CE LHIN and the Ontario Stroke System August 28th, 2007 Presented by : Kasia Luebke (PhD)

1. CE LHIN and the Ontario Stroke System August 28th, 2007 Presented by : Kasia Luebke (PhD)

2. 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.

3. 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

4. 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

5. 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)

6. Continuum of Stroke Care Source: HKPR District Stroke Centre

7. Ontario’s 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

8. Goals of Ontario Stroke System • Reduce morbidity and mortality from stroke • Improve patient’s 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

9. 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)

10. 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 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 Joseph’s, 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 Components of Stroke System….

11. 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 • Central East CDPM Steering Committee – formed Feb 07 • Central East Rehabilitation Task Force - to be formed April 07

12. OSS Strategic Planning - Underway • Jan 2007, Provincial Stroke Steering Committee launched the OSS Strategic Planning Steering Group to lead strategic planning process. - completed by May, 2007. • The Vision for the OSS: Fewer Strokes. Better Outcomes • The Mission of the OSS: To contiuously improve stroke prevention, care, recovery and re-integration Source: OSS Strategic Planning Backgrounder for Consultations (March 15, 2007)

13. Ontario Stroke System Key Functions • Identifying and implement best practices-incorporating best available evidence and client-centered approaches • Promote equity and access to care and services • Set standards and targets, and evaluate system performance and outcomes • Build capacity through the generation , translation and integration of knowledge • Foster effective use of resources through innovation, system change, quality improvement, and integration and coordination of service delivery • Recommend on funding allocations; and • Provide a voice for the system to offer advice to governments and LHINS

14. Strategic Directions for the Ontario Stroke System • Credible Advisor to improve Stroke Prevention and Care Delivery • Infrastructure for Leadership and Coordination • Evaluation and support continuous improvement • Innovation and knowledge • Best Practices across the continuum of stroke care

15. CURRENT Strategic Accountabilities and Reporting Relationships for the OSS Source: OSS Strategic Accountabilities and Reporting Relationships Plan(Dec 2006)

16. Coordination…across three Stroke Networks

17. Coordination…across three Stroke Networks North & East GTA Region and Network Southeast Toronto Stroke Region & Network

18. 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)

20. Enhanced District Stroke Centres2004/05

21. District Stroke & Prevention Clinics2004/05

30. 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.

31. HKPR District Stroke CentreAcute Stroke Protocol (ASP) Key indicators March 31st/ 2006-March 31stt/2007

32. 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/specialist 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.

33. Telestroke CT Scanner Tandberg Intern PC Workstation with ViaVideo and Merge/eFilm software PC Workstation + Back-up Merge/eFilm Software

34. Where do we go from here? • Advocacy for increased funding for stroke care in the CE LHIN (specifically t-PA delivery in Durham)? • Advocacy for re-alignment of the OSS boundaries to align with those of the CE LHIN?

35. Other Thoughts and Reflections?