Improvement Story session at the 2013 Saskatchewan Health Care Quality Summit. For more information about the summit, visit www.qualitysummit.ca. Follow @QualitySummit on Twitter. Better Care for clients and families experiencing or at risk for stroke or transient ischemic attacks (TIA's) using telehealth and multidisciplinary and inter-regional resources was realized in Sunrise Health Region over the course of a two year pilot. Better Care Jacquie Holzmann, Sunrise Health Region, Shannon Schmidt, Sunrise Health Region

1. Saskatchewan Integrated Stroke Strategy
Jacquie Holzmann, Shannon Schmidt
This Session is sponsored by:

2. Working together…for healthy people in healthy communities.
Improvement Story:
Saskatchewan Integrated Stroke
Strategy:
2012 Evaluation
Sunrise Health Region
Presenters:
Jacquie Holzmann, Director of Therapies
Shannon Schmidt, Manager Integrated Therapies/Stroke
Services
Thursday, April 11th, 11:00 AM

3. together…Working for healthy people in healthy communities.
Outline
Improvement Story:
• 2012 Evaluation Results: Data………
• Lessons Learned
• Continuous Improvement

4. together…Working for healthy people in healthy communities.

5. Working together…for healthy people in healthy communities.

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Saskatchewan Integrated
Stroke Strategy-Pilot

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5 key elements
Stroke
Prevention
Clinic
Inpatient Stroke
Rehab
Integrated
Stroke Strategy
Steering
Committee
Stroke Services
Manager
Telehealth and
Diagnostic
Technology

8. Working together…for healthy people in healthy communities.
GOAL: To organize ( improve and integrate)
stroke care in the Sunrise Health Region.
“the right services ( best practise) in the
right place (close to where families live
and work; accessible) at the right time
(saves lives, improves outcomes)”

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Evaluation
• Data collection over 2 years- 2009-2011
• Document analysis
• Program indicator reports
• Client feedback
• Health care provider interviews
• Focus Groups

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Pre-Hospital and Emergency
Care

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Stroke Care
• Over 26 months- 285 people in SHR
received acute, Rehab and/or stroke
prevention care
• 70% from “rural”
• 30% TIA
• 36% stroke/CVAs
• 5% transferred to RQHR for care
• 4% received rtPA

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Acute Care

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Acute Care
• Non-cohort, acute care beds admitted on
average 45 TIA/Strokes/year
• Mean age 72 (19-93)
• Average LOS 10 days (1-121) (16 days -
Canadian Stroke Network, CSN 2011)

14. Working together…for healthy people in healthy communities.
Acute Care
• 50% returned to own home
• 20% outpatient therapy and/or community
support
• 22% returned to acute care
• 10% to LTC
• 2/3 started therapy in acute care
• 10% Living with Stoke/TIA Education
• 9% did not survive stroke

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Stroke Rehabilitation

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Interdisciplinary Team
• Physical Therapy
• Occupational Therapy
• Therapy Assistant
• Speech Language Pathologist
• Social Worker
• Clinic Care Coordinator-RN
• Special Care Aide

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Stroke Rehab Program
• 37 stroke survivors
admitted
• 81% diagnosis of
ischemic stroke
• 14% Hemorrhagic
stroke
• 11% had received rtPA
• Mean Age 72.2 (41- 96)

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Stroke Rehab Program
• 1/3 from Yorkton, 2/3 “rural”
• 2/3 from YRHC Acute Care
• Median time “medically stable” to admission-14.5 days
• 50% admitted within 14.5 days
• 75% admitted within 28 days
• ALOS 49 days (6-154)
• CSN- ALOS 35-42 days

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50% had FIM score of 20+ and clinically meaningful gains

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• 2009-56% had + change in FIM admission to discharge
• 83% in 2011
• Over 2 years 67%

22. • 55% returned home,
• 17% to LTC
• 11% ALC
• 15% returned to
Acute Care
• CSN- 60 % return
home, 10 % returned
to LTC

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Interdisciplinary Team
• Physical Therapy
100%
• Occupational Therapy
100%
• Speech Language
Pathology 65%
• Social Worker 89%*

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Stroke Prevention Clinic

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“It is not just the day we see patients via
telehealth in the clinic-there is a lot of before
and after testing, referral, follow-ups and
tracking and double checking that needs to
be done”

27. • 175 people with
stroke symptoms
received 215 visits
• 35% from Yorkton
• 65% Rural
Working together…for healthy people in healthy communities.

28. Referrals
• 50% Primary
care/physicians
• 20% Acute Care
• 17% ER
• 13% RQHR
neurologists or SPC
clinic
Working together…for healthy people in healthy communities.

29. • Median time ABDC² > 4 to clinic - 11 days (75%
21 days)
• 186 client visits :
– 49% CT scans
– 40% Carotid Dopplers
– 31% Holter monitors
– 24% Echocardiograms
– 7% EEG*
– 5% EMG*
• 19% specialist referrals
Working together…for healthy people in healthy communities.

30. “It was one on one, the same as being in
the office with him…he explained
everything very well…to me it was if I was
talking with the doctor in person”

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• 112 family members participated
• Mean age 73 years (17-96)
• 66% of visits were 70-89 years.

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Stroke Prevention Clinic
• 3 clients with symptomatic stenosis
referred for endartectomy
• 49% seen in SPC had documented
diagnosis not related to stroke

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Risk Factors
Of 175 clients:
• 60% Hypertension
• 39% Dyslipidemia
• 19% Coronary artery disease
• 17% Atrial fibrillation
• 16% Diabetes
• CSN- 64% Hypertension, almost ~25% Diabetes ,25%
Coronary artery disease, 16% Atrial fibrillation

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“Improved and
integrated stroke
care will change
the lives of
Saskatchewan
people who are at
risk or have
experienced a
stroke.”

35. Working together…for healthy people in healthy communities.
“I was very impressed with this
technology, it was easy for me and I think
cost effective for our health region.”
“It think it is a great way to access a
neurologist without long trips to Regina
and long wait times.”

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“The clinic saved me a trip and time and
money to go to Regina and I got the
same results.”
“Saved us so many trips to have all the
tests done in one day, my husband was
not well …”

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Challenges/Obstacles

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Rehabilitation
• Medical stability prior to transfer
• On site Physician support
• Increased Nursing/Rehab workload in acute
care and LTC
• Evening/weekend-programming

39. Working together…for healthy people in healthy communities.
Stroke Prevention Clinic
• Telehealth -larger screen/speakers
• Access-test results-EMR
• Recruitment (medical cardiac sonographer)
• Carotid Doppler's/Echocardiograms
• NP Model vs. Nurse

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Strengths/Highlights
• Stroke Services Manager
• RQHR SPC Team
• ELT support and culture of change
• Rehab facility that fosters functional
rehabilitation
• Health Foundation support

42. ``The more the complex the health needs and the more
interdependency needed to serve the patient, the greater
the need for team collaboration`` (CHSFR 2006)
Working together…for healthy people in healthy communities.

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What We Learned-Key Points
• Tertiary/Regional Partnerships
• Neurologists Partnership
• Staff training/education
• Telehealth
• Client and family centred stroke care

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Where Next?

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