Planning, Engagement, Integration

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Advancing the IHSP Chronic Disease Prevention
Management - Stroke Care Overview- March 27,
2007
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Discussion Items

• A system approach to CDPM in Central East LHIN
• Impact of Stroke
• Components of the Ontario Stroke System serving
  the Central East LHIN
• Opportunities and challenges for coordinated
  stroke care in the LHIN
• Current challenges/capacity issues related to
  delivery of stroke care.

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INITIATE A SYSTEMS APPROACH TO CDPM PLANNING
FUNDING.

• Central East LHIN FOUNDATIONAL WORK
• Establish a CDPM Network Steering Committee
• Form a broad Chronic Disease Prevention and
  Management Network
• Adopt a guiding CDPM Framework
• Build collective knowledge base - initial
  priority areas
• Cardiovascular disease stroke
• Chronic Kidney Disease
• Diabetes
• Respiratory disease (COPD, asthma)
• Arthritis and related conditions

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Burden of Stroke

• Stroke is the fourth leading cause of death in
  Canada, with stroke costs approaching 2.7
  Billion nationally.
• 75 of all Canadian adults have at least one
  health-style related risk factor for a stroke
  /or Transient Ischemic Attack mini-stroke
  (TIA)
• In Ontario
• third leading cause of death
• leading cause of patient transfer to a long-term
  care facility
• cost estimated over 850M per year
• at least 16,000 people suffer a stroke each year
• 90,000 Ontarians are survivors of a stroke
• Sources OSS Strategic Planning Backgrounder for
  Consultations (March 15, 2007) HKPR District
  Stroke Centre

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Impact of Stroke

• Over age 65, stroke is more common than heart
  attack
• As population ages - increase the prevalence of
  stroke.
• Stroke has the longest length of stay of any
  disease and the highest Alternate Level of Care
  (ALC) days.
• 22 of patients in Long-term Care Homes have had
  a stroke.
• High burden of disability due to depression (1/3
  of stroke survivors) and dementia/cognitive
  impairment.
• There is also increased evidence of the cognitive
  impact of TIAs and strokes.
• There is a heavy burden on family - nearly half
  of care partners suffering from depression.
• Source OSS Strategic Planning Backgrounder for
  Consultations (March 15, 2007)

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Continuum of Stroke Care
Source HKPR District Stroke Centre
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Ontarios Stroke System (OSS)

• The Ontario Stroke System (OSS) is a
  collaborative system of provider organizations
  and partners who deliver stroke prevention
  programs and stroke care across the continuum of
  care.
• Coordination of the system on a regional basis to
  provide stroke care based on best practices
• Improvement of public awareness-early
  recognition, health promotion, prevention.
• Development of stroke expertise in each region
  through professional education
• Evaluation and Monitoring
• Source HKPR District Stroke Centre

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Goals of Ontario Stroke System

• Reduce morbidity and mortality from stroke
• Improve patients functional outcome
• Enhance quality of life
• Optimize resource utilization
• Optimize access, coordination and integration of
  organized stroke care and services in the
  province
• Improve public awareness and early recognition
  for optimal recognition, prevention, treatment
  and recovery
• Source HKPR District Stroke Centre

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Development of OSS

• June 2000 MoHLTC announced a comprehensive stroke
  strategy based on joint Ministry/Heart and Stroke
  Foundation of Ontario (HSFO) report
• As of 2005 - 11 designated regional stroke
  programs, each with a Regional Stroke Steering
  Committee with responsibility for planning and
  overseeing delivery of stroke services. 11
  programs consist of
• 9 Regional Stroke Centres (RSCs)
• 18 District Stroke Centres (DSCs)
• and 24 Secondary Prevention Clinics.
• Each has roles in organizing the human and
  medical resources for their region and for
  developing a regional plan across the continuum
  of care.
• The Regional Stroke Centres also have the
  responsibility of providing leadership for the
  growth and development of the OSS for their
  region in partnership with the District Stroke
  Centres/Enhanced DSC, community hospitals,
  community systems and other key stakeholders.
• Source OSS Strategic Planning Backgrounder for
  Consultations (March 15, 2007)

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Components of Stroke System.

• 15 District Stroke Centres
• Timmins and District Hospital
• Sault Area Hospitals
• North Bay General Hospital
• York Central Hospital, Richmond Hill
• Niagara Health System Niagara General
• Brantford General
• Grey Bruce Health Services, Owen Sound
• Bluewater Health, Sarnia
• Stratford General Hospital
• Grand River Kitchener
• St Josephs, Chatham
• Peterborough Regional serving Haliburton,
  Northumberland, Kawartha Lakes and Peterborough
• Pembroke General
• Quinte Healthcare, Belleville
• Huntsville District Memorial
• Stroke Prevention Clinics at Hospitals 29
  hospitals report having Clinics on site (ICES
  March 2006)
• Lakeridge Healthcare Corporation

• PURPLE Serving Central East LHIN
• 9 Regional Stroke Centres
• University Health Network, Toronto Western
• St. Michael's Hospital
• Sunnybrook and Women's College Health Sciences
  Centre
• Hamilton Health Sciences Centre
• Kingston General
• Trillium Health Centre
• Thunder Bay Regional
• The Ottawa Hospital
• London Health Sciences Centre
• 3 Enhanced District Stroke Centres
• Sudbury Regional Hospital
• Royal Victoria Hospital, Barrie
• Windsor Hotel Dieu Grace

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Opportunities and Challenges to Coordinated
Stroke Care in Central East LHIN

• Multiple Stroke Networks supporting care in
  Central East LHIN
• OSS Provincial Strategic Planning is currently
  underway
• Provincial Reporting relationships and roles
  under discussion (MOHLTC, OSS, LHINs)
• Provincial Rehab Consensus Panel Report to be
  released March 28
• Central East CDPM Steering Committee formed Feb
  07
• Central East Rehabilitation Task Force - to be
  formed April 07

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Coordinationacross three Stroke Networks
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Coordinationacross three Stroke Networks
North East GTA Region and Network
Southeast Toronto Stroke Region Network
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OSS Strategic Planning - Underway

• Jan 2007, Provincial Stroke Steering Committee
  launched the OSS Strategic Planning Steering
  Group to lead strategic planning process. -
  completed by April 20, 2007.
• Source OSS Strategic Planning Backgrounder for
  Consultations (March 15, 2007)

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CURRENT Strategic Accountabilities and Reporting
Relationships for the OSS Source OSS Strategic
Accountabilities and Reporting Relationships
Plan(Dec 2006)
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Current Challenges/Capacity questions.

• Access to support of Regional Stroke Centres
• Equity of District and Regional resourcing. Not
  all regional and district centres are resourced
  equally. (i.e. absence of Enhanced/Outreach Best
  Practice Care Team, including a Case Manager in
  CE Network, three Toronto RSCs share one Full
  Time Equivalent Rehabilitation Coordinator)
• Equitable access to t-PA for Durham residents
• Telestroke capacity provincial and local
• Secondary prevention (e.g. Lakeridge Healthcare
  only MoHLTC funded centre in LHIN)

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Tissue Plasminogen Activator (t-PA)

• t-PA is a clot buster that can be used to treat
  stroke caused by a blood clot to patients who
  meet strict criteria must be given within 3hrs
  from start of symptoms
• According to provincial protocol, key decision
  maker in administration of t-PA must be
  neurologist or specialist internist. ER physician
  can administer shot of tPA but is not the key
  decision-maker. Ideally the neurologist would
  administer the tPA and provide follow up.
• Example At the HKPR District Stroke Centre at
  Peterborough Regional Health Centre - 24/7
  neurology coverage is achieved by combination of
  3 days coverage by the three PRHC neurologists
  and 4 days coverage by the Telestroke system.

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HKPR District Stroke CentreAcute Stroke Protocol
(ASP) Key indicators March 31, 2006-January
31st, 2007
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Telestroke

• Telestroke portable video consultation unit
  used in ER connected to Telestroke provincial
  system. When District Stroke Centres were
  allocated Telestroke was not in place hence the
  requirement for neurologist on site.
• In Hospitals without access to neurologist/special
  ist intern, for ER physicians to be able to
  administer t-PA they would have to rely on
  Telestroke coverage 24/7.
• Provincial Telestroke system is at capacity as
  there is a waiting list for new communities to
  gain access to the system. Ontario Telehealth
  Network is being restructured thus ability to
  accept new sites is limited.

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Telestroke
CT Scanner
PC Workstation with ViaVideo and Merge/eFilm
software
Tandberg Intern
PC Workstation Back-up Merge/eFilm Software
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Other Thoughts and Reflections?