The Canadian Stroke Strategy: Changing Systems and Lives

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The Canadian Stroke Strategy Changing Systems
and Lives
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The issue and the solution

• In Canada, every 10 minutes
• One clinically evident stroke
• Two silent strokes leaving cognitive damage
• Canadians spend three million days in hospital
  per year
• 30 of patients will develop dementia 50 of
  family caregivers will experience clinical
  depression
• The solution
• Stroke is largely preventable and treatable
• We know what to do were just not doing it.
• An integrated strategy closes the gap between
  evidence and policy/practice
• Convincing Canadian evidence that integrated
  stroke care improves patient outcomes (Ontario
  Stroke Strategy)

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What is an integrated stroke strategy?

• A model to guide other disease strategies
• Focused on real systems change
• Integration and coordination
• along the full continuum of care
• focusing on implementation of evidence-based best
  practice
• using an inter-disciplinary team approach

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The Foundation Core Elements of a Stroke
Strategy

• Developed by the Canadian Stroke Strategy
  Steering Committee (adapted from Ontario Stroke
  System and other sources)
• Core elements are
• the defining elements of an integrated,
  coordinated stroke strategy
• the necessary organization of the system to help
  close the gap between evidence and practice
• focused on integration and coordination along the
  full continuum of care

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Examples of Core Elements of a Strategy

• Stroke Prevention Clinics must be in place to
  improve secondary stroke prevention (effective,
  consistent prevention with early recognition of
  risk factors and timely, targeted interventions)
• Organized stroke care (stroke units with critical
  mass of trained staff, multidisciplinary team)
  must be in place
• Consistent use of effective treatments (e.g.
  clot-busting drug)
• Timely access to appropriate levels of
  rehabilitation intensity for stroke survivors
  must be available

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Core Elements of a Strategy available at
www.canadianstrokestrategy.ca
SAMPLE
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Impact of an integrated strategy The Ontario
Stroke Strategy

• Convincing Canadian evidence that integrated
  stroke care improves patient outcomes results
  of the Ontario Stroke Strategy
• 67 of stroke patients discharged from emergency
  receive referrals to stroke prevention clinics
  following initial stroke/TIA to prevent more
  serious event (there are now 24 prevention
  clinics in Ontario)
• tPA A clot-busting drug - the only proven
  treatment in stroke Average tPA rate increased
  from 25 to 30 for eligible patients in
  designated regional stroke centres
• Inpatient admissions for stroke decreased by 21,
  mostly attributable to a decrease in admissions
  for transient ischemic attacks (TIA) or small
  strokes
• 2007 Evaluation of the Ontario Stroke Strategy
  Ontario Stroke Evaluation Advisory Committee
  (Comparisons to 2000 before strategy
  implementation)

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Impact of an Integrated Strategy

• Number of patients now managed on specialized
  stroke units increased from 18 to 63
• Decreased utilization in inpatient resources
• Physiotherapy assessments before hospital
  discharge have increased from 47 to 75, and
  occupational therapy consults from 38 to 71
• 8.7 of patients require admission to long-term
  care - major decrease from two years previously
• 95 of patients discharged on antiplatelet
  medications to help prevent another stroke
• 30 day mortality rate decreased to 12.6

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Economic impact of an integrated stroke strategy

• Based on current Canadian population, the net
  benefit of providing coordinated stroke care,
  over next 20 years
• Prevent 160,000 strokes
• Prevent disability in 60,000 Canadians
• Achieve net savings of 8 billion
• Economic analysis is very conservative - does not
  include
• primary prevention interventions other than
  hypertension,
• secondary prevention clinics, and
• improved post-acute rehabilitation
• Projected impact would be significantly higher
• Source Dr. Mike Sharma (in partnership with
  Caro Research) - based on systems changes
  implemented through the Ontario Stroke Strategy,
  extrapolated for all of Canada, multiple data
  sources

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Canadian Stroke Strategy

• Canadian Stroke Strategy (CSS) is a joint
  initiative of the Canadian Stroke Network and the
  Heart and Stroke Foundation of Canada
• A strategy of strategies
• Canadian Stroke Network (CSN)
• One of Canadas federally-funded Networks of
  Centres of Excellence
• Brings a strong research network, evidence and
  content expertise
• CSS is its key knowledge translation initiative
• Heart and Stroke Foundation of Canada
• One of Canadas largest national health charities
  
• A federation of 10 independent provincial
  organizations
• Brings a strong, well-recognized brand and
  experience in public awareness, advocacy and
  research

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The Vision

• All Canadians have optimal access to integrated,
  high quality, and efficient services in stroke
  prevention, treatment, rehabilitation and
  community reintegration. The Canadian Stroke
  Strategy serves as a model for innovative and
  positive health system reform in Canada and
  internationally.

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The CSS Model

• Decrease burden of stroke
• Improve quality and efficiency of care
• Establish Canada as an international leader

Provincial/Territorial/Regional Implementation of
Best Practice
Prevention Prevention Clinics
Treatment Protocols, Stroke Teams
Rehabilitation Personal Care Plans
Reengagement Coordinated Support
National Platforms to Support Provincial/Territori
al/Regional Strategies
Public Awareness
Best Practice Guidelines and Standards of Care
Professional Development
Information/Evaluation
Coordinated Research
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National Platforms to Support Provincial/Territori
al Strategies

• Provincial scanning pointed to need for
  coordinated activity at the national level to
  support best practice implementation on the
  ground
• National Platforms are
• Addressing needs common to all provinces and
  territories
• Developed across the continuum
• Aligned with federal and provincial health
  priorities
• Ensuring sharing of knowledge, experience,
  successes
• Creating efficiencies and helping to avoid
  duplication
• Have engaged diverse stakeholders and partners
  from across Canada at Consensus Conferences
  reaching consensus on the scope of the platform
  and high-level plan - What needs to be done in
  this area in stroke across Canada who needs to
  be involved what is the role of the CSS?

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Provincial/Territorial Implementation of Best
Practices

• Key theme in provincial, territorial and national
  health reform is the application of research in
  practice
• Implementing best practices will require changing
  process, systems, policies and educating people
• National strategy is providing coordination and
  support but the real changes need to occur at the
  local level
• Each region is customizing its own solution given
  unique profile and constraints

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Governance and Operational Structure
HSFC Board of Directors
CSN Board of Directors
Canadian Stroke Strategy Steering Committee
CSS Director
Provincial/ Territorial Strategies
National Platform Working Groups
Provincial/Territorial Roundtable
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CSS Steering Committee

• Strategic and policy focused leading systems
  change
• Mandate is to lead the development and
  implementation of the Canadian Stroke Strategy
  (CSS)
• 13 appointed members from across Canada recruited
  through national nomination process (not
  representational mission focused)
• Five year Strategic Plan for Steering Committee
  now developed

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National Platforms

• Information and Evaluation
• Focus on data, surveillance, monitoring and
  evaluation
• Development of indicators (evidence-based -
  focused on patient level processes and outcomes)
• Evaluation of strategy overall
• Best Practices and Standards
• Development, dissemination and uptake of evidence
  based best practices and guidelines along the
  continuum of care
• Canadian Best Practice Recommendations publicly
  released in November 2006 available in print
  and on CD
• Knowledge Translation strategy now underway
• Long term goal to synthesize more comprehensive
  list of Canadian best practices and standards
  with focus on effective dissemination and uptake

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National Programs (continued)

• Professional Development and Training
• To coordinate and enhance professional
  development and training across the continuum of
  care
• Priorities have been identified partnerships
  will be critical
• Coordinated Research
• Leadership from CSN, HSFC in partnership with
  CIHR, Canadian Stroke Consortium, and others
• To assess current status of stroke research,
  identify and address gaps that still exist in the
  evidence base
• Public Awareness
• Leadership from Heart and Stroke Foundation of
  Canada
• Public Awareness to focus on effective ways of
  ensuring that the public knows what a stroke is,
  risk factors, signs and symptoms and the
  appropriate response

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Provincial/Territorial Roundtable

• Includes representatives from all provinces who
  are facilitating development of a stroke strategy
  in their province
• some positioned at HSF offices
• some in provincial ministries
• Mandate focuses on implementation effective
  mechanism for networking, information sharing and
  leveraging of resources
• Currently addressing identified gap in
  territorial and First Nations representation

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Provincial Progress

• Steering or Advisory Committees in all provinces
• Most provinces have hosted province-wide
  conferences/summits
• Strategy proposals and plans developed in most
  provinces and presented to key decision-makers
• Ongoing dialogue with governments to move towards
  strategy implementation
• Role of CSS Central Office
• Catalyst and support through financial support to
  provinces
• Hosting of nationwide forums for information
  exchange
• Development of tools common to all strategies

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Key Deliverables to Date

• Governance and operational structure
• Core elements of an integrated stroke strategy
• Standardized performance indicators and
  evaluation framework
• Canadian Best Practice Recommendations
• Supported by highest level of evidence and/or
  considered essential in delivering best practice
  and integral to driving systems change
• Released November 2006 see CSS Website
• www.canadianstrokestrategy.ca

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• National Survey/Inventory of Stroke Services and
  Resources
• First national hospital-based survey conducted in
  spring 2006 to provide comparative information on
  staffing levels, processes of care, available
  technologies, access, data collection, etc.
• Development of Economic Model with capacity to
  test key what if scenarios currently working
  with provinces to provide provincial economic
  analyses
• Consensus on priorities for professional
  development and training

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National Plan

• A framework and plan to support provincial,
  regional and local initiatives
• Vision, mission, goals and performance measures
  will align national activities differ from
  provincial and local activities
• Three primary national goals

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To heighten the visibility of stroke as a
critical health issue

• Key tactics and deliverables include
• a major communications and social marketing
  campaign,
• a comprehensive advocacy and engagement strategy,
  and
• ongoing forums for knowledge exchange.

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To actively support the Provinces and
Territories in moving beyond plan development to
implementation

• Key tactics and deliverables include
• Providing each province and territory with
  economic data to construct a sound business case
• Implementing a national measurement and
  information management system
• Implementing a National Stroke Inventory/Survey
  and National Report on stroke
• Creating initiatives to enhance professional
  development and training and
• Developing and supporting the implementation of
  best practices and standards.

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To maintain the required national
infrastructure to support strategy development
and implementation

• Key tactics and deliverables include
• Maintaining and monitoring a relevant
  infrastructure by conducting annual reviews and
  continually addressing gaps
• Developing and implementing a national
  partnership and funding strategy and
• Developing and implementing a volunteer program.

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Enablers and Barriers Summary

• Engagement and consultation
• Use of change management principles
• A clear governance structure
• Dedicated resources (people and money) to support
  strategy development and implementation
• Volunteer involvement and local champions
• Communications
• Solid data and evidence
• Advocacy and engagement
• Partnerships and collaborations
• Visibility and profile
• Flexibility and adaptability

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Merci de votre attention

• For further information, please contact
• Debra Lynkowski
• Director, Canadian Stroke Strategy
• debra_at_canadianstrokenetwork.ca
• Site Web  www.canadianstrokestrategy.ca