Case Management Best Practice for Community Stroke Care

1
Case Management Best Practice for Community
Stroke Care

• October 2003
• We gratefully acknowledge funding for this event
  from the Ministry of Health and Long-Term Care

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Agenda

• 830 Registration/continental breakfast
• 845 Welcome and objectives
• 850 Vision and current CCAC analysis
• 930 Best Practice Guidelines overview and small
  group work
• 1020 Break
• 1035 Report back
• 1100 Case management best practices/ case study/
  report back
• 1200 Lunch
• 1245 Other resources
• 130 Implementation plans
• 200 Regional initiatives
• 300 Wrap-up and evaluation

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Objectives for the Day

• Describe the Coordinated Stroke Strategy
• Discuss best practice guidelines for stroke care
  in long-term care/community
• Discuss role of moderators/facilitators in stroke
  care
• Discuss strategies and resources for case
  managers and educators to enhance stroke care
• Describe related initiatives in Central
  South/Central West

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Vision

• Individuals who experience a stroke will have
  timely access to the appropriate intensity and
  duration of rehabilitation services. These
  services will be provided in a comprehensive and
  coordinated way to patients and families, by
  agencies and health care providers who are expert
  in stroke care and practice rehabilitation.
• Consensus Panel on Stroke Rehabilitation, May
  2000 adopted by Joint Strategy Working Group

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The Coordinated Stroke Strategy

• The purpose is to decrease the incidence of
  stroke and improve patient care and outcomes for
  persons who experience stroke by reorganizing
  stroke care delivery to ensure that all Ontarians
  have access to appropriate, quality stroke care
  in a timely manner
• The strategy has three major components
• System Change
• Public Awareness
• Professional Education

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History of the Coordinated Stroke Strategy

• A three year demonstration project in Ontario was
  initiated in 1998 to test a model of
  region-wide, coordinated stroke care that spans
  the continuum of care involving 4 sites
• Hamilton Health Sciences Corporation (Central
  South/Central West)
• London Health Sciences Centre (South West)
• Queens University Care Delivery Network (South
  East)
• West GTA (a consortium of hospitals and CCACs)

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History of the Coordinated Stroke Strategy

• In June 2000, Towards an Integrated Stroke
  Strategy released by Minister Witmer
• A road map for the province
• Report of Joint Heart and Stroke/MOHLTC Working
  Group

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Findings of Report (Selected)

• Stroke is a devastating disease which is costly
  to individuals and to society
• Number of strokes will increase in the future
  (the risk of stroke doubles with each decade
  after 55)
• Implementation of best practice in stroke
  prevention could substantially reduce the number
  of strokes
• If acute care was organized, stroke mortality and
  morbidity could be reduced and patient outcomes
  improved

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Recommendations (Selected)

• A system of regional and district stroke centres
  should be established linking all acute care
  hospitals in Ontario
• When a person survives a stroke, evidence-based
  rehabilitation enables survivors to maximize
  their quality of life
• MOHLTC should support health promotion efforts
  that contribute to the primary prevention of
  stroke
• Stroke prevention clinics should be developed to
  improve secondary stroke prevention
• Stroke should be designated a priority of the
  MOHLTC

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Ontario Stroke Strategy-Implementation

• In March 2001, MOHLTC embraced the principles of
  the strategy and launched the Ontario Stroke
  Strategy
• To date 9 Regional Stroke Centres and 14 District
  Stroke Centres have been named
• Building to 30 million per year for the province
  of Ontario

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Where are the Stroke Centres?

• Regional Stroke Centres
• Hamilton Health Sciences
• London Health Sciences Centre
• Trillium Health Centre
• Toronto Western Hospital
• Sunnybrook Womens
• Kingston General Hospital
• Ottawa Hospital
• Thunder Bay
• St. Michaels Hospital

• District Stroke Centres
• St. Catherines
• Kitchener-Waterloo
• Owen Sound
• Stratford
• Sarnia
• Windsor
• Oshawa
• Chatham
• Niagara
• Barrie
• Richmond Hill
• Timmons
• Sault Area
• North Bay
• Sudbury

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Roles of the Regional Centres

• Full continuum of care within a region
• Collaboration and strategic alliances
• Local and regional commitment
• Local and regional care plans
• Data and information
• Education of the public, clients and providers
• Provincial system of linkages

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The Continuum of Stroke Care

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Stroke Rehabilitation Consensus Panel Report (May
2000)

• Heart and Stroke Foundation convened panel of 26
  experts from across province, charged with
• Summarizing what experts currently recommended in
  stroke rehabilitation based on best evidence
• Designing a system for stroke rehabilitation
• Proposing ways to close the gaps

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Recommendations (Selected)

• Development of a Regional Stroke Rehabilitation
  System
• Waiting lists for ambulatory and home based
  stroke rehabilitation be monitored to determine
  reinvestments required to meet regional needs
• Pilot projects to identify best practices for
  home based rehabilitation, including urban,
  rural, remote and northern locations
• Hospitals, CCACs and other health care providers
  work in partnership to improve the coordination
  of stroke rehabilitation, especially in the
  transition from hospital to community based care

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Stroke Rehabilitation Defined

• A progressive, dynamic, goal-oriented process
  aimed at enabling a person with an impairment to
  reach his or her optimal physical, cognitive,
  emotional, communicative and/or social function
  level
• Consensus Panel on Stroke Rehabilitation, Heart
  and Stroke Foundation of Ontario, May 2000

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Stroke Care in Long-Term and Community CareYears
1 and 2 (2000/2001, 2001/2002)

• Created a steering committee (membership includes
  representation from MOHLTC, OCAACA, Ontario
  Association of Non-Profit Homes and Services for
  Seniors, the Ontario Long Term Care Association,
  the Ontario Community Support Association and the
  Heart and Stroke Foundation of Ontario
• Developed Tips and Tools for Everyday Living A
  Guide for Stroke Caregivers and Stroke Strategy
  Case Management Best Practices for Community
  Stroke Care
• Developed 5 Stroke Care Pilot Projects in
  long-term and community care

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Stroke Care in Long-Term and Community CareYears
3 and 4 (2002/2003, 2003/2004)

• Implementing Tips and Tools and education to
  support the uptake of best practices in community
  and long-term care settings
• Region specific projects

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Heart and Strokes Role Moving Forward

• Dissemination and implementation of Best Practice
  Guidelines for Stroke Care, 2003
• Public awareness campaign on signs and symptoms
  of stroke launched September 29, 2003
• Education initiatives across the continuum
• Convenes Community and Long-Term Stroke Care
  Steering Committee
• Tips and Tools resource
• Research leader
• Patient information

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Best Practice Guidelines for Stroke

• 19 Best Practice Guidelines
• Evidence supporting guidelines
• Proposed care guides
• Sample protocols and guidelines in use across
  Ontario
• Assessment and outcome measurement tools
• Resources
• CD ROM included

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19 Best Practice Guidelines

• Stroke recognition
• Stroke prevention (2)
• Pre-hospital care (2)
• Emergency management
• Acute treatment
• Transition management (4)
• Rehabilitation management (4)
• Community re-engagement (4)

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Transition Management

• Effective transitions identified by stroke
  survivors as integral to client-centered care
• Protocols needed at each transition point
• Interdisciplinary team using standardized
  information and processes leads to continuity
• Primary care provider needs to be kept informed
• Need for ongoing access to rehab and community
  services during all phases of care

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Transition Management BPG8

• Develop and follow protocols
• At each transition point
• Across the continuum of care
• To ensure
• Appropriate access to services
• Timely access to services

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Transition Management BPG9

• Manage transitions
• With interdisciplinary team
• All using standardized information and processes
• To ensure
• Transfer of relevant documentation with client
• Continuity of clinical and case management
• Practical tips
• Establishing client-centred goals that travel
  with stroke survivor
• Establishing direct communication between
  referring receiving clinicians

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Transition Management BPG10

• Identify and confirm primary healthcare provider
• Before stroke survivor discharged from acute care
• Keep this individual informed
• Throughout all phases of care

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Transition Management BPG11

• Provide stroke survivors and their families
• Opportunities for ongoing access to
• Rehabilitation
• Community services
• During all phases of care

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Rehabilitation Management

• Stroke rehabilitation significantly reduces
  morbidity and improves quality of life
• Complete assessment needed to evaluate the
  potential for each client
• Rehabilitation plan to meet individual client
  needs and goals
• Timely access to appropriate intensity and
  duration of service along the continuum
• Family and caregiver involved

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Principles of Comprehensive Stroke Rehabilitation

• Continuity of care throughout the entire stroke
  continuum
• Care delivered by an experienced and dedicated
  interdisciplinary team of health care
  professionals
• Focus on recognition and optimal management of
  comorbidities and complications
• Early initiation of goal-directed treatment that
  enhances the stroke survivors abilities and
  minimizes disabilities

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Principles, cont

• Implementation of a secondary stroke prevention
  program
• Routine and systematic assessment of progress and
  adjustment of treatment
• A focus on the importance of education for the
  stroke survivor, the family and the caregiver
• Attention to psychological and social issues
  affecting the stroke survivor, the family and
  caregiver

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Principles, cont

• Early discharge planning to ensure effective
  community re-engagement and early resumption of
  home, family, recreational and vocational roles
  wherever possible
• Stroke survivor and family education about the
  possibility of discharge, not to home, but to an
  alternative care facility

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Assessing Stroke Survivors for Rehab Potential

• Current clinical status
• Neurological deficits
• Comorbid diseases
• Functional status

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Assessing Stroke Survivors, cont

• Special emphases
• Pre-stroke functional status
• Current functional deficits
• Mental status and ability to learn
• Emotional status and motivation for
  rehabilitation participation
• Functional communication
• Physical activity endurance

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Assessing Stroke Survivors, cont

• Social and environmental factors
• Presence of spouse of significant others
• Previous living situation
• Ethnicity and first language
• Adjustment of stroke survivor and family to
  stroke
• Rehabilitation preferences and expectation
• Support network available
• Potential post-discharge environment

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Rehabilitation Management BPG12

• For each client
• Evaluate
• Rehabilitation potential
• Including complete assessment conducted by stroke
  rehab team
• Develop
• Rehab plan reflecting
• Severity of stroke
• Needs and goals of stroke survivor

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Rehabilitation Management BPG13

• Ensure
• Access to appropriate intensity of rehabilitation
  services
• Available along continuum of care

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Rehabilitation Management BPG14

• Assess
• Ability of family and caregiver
• To support stroke recovery process
• Develop
• Strategy that includes educational component
• To address caregiver burden

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Rehabilitation Management BPG15

• Discharge
• Stroke survivors from rehab units
• In a timely manner
• Once realistic goals been achieved
• Once intensive inpatient rehab no longer required

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Community Re-Engagement

• Re-engagement reflects WHO concept of
  participation
• Stroke survivors and family need assistance with
  an evolving care plan including follow-up
  assessment of health status, community
  participation and prevention strategies
• Stroke expertise required in community and
  long-term care settings
• Caregivers need support
• Social support is crucial

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Components of Community Re-Engagement

• Health management
• Life roles
• Social network
• Environment
• Communications
• Mobility
• Caregiver support

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Community Re-Engagement BPG16

• Assist
• Stroke survivor and family
• Develop and implement care plan
• Assess
• 6-weeks, 3-months and 1-year
• Health status
• Community participation
• Links to prevention services

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Community Re-Engagement BPG17

• Create strategies enabling
• Healthcare professionals and caregivers
• Community and long-term care settings
• To develop stroke care expertise
• To support stroke survivors in achieving goals

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Community Re-Engagement BPG18

• Support caregivers
• Balance personal needs and caregiving
  responsibilities
• Provide
• Community programs
• Respite care
• Educational opportunities
• Link caregivers to programs

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Community Re-Engagement BPG19

• Assist stroke survivors to
• Maintain
• Enhance
• Develop
• Appropriate social support

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Moderators/Facilitators Objectives

• Increase awareness regarding the impact strokes
  have on survivors, caregivers and families
• Provide knowledge regarding current evidence for
  stroke care
• Identify current best practices and barriers to
  implementation
• Provide an opportunity to review and discuss best
  practices
• Increase benefits for stroke clients and their
  caregivers

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Best Practices for Community Stroke Care

• Partnership between the Heart and Stroke
  Foundation and the OACCAC to increase efficiency
  in organization and delivery of stroke care
• Two opportunities for learning
• Consult the Case Management for Community Stroke
  Care manual
• Visit the web site www.bpp.oaccac.on.ca/strokestr
  ategy
• Both contain case studies, presentations,
  resources

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Case Management Manual

• Three ways to use this manual
• The goal is to enhance stroke care by learning
  and sharing current knowledge and best practices.
• Format One ½ day seminar
• Description Provides an avenue for case managers
  to get an overview of best practices and to work
  through some case studies.
• Format Two ½ day team meeting
• Description Case managers present cases from
  their own experience, followed by group
  discussion.

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Moderators Guide and Group Learning Kit

• Format Three Regular staff meetings
• Description Devote part of a staff meeting to
  review best practices.

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Other Resources

• Heart and Stroke Foundation Professional
  Education Website
• www.heartandstroke.ca/profed
• REPS-Rehabilitation Education Program for Stroke
• Tips and Tools for Everyday Living

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Heart and Stroke Prof Ed Web Site

• Visit www.heartandstroke.ca/profed for more
  information on the Coordinated Stroke Strategy
  and to obtain copies of resources, reports and
  presentations.

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REPS

• A multifaceted education program for
  Speech-Language Pathology, Occupational Therapy,
  Physiotherapy and Nursing
• 3 parts self-directed online learning module
  regional mentors Internet Training and Mentor
  Training
• For more information, visit http//bul.med.utoront
  o.ca/reps

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Tips and Tools for Everyday Living

• The Tips and Tools Resource consists of a manual,
  video and Facilitators Guide
• Tips and Tools provides practical knowledge and
  skills for frontline workers and caregivers in
  LTC/community and CCACs
• The Toolbox newsletter highlights the experiences
  of caregivers as they implement Tips and Tools

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Tips and Tools for Everyday Living

• The manual has over 70 pages of information on
• Psychosocial effects of stroke
• Communication impairments
• Cognitive and perceptual problems
• Managing leisure and activities of daily living
• Mobility, skin care and continence

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Tips and Tools for Everyday Living

• The video demonstrates some of the techniques
  described in the manual.
• The Facilitators Guide is a resource for
  caregivers who have volunteered to act as
  "coaches" to frontline workers.
• The coach helps frontline workers to gain the
  knowledge and skills that encourage the stroke
  survivor to be as independent as possible.
• Tips and Tools is available by contacting
  416-489-7111, ext. 389, csor_at_hsf.on.ca or
  visiting www.heartandstroke.ca/profed

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Implementation Plan

• 3 things I have learned that I can apply to my
  day-to-day work are
• The 3 things I think others in my CCAC should
  know about are
• I plan to share my knowledge by

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Regional Initiatives

• Name of Region

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Initiatives in NAME OF REGION

• List and describe the specific initiatives for
  stroke community care in your region.