Experience in Other Provinces: Ontario Stroke Analysis Quebec Stroke Summit October 7, 2008

1. 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

2. Mission: To continuously improve stroke prevention, care, recovery and re-integration.

3. History • Guiding Principles: • Comprehensive • Integrated • Evidence-based • Province-wide

4. OntarioStroke System Foundation of the Ontario Stroke System Communication Evaluation Monitoring, & CQI Research & Education Clinical, Process Standards Best Practice across the Continuum of Care Fewer strokes. Better Outcomes. Patient and Family Health care team Emergency Acute Prehospital Transition Stroke recognition Rehab Prevention Community & LTC Integration: System change

5. Medical Director Regional Manager Education Coordinator Rehab Coordinator Community & LTC Coordinator Allied Health Outreach Admin support 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 CNS Behaviour Modification Admin/Coordinator

7. OntarioStroke System Best Practice across the Continuum of Care Emergency Acute Prehospital Transition Stroke recognition Rehab Prevention Community & LTC • 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 • 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 • Infrastructure • Research • Best practice guidelines • Clinical process standards • Education • Interprofessional care & expertise • Evaluation & CQI

8. 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

9. 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

10. Lewis M, Trypuc J, Lindsay P, O’Callaghan C, Dishaw A.Healthcare Quarterly 9:50-59, 2006

12. OSS Successes: Regional Stroke Centres Stroke registry of the CSN

13. OSS Successes: Provincial Provincial CIHI DAD data

14. 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

15. Other Successes • Capacity building • Partnerships • Emergence of the Canadian Stroke Strategy • Cross Continuum Approach • New organisational design

16. 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

17. OSS Rehab Challenges Provincial CIHI NRS data

18. Recent Rehab Successes • Uptake from rehabilitation pilot projects • One region: Specialized stroke community rehab teams • Action plans for implementation of rehab consensus panel standards

19. 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

20. 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

21. Future Directions Fewer strokes. Better Outcomes. Patient and Family Health Care Team Emergency Acute Prehospital Transition Stroke recognition Rehab Prevention • 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 Community & LTC

22. Thank you! For more info, visit: www.heartandstroke.ca/profed