continuum of the stroke system

• Develop transitional and discharge plans

• Ensure the right patient receives the right care

at the right time through management of wait

lists

Make acute care work better for patients

� Staff education surrounding best practices

• Patients automatically transition to rehab (no application)

• Expanding care plan to reflect best practice (e.g. oral care, continence assessment, etc)

• Improving access (move to 7 day a week care model for therapy, transfers and discharges)

– Currently a 5 day a week model

• Documentation – doing the right thing but remains a challenge to capture it and flow across and between sites

Making rehabilitation better for patients

New system changes include:

• Getting faster rehab access (inpt & outpt)

• Improve access for severe stroke patients getting to inpatient rehab

• Longer and more intensive therapy (move to 3 hrs/day 6-7 days a week)

– Currently patients receive an average of a little over 1 hour of therapy per day 5 days per week

• Specialized stroke rehabilitation units with dedicated teams (nursing, allied health, medical)

What will our communities gain?

A stroke patient’s time in hospital is short.

Their time at home is longer.•Ensure that patients are embraced and supported with an

appropriate community resource when they return to their

community

•Work with stream lead organizations to develop the

community services sector of the standardized care paths

•Develop trust and capacity in the system to ensure patients

get the right care, at the right time, in the right place

•Link with primary care to ensure that they have information

regarding the availability/processes to access community

services

Community Planning

Community Integration Teams

Features of WWCCAC Proposed Stroke

Rehabilitative Care Model1. Designated hospital and community care coordinators

to support client transition to home and/or community

programs; and work closely with Stroke Flow Navigator.

2. ‘Discharge Link’ meeting with most responsible

community clinician, hospital team, and hospital care

coordinator.

3. Most responsible community clinician to make first

treatment visit to client within 7 days of hospital

discharge. (Phase 1 and 48 hours Phase 2)

4. ONE community service provider for all disciplines to

facilitate development of skills in stroke treatment and

inter-disciplinary communication.

5. Improved linkage with primary care

What’s a care pathway?

Why does it matter?

Working Groups across the Continuum

Integrated care pathway

• It’s a way of knowing every step of a patient’s care when they have a stroke.

• We can then respond faster and better to their needs at a given point.

• Six groups across continuum are mapping out the patient journey

• They’re working with the identified clinical experts to develop a better system that will be more responsive to patients, whether they’re in an ambulance, in hospital or back at their homes

What is the timeline for change?

• March and April: consult with communities• April: hospitals/health providers to consider the

changes• June: decision by LHIN Board• Full implementation of changes to be completed in

2013 - 2014

Discussion

What’s important to you for stroke care?

What do you think about what you’ve seen?

Do you have questions/concerns that you would like followed-up on?

How do you want receive updates/information moving forward