North East LHIN Stroke Care Review - 2013 Northeastern Ontario Stroke Network Steering Committee December 20 th, 2013
Table of Contents Item Page Executive Summary 1 A. Regional Stroke Review 2 B. Major References 2 C. Stroke and TIA Diagnostics Groups 2 D. Future State: Improved Access to Best Practice Stroke Care 2 E. Evidence and Supporting Rationale 3 F. Recommendations 5 G. Financial Implications 13 H. Contact 13 Appendix R-1: Inpatient Stroke Care Consolidation and Stroke Unit 14 Appendix R-2: North East LHIN Regional Stroke Flow 18 Appendix R-3 Outpatient Rehab Programs at Designated Stroke Centres 19 Appendix R-5 Outpatient Treatment Hubs 22 Appendix II Summary of Allied Health Human Resource Costs 24
Executive Summary Within the North East Local Health Integration Network (NE LHIN), there are areas of stroke care delivery that require improvement and closer adherence to accepted best practice, especially when compared to provincial benchmarks. 1 During the 2013 calendar year, the Northeastern Ontario Stroke Network (NEOSN) Steering Committee completed a review of the regional stroke system of care. The completion of this review was endorsed by the NE LHIN. The goals of the review were twofold: a) Develop a vision for a fully integrated regional model of stroke/tia care for the North East, and b) Develop system-level recommendations to narrow the gap between current and best practice. NEOSN envisions a future state of stroke care that would see all residents living in northeastern Ontario benefiting from improved access to: acute thrombolytic therapy; secondary stroke prevention services; dedicated acute stroke and rehabilitation inpatient units; palliative care; interdisciplinary outpatient stroke follow-up and rehabilitation services; and a community navigation program that links stroke survivors and families with community-based services. NEOSN is putting forth the following six recommendations to improve the quality of stroke and TIA care in the NE LHIN: 1. Inpatient stroke care (both acute and rehabilitation care) be consolidated to the NE LHIN s four designated stroke centres at Sault Area Hospital, Timmins and District Hospital, North Bay Regional Health Centre and Health Sciences North (Sudbury). 2. The existing Memorandum of Understanding for Medical Redirect and Repatriation of Northeastern Ontario Acute Stroke Patients be revised and expanded to include all aspects of patient transfers related to the delivery of inpatient stroke care. 3. A stroke-specific outpatient program be developed at each of the NE LHIN s designated stroke centres that provides both an interdisciplinary Stroke Re-Check Clinic and individual therapies delivered by a full interdisciplinary team. 4. The Northern Ontario Independent Living Association s (NILA) proposal entitled North East Regional Post-Stroke Transitional Program submitted to the NE LHIN in June 2013 be endorsed and funded as proposed. The NILA proposal provides an integrated regional framework for the delivery of post-stroke community navigation including access to assisted living housing and connecting stroke survivors and their families with community-based services. 5. Community Outpatient Treatment Hubs be developed at seven community hospitals across the LHIN, to ensure the majority of stroke patients in the NE LHIN can access outpatient rehabilitation services within a 45 minute drive of their home community. 6. A Regional Stroke Best Practice Implementation Committee be struck with NE LHIN leadership, to develop and implement an Action Plan based on the recommendations outlined in this report. NEOSN has contributed to the work of the NE LHIN Clinical Services Review Steering Committee as it develops a strategic plan for the implementation of the Quality Based Procedures (QBP s). NEOSN believes the recommendations included in this report are in alignment with the ongoing QBP work and facilitate the adoption of stroke and TIA best practices across the entire LHIN in a coordinated and integrated manner. NEOSN is committed to working under the guidance of the NE LHIN and in partnership with stroke care stakeholders across the region to implement changes that will ultimately provide a sustainable, high quality and cost-efficient stroke care system in the North East. 1 2013 Ontario Stroke Network Report Card North East LHIN found at www.neostrokenetwork.com Page 1 North East LHIN Stroke Review - 2013
A. Regional Stroke Review In the fall of 2012, the North East LHIN endorsed the completion of a review of the current model of stroke care delivery across the LHIN. Working under the auspices of the North East LHIN Rehabilitation and Complex Continuing Care Steering Committee, the review was led by the Northeastern Ontario Stroke Network (NEOSN) Steering Committee. This committee s membership was expanded on an ad-hoc basis to ensure the voice and opinions of stroke survivors, caregivers, health care providers and administrators from across the LHIN were included. The review included nine formal meetings of up to four hours in length in addition to several smaller subcommittee meetings between February and December, 2013. The recommendations included in this report have been formally approved by the NEOSN Steering Committee for submission to the North East LHIN. B. Major References The following references were used as the gold standard in determining the gap between current stroke care provision across the North East LHIN and the desired future state. Canadian Best Practice Recommendations for Stroke Care (www.strokebestpractices.ca) - referred to as SBPR within this document. Quality-Based Procedures (QBP): Clinical Handbook for Stroke (MOHLTC) Ontario Stroke Reference Group - Rehabilitation and Complex Continuing Care Expert Panel: Phase I Report. Toronto, Ontario; 2011. Ontario Stroke Network Regional Economic Overview North East LHIN; (Meyer, Callaghan, Kelloway, Jermyn) - (www.neostrokenetwork.com) Taking Action Towards Optimal Stroke Care: A resource to support implementation of best practice stroke care (http://www.strokebestpractices.ca/index.php/hyperacute-strokemanagement/emergency-department-evaluation-and-management/) The Report of the Multidisciplinary Learning Objectives for Stroke Care Project Hamilton Health Sciences Regional Stroke Strategy. C. Stroke and TIA Diagnostic Groups As per the QBP Clinical Handbook for Stroke, the following most responsible diagnoses are included when the term stroke or stroke and TIA are used in this document. Stroke Type ICD-10-CA Code Transient Ischemic Attack (TIA) G45 (excluding G45.4) Intracranial Hemorrhage (ICH) I61 Ischemic I63 (excluding I63.6), H34.1 Unable to Determine I64 D. Future State: Improved Access to Best Practice Stroke Care If the recommendations in this document are fully implemented, it is believed that all residents living in northeastern Ontario will have improved access to: 1. A dedicated inpatient Acute Stroke Unit (ASU) staffed by an interdisciplinary team with stroke care expertise, accessible by all patients requiring hospital admission. Page 2 North East LHIN Stroke Care Review 2013
2. An inpatient Stroke Rehabilitation Unit (SRU) staffed by an interdisciplinary team with stroke care expertise. 3. Palliative care provided in the most appropriate setting as close to home as possible. 4. An outpatient Stroke Re-Check Clinic staffed with an interdisciplinary team to monitor stroke patients for a minimum of one year post stroke. 5. Outpatient rehabilitation services in the appropriate setting based on their needs (e.g. CCAC - based care in a patient s residence and/or hospital based outpatient programs) and provided as close to their home community as possible. 6. A Community Navigation Program that links stroke survivors/families with community-based services (assisted living housing, respite, exercise classes, support groups, etc.) In addition to these improvements in access to best practice stroke care, residents of Northeastern Ontario will continue to have access to hyperacute thrombolytic therapy (via the existing Northeastern Ontario Acute Stroke Protocol) and outpatient stroke prevention services for the urgent management of TIA (via the existing four Stroke Prevention Clinics at each designated stroke centre). E. Evidence and Rationale Supporting Recommendations As the recommendations were developed, the following major elements of best practice stroke care were considered. This is by no means a complete list of the evidence behind best practice stroke care but they are the elements most relevant to the recommendations made. a. Critical Mass As described in the Quality-Based Procedures: Clinical Handbook for Stroke, to optimize outcomes and efficiencies of those acute ischemic stroke patients that require admission, reaching a critical mass of stroke volumes in a given year is necessary. As such, organizations that provide acute stroke care should be caring for 165 acute ischemic stroke patients or more per year. b. Stroke Unit Care SBPR recommendation 4.1.1 states: Patients admitted to hospital with an acute stroke or transient ischemic attack should be treated on an inpatient stroke unit [Evidence Level A]. A stroke unit is a specialized, geographically defined hospital unit dedicated to the management of stroke patients and staffed by an experienced interprofessional stroke team. Stroke unit care reduces the likelihood of death and disability by as much as 30 percent for men and women of any age with mild, moderate, or severe stroke. c. Interprofessional Stroke Team Stroke patients should have access to an interdisciplinary team with stroke care expertise. SBPR recommendation 4.1.1 also states: the core interprofessional team on the stroke unit should consist of healthcare professionals with stroke expertise including physicians, nursing, occupational therapy, physiotherapy, speech-language pathology, social work, and clinical nutrition (dietitian) [Evidence Level A]. All stroke teams should include hospital pharmacists to promote patient safety, medication reconciliation, provide education to the team and Page 3 North East LHIN Stroke Care Review 2013
patients/family regarding medication(s) (especially side effects, adverse effects, interactions), discussions regarding adherence, and discharge planning (such as special needs for patients, e.g., individual dosing packages) [Evidence Level B]. Additional members of the interprofessional team may include discharge planners or case managers, (neuro) psychologists, palliative care specialists, recreation and vocational therapists, spiritual care providers, peer supporters and stroke recovery group liaisons [Evidence Level B]. d. Intensity of Therapy Stroke patients should receive inpatient therapy as outlined by the Ontario Stroke Reference Group: Stroke patients should receive, through an individualized treatment plan, at least 3 hours of direct task-specific therapy per day by the interprofessional stroke team for at least 6 days per week. e. Staffing Ratios As per the Ontario Stroke Reference Group, the recommended staffing ratios (patients: therapist) include 6:1 for physiotherapy and occupational therapy, 12:1 for speech language pathology and a 2:1 ratio of therapists to therapy assistants (e.g. PTA, OTA, CDA) working on the stroke unit. As per the Canadian Stroke Strategy: A Guide to the Implementation of Stroke Unit Care, the recommended nursing ratio ranges from 2:1 to 3:1 (Patients: RN). f. Access to Diagnostics To make an accurate diagnosis of stroke or TIA, all patients must undergo (as a minimum) a noncontrast CT scan of the head. CT scans are only available at 6 of the NE LHIN s 24 hospitals. Other diagnostic imaging required for best practice stroke care includes (but is not limited to: CT Angiography, MRI, MRA, Carotid Doppler and Echo). g. Provision of Community-Based Services as close to home as possible: Stroke patients returning home should have access to services in the community in the most appropriate setting based on their needs. Services may be provided in hospital-based outpatient departments or through CCAC. The recommended frequency/intensity of therapy in either scenario (outpatient or CCAC) is 45-minute therapy sessions (up to 3 hours per day all therapies combined), 3-5 visits per week, for 8 to 12 weeks following hospital discharge. h. Managing Transitions The SBPR have been updated with a section highlighting the importance of providing support to stroke patients and families during each transition care point. Specifically, the SBPR state the following: Stroke case managers and/or stroke system navigators are valuable additions to the stroke care team, and where resources permit should be made available to patients, families and informal caregivers. Stroke navigators empower patients and families to be involved in their own care, build self-management skills and confidence, and aid in access to community resources, support groups and linkages. Providing support mechanisms like these may reduce the burden to the health system and to health care professionals providing reactive care; evidence shows that this is typically more costly to the health system and an increased care burden on health providers. Page 4 North East LHIN Stroke Care Review 2013
F. RECOMMENDATIONS: Notes: Each recommendation encompasses patient-centred care and the vision of the Ontario Stroke Network: Fewer Strokes, Better Outcomes. Recommendations 1, 2, 3 and 5 have an accompanying appendix, which includes information that is more detailed. Suggested performance measures are indicated for select recommendations. These can be used as part of an evaluation of the improvement in stroke patient care across the North East LHIN over time. Recommendation 1: Inpatient Stroke Care Consolidation and Stroke Unit Care (Appendix R-1) 1.1 Inpatient stroke care (both acute and rehabilitation care) be consolidated to the North East LHIN s four designated stroke centres at Sault Area Hospital, Timmins and District Hospital, North Bay Regional Health Centre and Health Sciences North (Sudbury). 1.1.1 Stroke patients that present to a North East LHIN community hospital, or activate EMS in the community, and meet the criteria for possible acute thrombolysis, continue to be transferred on an emergent basis to the closest designated stroke centre (SAH, TDH, NBRHC, HSN) and/or Telestroke site (Temiskaming Hospital) as per the current North East LHIN Acute Stroke Protocol Memorandum of Understanding (regional agreement established in 2011). 1.1.2 Stroke patients that activate EMS in the community but do not meet the criteria for possible acute thrombolysis continue to be transported to the closest hospital emergency department. 1.1.3 Stroke patients that present to a North East LHIN community hospital, ineligible for tpa therapy, but require hospital admission, be urgently transferred and admitted directly to a bed on an Acute Stroke Unit (ASU) at a designated stroke centre hospital. These transfers are to be completed on an urgent basis to ensure proper diagnostic testing, clinical evaluation and initial treatment is undertaken as soon as possible following the onset of stroke or TIA symptoms. The protocol for these patient transfers would be incorporated into the revised North East Stroke MOU (see Recommendation 2). Performance measures: % patients transferred to an ASU within 12 hours of initial presentation at community hospital % patients transferred to an ASU within 24 hours of presentation at the community hospital. % patients that receive brain CT/MRI within 24 hours of arrival at ED (Ontario Stroke Report Card indicator #6) 1.1.3.1 Measures be taken by the community hospital to initiate early mobilization of the stroke patient and to implement, if available, rehabilitation therapies (e.g. PT, OT, SLP) and best practice interventions (e.g. swallowing screen), if there is a delay beyond 12 hours in transferring a patient to a designated stroke centre. 1.1.4 TIA patients (or suspected TIA patients) that present to a community hospital and do not require inpatient admission be referred to one of the outpatient Stroke Prevention Clinics Page 5 North East LHIN Stroke Care Review 2013
located at each of the designated stroke centres. All hospitals in the North East should be using the TIA triage tool as outlined in the SBPR: (http://www.strokebestpractices.ca/wp-content/uploads/2012/10/csn-taking-action- Poster_WEBFFF.pdf) Performance Measure Number of patients/year referred to Stroke Prevention Clinics from community hospital emergency departments. 1.1.5 Where clinically appropriate, stroke patients that are deemed palliative be provided the opportunity to receive inpatient care at the hospital closest to their home community. This does not preclude a patient from being transferred to a designated stroke centre s ASU for care, but the wishes of the patient and family should be respected during this period. 1.2 Each of the North East LHIN s designated stroke centres has a dedicated inpatient acute stroke unit (ASU) that meets the minimum requirements as outlined in the SBPR. 1.2.1 At a minimum, these beds will be clustered on a common inpatient unit, preferably down a single hallway visibly designated as the Acute Stroke Unit. Based on the anticipated consolidated patient volumes, the required bed allocation required for the ASU at each designated stroke centre is outlined in Appendix R-1 1.2.2 Each designated stroke centre create a dedicated interdisciplinary Acute Stroke Team that will be responsible for providing care on the ASU. Team members will include a physician, nurse, physiotherapist, occupational therapist, speech-language pathologist, social worker, dietitian and recreation therapist. Based on the anticipated consolidated patient volumes, the required nursing ratio and allied health full-time equivalent (FTE) for PT, OT, SLP, PTA, OTA and CDA on each ASU is outlined in Appendix R-1. In addition to these dedicated Acute Stroke Team FTE s, each ASU should also have access to a member of each discipline outlined in SBPR #4.1.1, including pharmacists, discharge planners or case managers, palliative care specialists, (neuro) psychologist, spiritual care providers, peer supporters and stroke recovery group liaisons. 1.2.3 The professionals that make up the Acute Stroke Team (either on a permanent or rotational basis) demonstrate, at a minimum, the core competencies listed in: The Report of the Multidisciplinary Learning Objectives for Stroke Care Project Hamilton Health Sciences. 1.2.4 Stroke and TIA patients admitted to an ASU, based on tolerance, receive 3 hours per day of core therapies (PT, OT and SLP), a minimum of 6 days per week. Performance Measure Statistical analysis of direct patient care provided by inpatient therapist (hours/patient) Page 6 North East LHIN Stroke Care Review 2013
1.2.5 Patients admitted to an ASU be screened for swallowing difficulties within 24 hours of admission (including weekends). As such, each ASU be staffed with trained professionals that can perform the institution s dysphagia screening tool on a 24/7 basis. Performance Measures % patients screened for dysphagia (Ontario Stroke Report Card Indicator #9) 1.2.6 Patients admitted to an ASU be mobilized (initiating sitting, standing, early ambulation) within 24 hours of admission by all interdisciplinary team members who have been trained in early mobilization concepts by Physiotherapists / Occupational Therapists/ Nurse Clinicians/ Stroke Nurses. Performance Measures % patients mobilized within 24 hours of admission to an Acute Stroke Unit 1.2.7 On each ASU, each member of the interdisciplinary team complete their initial assessment (either individually or as part of an interdisciplinary assessment) on each stroke and TIA patient within 48 hours of the patient s admission (including weekends). 1.2.8 Each designated stroke centre develops a Regional Stroke Patient Flow protocol to ensure an inpatient bed on their ASU can be made available on an urgent basis (12-24 hours following stroke/tia onset). This will ensure patients from across the designated stroke centre s catchment area have equitable access to the ASU. 1.2.9 Each designated stroke centre s ASU has a most responsible physician (MRP) model in place that supports and utilizes the most current best practice recommendations. 1.2.10 As per the Quality Based Procedures: Clinical Handbook for Stroke, the expected length of stay on the ASU is 5 days for ischemic stroke and 7 days for hemorrhagic stroke. In many cases, following their acute care stay, patients are deemed ALC. The following actions should be taken for the following ALC designations: ALC-LTC Placement as appropriate, these patients to be repatriated to their home hospital. This will ensure the necessary patient flow to allow each ASU to continually admit and provide care for acute stroke and TIA patients from across their geographic catchment area. ALC-Rehab these patients to remain as an inpatient at the designated stroke centre hospital as they await transfer to the inpatient rehabilitation program. Performance Measure Acute LOS and ALC LOS Data for Ischemic, Hemorrhagic and TIA patients 1.3 Each designated stroke centre has a dedicated inpatient stroke rehabilitation unit (SRU) as part of their general inpatient rehabilitation program. Page 7 North East LHIN Stroke Care Review 2013
1.3.1 Based on the anticipated consolidated patient volumes, the required bed allocation required for the SRU at each designated centre is outlined in Appendix R-1. 1.3.2 Each designated stroke centre creates a dedicated interdisciplinary Rehab Stroke Team responsible for providing care on the SRU. Team members will include a physician, nurse, physiotherapist, occupational therapist, speech-language pathologist, social worker, dietitian, recreation therapist, and psychologist. Based on the anticipated consolidated patient volumes, the required nursing ratios and allied health full-time equivalents (FTE) for PT, OT, SLP, PTA, OTA and CDA on each SRU is outlined in Appendix R-1. In addition to these dedicated Rehab Stroke Team FTE s, each SRU will have access to a member of each discipline outlined in SBPR #4.1.1, including pharmacists, discharge planners or case managers, palliative care specialists, vocational therapists, spiritual care providers, peer supporters and stroke recovery group liaisons. 1.3.3 The professionals that make up the Rehab Stroke Team (either on a permanent or rotational basis) demonstrate, at a minimum, the core competencies listed in: The Report of the Multidisciplinary Learning Objectives for Stroke Care Project Hamilton Health Sciences. 1.3.4 Stroke patients admitted to the SRU, based on tolerance, receive 3 hours per day of core therapies (PT, OT, SLP), a minimum of 6 days per week. 1.3.5 Each SRU has an admission process in place that allows patients to be admitted 7 days/week. Performance Measure Statistical analysis outlining the % of patients admitted to an inpatient rehabilitation bed on each day of the week. 1.3.6 Each designated stroke centre s SRU has a most responsible physician (MRP) model in place that supports and utilizes the most current best practice recommendations. 1.3.7 In many cases, following their inpatient rehabilitation stay, patients are deemed ALC- LTC. The following actions should be taken when patients are deemed ALC-LTC: As appropriate, these patients to be repatriated to their home hospital. This will ensure the necessary patient flow to allow each SRU to continually admit and provide care for acute stroke patients from across their geographic catchment area. 1.4 Stroke patients that would previously receive inpatient acute and rehabilitation care at the West Parry Sound Health Centre (mean volume of 44 acute stroke admissions per year and 10 inpatient stroke rehabilitation admissions per year) receive care at the closest designated stroke centre to their home community. In general, patients in this catchment would be transferred to the designated stroke centre at the Muskoka Algonquin Healthcare Huntsville District Memorial Hospital Site (part of North Simcoe Muskoka LHIN planning area). Patients in the northernmost aspect of WPSHC s normal catchment area may be transferred to the designated stroke centres in either Sudbury or North Bay. Page 8 North East LHIN Stroke Care Review 2013
Recommendation 2: Revision and Expansion of Regional Stroke Memorandum of Understanding to Include non tpa Stroke/TIA Patient Flow and Repatriation (Appendix R-2) 2.1 In order to facilitate the consolidation of inpatient stroke care across the NE LHIN, the existing Memorandum of Understanding for Medical Redirect and Repatriation of Northeastern Ontario Acute Stroke Patients (herein referred to as the North East Stroke MOU ) be revised and expanded to include all aspects of inpatient stroke care. This expanded North East MOU to be signed off by all hospital and EMS organizations in the North East LHIN to ensure a consistent approach is adopted for stroke management and patient flow across the entire NE LHIN. 2.1.1 The North East Stroke MOU repatriation policy should be revised to read that patients redirected or transferred to a designated stroke centre, diagnosed as having suffered a stroke or TIA (regardless if tpa is received or not) and require hospital admission, now complete their acute care admission at the designated stroke centre (vs. being repatriated to their home hospital). One exception to Recommendation 2.1.1 is outlined below for patients redirected or transferred to the Temiskaming Hospital (Telestroke site) for possible thrombolysis. 2.1.1.1 Patients that are redirected or transferred to the Temiskaming Hospital for possible thrombolysis, having a confirmed diagnosis of stroke or TIA and requiring hospital admission (regardless if tpa is delivered or not), be transferred to the ASU at the designated stroke centre closest to their home community (in most cases this will either be North Bay Regional Health Centre or Timmins and District Hospital). 2.1.2 The current North East Stroke MOU Algorithm be expanded to ensure that non-tpa candidate stroke and TIA patients that present to a community hospital emergency department be transferred, on an urgent basis, directly to a designated stroke centre s Acute Stroke Unit. 2.1.3 A new Rehabilitation section be added to the North East Stroke MOU outlining the procedure for referrals from community hospitals to the inpatient stroke rehabilitation programs at the designated stroke centres. In these cases, the existing External Rehabilitation Referral Form (developed by the North East Rehab Network (NERN)) would be utilized to ensure consistency in information provided and allow collection of statistics on a regional basis to guide future revisions to the program. 2.1.4 Revisions be made to North East Stroke MOU Repatriation Agreement to detail repatriation protocol for patients deemed ALC following their acute care stay at a designated stroke centre hospital. Recommendation 3: Expansion of Designated Stroke Centre Outpatient Stroke Rehabilitation Services (Appendix R-3) 3.1 A stroke-specific outpatient program be operationalized at each of the North East LHIN s designated stroke centres (HSN, NBRHC, SAH, TDH) and provide both an interdisciplinary Stroke Re-Check Clinic and individual outpatient therapies provided by a full interdisciplinary team. Page 9 North East LHIN Stroke Care Review 2013
3.1.1 Each Stroke Re-Check Clinic provide services to all patients discharged home from inpatient acute or rehabilitation care, (including those living with family, in retirement home or short-term assisted living). The primary purpose of the clinic would be to screen, assess, and identify stroke patients for physical, cognitive, social or medical issues related to their recovery and refer to professional and/or community-based services as necessary. 3.1.2 Each Stroke Re-Check Clinic be staffed by an interdisciplinary team including a Stroke Community Navigator (see 3.1.3). Appendix R-3 outlines an example of the recommended allocation of FTE s for each clinic, based on anticipated volumes. Individual clinics may utilize different professionals as part of their interdisciplinary team (e.g. Registered Nurse included on team). At a minimum, these clinics operate one day per week and follow stroke patients at 6 weeks, 3 months and 1 year post-hospital discharge. 3.1.3 Each Stroke Re-Check Clinic develop a formal partnership with the Northern Ontario Independent Living Association (NILA) community agency providing the Stroke Community Navigation Program (as outlined in Recommendation 4) in their geographic area. The Stroke Community Navigator becomes a member of the Stroke Re-Check Clinic interdisciplinary team. 3.1.4 Each designated stroke centre provide stroke-specific outpatient rehabilitation therapies, consisting of 45-minute therapy sessions (up to 3 hours per day for all therapies combined), 3-5 sessions per week, beginning within 48 hours post-acute care discharge or 72 hours post-inpatient rehabilitation discharge; for 8 to 12 weeks following discharge from inpatient care. Recommended FTE s based on anticipated volumes outlined in Appendix R-3. Performance Measure Frequency and intensity of care provided by designated stroke centre outpatient programs. 3.1.5 Each stroke outpatient program provides access to a primary care provider (Physician and/or Nurse Practitioner) to address issues related to medical management. 3.1.6 Staff working in the outpatient program has allocated time to allow them to utilize Telemedicine as necessary to allow patients to receive follow-up care/intervention closer to home where appropriate. Telemedicine could also be used to provide mentorship or clinical advice to outpatient clinicians working in the Community Outpatient Treatment Hubs (outlined in Recommendation 5). Recommendation 4: Expanding Regional Community Navigation Model 4.1 The proposal entitled North East Regional Post-Stroke Transitional Program submitted by the Northern Ontario Independent Living Association (NILA) to the North East LHIN in June 2013 be endorsed and fully funded. Their proposal provides an integrated regional framework for the delivery of post-stroke community navigation including access to assisted living housing and connecting stroke survivors and their families with community-based services. NILA has requested an annual funding envelop of $1,015,968 to operate the program that will serve up to 550 stroke patients per year. This represents an investment of approximately $1,800 per patient Page 10 North East LHIN Stroke Care Review 2013
towards successful community reintegration. This upfront investment is expected to lead to decreased hospital acute length of stay and decreased hospital readmission rates for patients that have suffered a stroke, thus increasing capacity in the regional acute care system. 4.1.1 The Stroke Community Navigator positions outlined in the NILA proposal are fully integrated into the interdisciplinary team as part of the recommended outpatient Stroke Re-Check Clinics described in Recommendation #3. The partnership between ICAN and HSN in Sudbury be used as an example to expedite implementation in other districts. 4.1.2 Each designated stroke centre work with each NILA member organization to develop a protocol/procedure to ensure stroke patients that meet the appropriate criteria, can access the assisted living units outlined in the proposal. Recommendation 5: Establishment of Rural Community Outpatient Treatment Hubs and Partnership with CCAC (Appendix R-5) 5.1 Community Outpatient Treatment Hubs (map outlined in Appendix R-5) be developed in the following community hospitals, to ensure the majority of stroke patients in the NE LHIN can access outpatient rehabilitation services within a 45 minute drive of their home community: Manitoulin Health Centre (Little Current Site) St. Joseph s General Hospital - Elliot Lake Temiskaming Hospital Kirkland and District Hospital Anson General Hospital - Iroquois Falls Sensenbrenner Hospital - Kapuskasing West Parry Sound Health Centre 5.1.1 Each Community Outpatient Treatment Hub be staffed with a PT, OT and SLP to provide therapy as per the SBPR. The recommended FTE allocation for each Treatment Hub is outlined in Appendix R-5. 5.1.2 Each Community Outpatient Treatment Hub be equipped with Telemedicine to allow for contact with designated stroke centre Stroke Re-Check Clinic and outpatient staff to assist with treatment progression, clinical advice etc. 5.1.3 To address the human resources issue of recruiting the necessary staffing for the Community Outpatient Treatment Hub, hospital organizations and the North East CCAC explore opportunities to share human resources. Example: CCAC physiotherapist serving patients in the community of Elliot Lake could work 2-3 half days per week at St. Joseph s General Hospital to provide treatment to patients that can transport themselves to the hospital for outpatient care. 5.1.4 Those stroke patients that require outpatient rehabilitation services but live more than a 45-minute drive from a designated stroke centre or a Community Outpatient Treatment Hub be automatically deemed eligible to receive rehabilitation services via the North East CCAC. Page 11 North East LHIN Stroke Care Review 2013
5.1.4.1 Where it is appropriate for stroke and/or TIA patients to receive nursing or rehabilitation services in their home via the North East CCAC, the intensity and frequency of this care meet the SBPR recommendation of 45 minute therapy sessions (up to 3 hours per day all therapies combined), 3-5 sessions per week for up to 8 to 12 weeks following hospital discharge. These services to be provided within 48 hours of discharge from acute care or within 72 hours of discharge from inpatient rehabilitation. Performance Measure Wait times and frequency/intensity of CCAC services provided for stroke clients. Recommendation 6: North East LHIN Regional Stroke Best Practice Implementation Committee 6.1 The North East LHIN lead a Regional Stroke Best Practice Implementation Committee to develop and implement an Action Plan based on the recommendations in this review. Committee members will include senior management and administrative leads from each North East LHIN hospital, each North East EMS provider, the North East CCAC, Northern Independent and Living Association (NILA) and the Northeastern Ontario Stroke Network. 6.1.1 As part of its Action Plan, this committee will develop a timeline for implementation of each recommendation that will allow for adequate consultation and participation of key stakeholders across the continuum. Page 12 North East LHIN Stroke Care Review 2013
G. Financial Implications Although the total number of stroke and TIA patients admitted to hospital across the North East LHIN has remained stable over the past 5 years, regional demographics dictate that this number will rise over the next 10-20 years. The recommendations that stem from this review target the development of a system of care that can support current and predicted future volumes. Opportunities definitely exist to realize cost savings in acute care, particularly if the Quality Based Procedure (QBP) recommendations are realized, including a reduction in inpatient length of stay (5 days for ischemic stroke and 7 days for hemorrhagic stroke) and a reduction in the number of TIA patients admitted to hospital. The recommended intensity, frequency and duration of treatment in the inpatient, outpatient and community setting, however, are considerably greater than what is currently provided and thus an investment in the system will be required. Investments are also likely required to ensure the existing Stroke Prevention Clinics can manage a higher number of TIA patients, leading to fewer inpatient admissions. This report does not provide an estimate for the total cost of stroke care in the North East LHIN. It does provide, however, several estimates of the allied health human resource costs associated with the Acute and Rehab Stroke Teams, Designated Stroke Centre Stroke Re-Check and Outpatient Programs and the Community Hospital Outpatient Treatment Hubs. A summary of these allied health costs is provided in Appendix II. In addition to these costs, the North East LHIN will also need to consider the costs associated with consolidating inpatient stroke care to the region s four designated stroke centres including the following: The required increase in acute and rehabilitation beds at the designated stroke centres The increase in costs associated with diagnostic imaging, laboratory and related testing at the designated stroke centres The costs associated with the increase in patient transfers and repatriation between community hospitals and designated stroke centres The costs associated with the recommended increase in nursing ratios on both the acute and rehab stroke units at the designated stroke centres The soon-to-be -released QBP funding formula will likely provide guidance for patient-specific costs, however the additional costs associated with consolidating care (i.e. patient transportation, additional bed requirements) will definitely require further discussion by the LHIN. H. Contact Darren Jermyn Regional Director, Northeastern Ontario Stroke Network Health Sciences North 41 Ramsey Lake Road Sudbury, ON P3E 5J1 djermyn@hsnsudbury.ca 705-523-7100 ext. 3138 Page 13 North East LHIN Stroke Care Review 2013
Appendix R-1: Inpatient Stroke Care Consolidation and Stroke Unit Inpatient Acute Care Consolidation Volumes: It is recommended that all acute stroke and TIA patients requiring hospital admission in the North East LHIN be admitted to an acute stroke unit (ASU) at one of the four designated stroke centres within the LHIN boundaries. Based on CIHI data from 2008-2012, and assuming on average, the same number of patients would be admitted per year, the total volume of acute patients requiring transfer to a designated stroke centre would be as follows 1 : Designated Stroke Centre Current Avg. Yearly Inpatient Acute Volume Additional Acute Care Transfers Anticipated NEW Yearly Acute Stroke Volume HSN 322 88 410 TDH 79 87 166 NBRHC 165 79 244 SAH 209 13 222 Community Hospitals in Designated Stroke Centre Catchment Area Elliot Lake, Espanola, Manitoulin Island, Parry Sound* Chapleau, Hearst, Kapuskasing, Smooth Rock Falls, Cochrane, Iroquois Falls, Matheson, Kirkland Lake, Moosonee/Moose Factory Englehart, Temiskaming, Mattawa, West Nipissing, Parry Sound* Blind River, Wawa, Hornepayne Totals 775 267 1042 1 CIHI Data 2008-2012 mean value of stroke and TIA admissions Note: West Parry Sound Health Centre s mean inpatient volume (44 patients/year) is not included in above figures, as the majority of these patients would transfer to the proposed Integrated Stroke Unit at the Muskoka Algonquin Healthcare, Huntsville District Memorial Hospital as part of the North Simcoe Muskoka LHIN Stroke Care planning mode (Recommendation 1.4) Consolidated Volumes by Diagnosis: Designated Stroke Centre Hemorrhagic Stroke Ischemic Stroke Unable to Determine TIA Total HSN 55 135 124 96 410 TDH 11 41 64 50 166 NBRHC 18 64 81 81 244 SAH 26 56 66 74 222 Totals 110 296 335 301 1042 Page 14 North East LHIN Stroke Care Review 2013
Acute Stroke Unit Bed Requirements The table below outlines the required dedicated Acute Stroke Unit inpatient beds required at each designated stroke centre. Designated Stroke Centre Consolidated Volume Acute Stroke Unit # Additional Beds Required for District Volume 2 Consolidated Acute Stroke Unit Size (Beds) 2 HSN 410 2.3 11.2 TDH 166 2.3 4.3 NBRHC 244 2.0 6.0 SAH 222 0.4 5.8 Total 1,042 7.0 27.3 2 Bed numbers were calculated assuming a 90% occupancy rate and an average acute length of stay (ALOS) of 10 days for acute stroke (ischemic or hemorrhagic) and 5 days for TIA. Dedicated Acute Stroke Unit: Recommended Staffing 3,4 Site Unit Size (Beds) HSN 11.2 TDH 4.3 NBRHC 6.0 SAH 5.8 Nursing (RN Model) 3:1 days 5:1 nights 3:1 days 5:1 nights 3:1 days 5:1 nights 3:1 days 5:1 nights PT OT SLP PTA OTA CDA Acute Stroke Team Allied Health FTE Cost 1.2 1.2 0.6 0.6 0.6 0.3 $394,342 0.5 0.5 0.2 0.3 0.2 0.1 $157,467 0.7 0.7 0.3 0.4 0.3 0.2 $225,875 0.6 0.6 0.3 0.3 0.3 0.2 $199,855 Totals 27.3-3.0 3.0 1.4 1.6 1.4 0.8 $977,538 3 Nursing ratios based on models presented in Ontario Stroke Reference Group - Rehabilitation and Complex Continuing Care Expert Panel: Phase I Report. Toronto, Ontario; 2011. 4 Based on model develop by M. Meyer; FTE s calculated based on anticipated volumes, providing care at the recommended therapist: patient ratio and at the SBPR recommended intensity (Note: the cost of nursing FTE s is not included in the Acute Stroke Team Allied Health FTE Cost ) Page 15 North East LHIN Stroke Care Review 2013
INPATIENT REHABILITATION CARE: Inpatient Rehab Care Consolidation Volumes: Based on historical volumes and a move towards the provincial benchmark of 42% of acute stroke patients (not including TIA) being admitted to inpatient rehabilitation, the anticipated new volume of rehabilitation patients at each of the designated stroke centres would be as follows. Designated Stroke Centre Avg. Yearly Inpatient Rehab Volumes ( 07-12) 5 Potential Additional Rehabilitation Transfers (to reach benchmark of 42% of admitted stroke patients) Anticipated New Yearly Inpatient Stroke Rehabilitation HSN 96 21 117 TDH 28 22 50 NBRHC 38 33 71 SAH 52 12 64 Totals 214 88 302 5 NRS Data 6 Ontario Stroke Report Card Benchmark for proportion of acute stroke (excluding TIA) patients discharged from acute care and admitted to inpatient rehabilitation Stroke Rehabilitation Unit (SRU) Bed Requirements The table below outlines the required dedicated Rehabilitation Stroke Unit inpatient beds required at each designated stroke centre. Designated Stroke Centre Consolidated Rehab Volume Inpatient Stroke Rehabilitation Unit (SRU) 7 # Additional Beds Required for District Volume Consolidated Stroke Rehabilitation Unit Size (Beds) HSN 117 2.1 10.7 TDH 50 2.1 4.1 NBRHC 71 1.9 5.6 SAH 64 0.3 5.0 302 6.4 25.4 7 The bed numbers below were calculated assuming a 90% occupancy rate and an average Acute LOS of 30 days in inpatient rehabilitation Page 16 North East LHIN Stroke Care Review 2013
Dedicated Stroke Rehabilitation Unit (SRU) - Recommended Staffing 8 Site Nursing Model (RN/RPN Model) PT OT SLP PTA OTA CDA Rehab Stroke Team Allied Health FTE Cost HSN 4:1 1.5 1.5 0.7 0.7 0.8 0.4 $488,769 TDH 4:1 0.5 0.5 0.3 0.2 0.3 0.1 $168,467 NBRHC 4:1 1.2 1.2 0.6 0.6 0.6 0.3 $394,342 SAH 4:1 0.8 0.8 0.4 0.4 0.4 0.2 $262,894 Totals - 4.0 4.0 2.0 1.9 2.1 1.0 $1,314,472 8 Based on model develop by M. Meyer; FTE s calculated based on anticipated volumes, providing care at the recommended therapist : patient ratio and at the SBPR recommended intensity. (Note: the cost of nursing FTE s is not included in the Rehab Stroke Team Allied Health FTE Cost ) Page 17 North East LHIN Stroke Care Review 2013
Telestroke (tpa Administration) Appendix R-2: North East LHIN Regional Stroke Flow Outpatient Care Inpatient Care Outpatient Care Community Hospitals Emergency Department Patients that are either palliative (and can be cared for at community hospital) or do not meet criteria for transfer to designated stroke centre Palliative Care ALC LTC Placement Care Outpatient Treatment Hubs (PT, OT, SLP) - 7 sites across NE (Elliot Lake, Manitoulin Island, Parry Sound, Temiskaming, Kirkland Lake, Iroquois Falls, Kapuskasing) Telemedicine (OTN) Care Transitions in italics Stroke Onset Patients that do not meet EMS Paramedic Prompt Card for possible tpa or walk-in to local ED Patients that meet EMS Paramedic Prompt Card for possible tpa admin - transported to ED at Designated Stroke Centre TIA or suspected TIA patients that do not require admission Patients that meet tpa administration criteria sent via EMS as part of NE Stroke Protocol Stroke or suspected stroke patients that do not meet tpa criteria but require hospital admission admitted directly to Acute Stroke Unit Patients that are either palliative (and can be cared for at community hospital) or no longer require acute care services and are deemed ALC LTC Placement Outpatient stroke care provided as close to home as possible. Telemedicine used to link Stroke Centre Outpatient Treatment Services and Stroke Re-Check Clinic with Outpatient Treatment Hubs across NE Patients connected to CCAC and/or NILA Services during either inpatient or outpatient care NE CCAC Services NILA Post- Stroke Programs + Community Navigation Designated Stroke Centres HSN, TDH, NBRHC, SAH Outpatient Stroke Prevention Clinic (TIA Management) TIA or suspected TIA patients that do not require admission Page 18 North East LHIN Stroke Care Review 2013 Emergency Department Intensive Care Unit Palliative Care Acute Stroke Unit Stroke Rehabilitation Unit Patients discharged home from acute care Telemedicine (OTN) Stroke Centre Comprehensive Outpatient Treatment Services Stroke Re-Check Clinic
Appendix R-3 Outpatient Rehab Programs at Designated Stroke Centres A. Stroke Re-Check Clinics: i. Estimated Stroke Re-Check Clinic Volume Mandate of Stroke Re-Check Clinics: to provide follow up for stroke patients (non TIA) at 6 weeks, 3 months and 1 year for all patients discharged from hospital to home or retirement home (can include living with family) Estimated # Patients Returning to Stroke Re-Check Clinic 1 Stroke Centre Consolidated Acute Volume (including treatment hub areas) Remove Expired Patients (12% rate) Remove TIA Patients (data from DAD) Subtotal # Patients returning to Stroke Re-Check Clinic Sudbury 417 50 96 271 209 Timmins 178 21 54 103 49 North Bay 232 28 81 123 102 Sault Ste. Marie 215 26 74 115 86 Totals 1042 125 305 612 446 1 Estimated Re-Check Patient Volume = 75% X [(Total Patient Volume Expired Patients - TIA pts)] 75% value represents percentage of patients returning to home, family member's home or retirement home ii. Estimating Stroke Re-Check Clinics Days/Week at each Stroke Centre Each Clinic should operate a minimum of one day per week In a 7.5 hour clinic day, 6 patients could be seen Stroke Centre # Patients returning to Stroke Re-Check Clinic (75%) Mininum # Patient Visits (3 per client) per annum Weekly volume (assume 50 clinics per year) # Clinics Required per week Sudbury 209 627 13 2 Timmins 49 147 3 1 North Bay 102 306 6 1 Sault Ste. Marie 86 258 5 1 Page 19 North East LHIN Stroke Care Review 2013
iii. Recommended Staffing of Stroke Re-Check Clinics (FTE's) Stroke Centre Physiotherapy Occupational Therapy Social Work Community Navigator (part of NILA proposal) Admin Assistant* Estimated Cost Stroke Centre Sudbury 0.4 0.4 0.4 0.4 0.6 $197,739 Timmins 0.2 0.2 0.2 0.2 0.4 $104,078 North Bay 0.2 0.2 0.2 0.2 0.4 $104,078 Sault Ste. Marie 0.2 0.2 0.2 0.2 0.4 $104,078 Totals 1.0 1.0 1.0 1.0 1.8 $509,972 *Admin Asst also used for outpatient services outlined below Note: Individual clinics may utilize different professionals as part of their interdisciplinary team B. Outpatient Stroke Services at Designated Stroke Centres i. Estimated Volume of Stroke Patients Requiring Outpatient Services Consolidated Acute Volume (including treatment hub areas) Discharged from Acute Care Estimated # Patients Requiring Outpatient Rehabilitation 1 Discharged from Rehab Estimated Outpatient Volume # Urban Patients (live within 45 minute drive of stroke centre) # Rural Patients (live > 45 minute drive of stroke centre) 2 Community Hospitals within 45 minutes of Stroke Centre Sudbury 417 19 117 136 105 31 None Timmins 178 8 50 58 28 30 None North Bay 232 10 71 81 67 14 Mattawa, West Nipissing Sault Ste. Marie 215 10 56 66 62 4 None Totals 1042 47 294 341 261 80-1 Reference: Ontario Stroke Network Regional Economic Overview North East LHI: 13% of Acute Care Discharges and 100% of Rehab Discharges will require outpatient rehabilitation 2 Rural Patient will be treated at Community Treatment Hubs and/or via NE CCAC Services Page 20 North East LHIN Stroke Care Review 2013
ii. Outpatient FTE's at Designated Stroke Centres Stroke Centre Estimated # Stroke Outpatients PT OT SLP Social Work Registered Dietitian Pharm RN Estimated Staffing Cost Sudbury 105 1.4 1.4 0.7 0.7 0.4 0.4 0.4 $585,200 Timmins 28 0.4 0.4 0.2 0.2 0.1 0.1 0.2 $173,026 North Bay 67 0.9 0.9 0.5 0.5 0.3 0.3 0.3 $402,331 Sault Ste. Marie 62 0.8 0.8 0.4 0.4 0.2 0.2 0.3 $335,083 Totals 262 3.5 3.5 1.8 1.8 1.0 1.0 1.2 $1,495,641 FTE s calculated as follows: PT/OT 100% of patients requiring care - average of 25 visits for PT, OT (low end of SBPR range 3-5 sessions/week X 8-12 weeks) SLP 50% of patients requiring care average of 25 visits SW estimated need as equivalent to SLP RD/Pharm/RN estimated need of 25% of population requiring these services Admin assistant position outlined in Stroke Re-Check Clinics would be utilized to assist with scheduling of outpatient services. Page 21 North East LHIN Stroke Care Review 2013
Appendix R-5 Outpatient Treatment Hubs i. Map of Potential Outpatient Treatment Hubs Page 22 North East LHIN Stroke Care Review 2013
ii. Staffing Allocation at Outpatient Treatment Hubs (FTE s) Treatment Hub Estimated # Stroke Outpatients Physio Occ. Therapy Speech Lang Pathology Admin Assistant (Booking Clerk) Estimated Staffing Cost St. Joseph's General - Elliot Lake (includes Blind River) Manitoulin Health Centre - Little Current (includes Espanola) Kapuskasing (includes Hearst and Smooth Rock Falls) Iroquois Falls (includes Cochrane and Matheson) Kirkland Lake (includes Englehart) 16 0.2 0.2 0.1 0.1 $57,831 15 0.2 0.2 0.1 0.1 $57,831 12 0.2 0.2 0.1 0.1 $57,831 7 0.2 0.2 0.1 0.1 $57,831 11 0.2 0.2 0.1 0.1 $57,831 Temiskaming Shores 10 0.2 0.2 0.1 0.1 $57,831 Parry Sound 14 0.2 0.2 0.1 0.1 $57,831 Totals 85 1.2 1.2 0.7 0.7 $404,818 FTE s determined using the following: Average of 25 visits/client for PT, OT, SLP (Best Practice states 3-5 sessions per week, 8-12 weeks); it is felt that a minimum of 0.2 PT and 0.2 OT per site is required to ensure services can be delivered at the minimum frequency as per SBPR. Page 23 North East LHIN Stroke Care Review 2013