Community Alliance for the Remodeling of Rural Health Systems:
Taking Action on Chronic Illness (CAHR)
Yarmouth Stroke Project: Rural Health Innovations

Project Information: Overview/Background

Purpose:

  • To develop a new model for organizing Canadian rural health systems for persons with chronic health problems.
  • To demonstrate how rural health services can be remodelled and sustained to enhance the quality of life of persons with chronic health problems, and to reduce the social and financial costs of chronic illness.

Introduction

Integrated models of health service across the continuum from prevention to community re-integration are valuable approaches to chronic disease management. However, health systems are not equally resourced (leadership, human and financial resources) to provide integrated care. The world's population is mostly comprised of low resourced health systems that struggle to interpret mountains of evidence, and to overcome barriers to adapting practice in the face of sustaining basic services. In most cases, the basic elements of care for chronic disease are not present, let alone integrated.

  • What are the challenges and adaptive strategies at play when rural health systems mobilize to improve services and develop integrated care?
  • How can university-community collaboration foster health system improvement?
  • How can governments reduce the health systems gradient to improve quality service for small and/or lower resourced systems?

The Canadian Institues of Health Research funded research project aimed to identify needed health service improvements for stroke and to develop an improved, integrated health system in a relatively rural region of eastern Canada. Known as the Yarmouth Stroke Project (YSP), the CIHR's Project was a 5-year initiative aimed at improving health care services for stroke survivors in rural Nova Scotia. Community-university research alliance funding provided an opportunity for partnerships between researchers, government and non-governmental agencies to take on substantive health issues, where evidence could be mobilized into action.

The four core partners involved in the Yarmouth Stroke Project (YSP) were: Dalhousie University (Atlantic Health Promotion Research Centre), the Heart and Stroke Foundation of NS, Southwest Nova District Health Authority, and the QEII Health Sciences Centre, Halifax. Additional research funding was later obtained from the Canadian Stroke Network for a "validation" study on application of findings to other health systems.

Project Objectives

  • To conduct a systematic assessment of best practices for rural community rehabilitation services;
  • To develop a profile of the target populations and services in the Yarmouth area for people with stroke and caregivers;
  • To map existing and potential stroke and related services as well as opportunities for student training and volunteer development;
  • To design a community-based rehabilitation program to be pilot tested in Yarmouth area. To disseminate project findings and develop strategies aimed at positively impacting to influence policy;
  • To develop and evaluate the pilot program;
  • To evaluate the process and outcomes of the research project.

The Problem - Stroke, Integrated Care and Rural Communities

Stroke is a debilitating and life-threatening vascular disease that affects millions of people worldwide each year. (Truelsen, Bonita, & Jamrozik, 2001) Approximately 50,000 Canadians and 700,000 Americans experience strokes annually. (HSF, 2006; WHO, 1998) Sixteen thousand Canadians die from strokes every year (HSF, 2006) and stroke survivors often are left with long-term physical and/or mental disability. (AHA, 2006; CDC 2001; HSF, 2006; WHO 1998; Burvill, Johnson, Jamrozik, Anderson, Stewart-Wynne, & Chakera, 1995; HSF, 2003) It is estimated that the disease costs Canada $2.7 billion per year. (Moore, Mao, Zhang, & Clarke, 1998; HSF, 2003)

Share of Health Expenditures in
Nova Scotia by Age Group
Senior Health Care is Very Expensive Nova Scotia, 1994 Age Group

Source: Health Canada, 1994

Deaths Due to Stroke in Canada, 2006
Deaths Due to Strokes in Canada, 2006

Source: Statistics Canada, 2006 (See Cerebrovascular diseases)

Characteristics of Nova Scotia Seniors

  • With 15.1% of Nova Scotia residents aged 65 or over in 2006, it was the oldest province in
    Eastern Canada and the second-oldest in the country behind Saskatchewan (15.4%).
  • Approximately 138,210 people were over the age of 65 in Nova Scotia.
  • 42.9% (59,415) were men;
    57% (78,800) wer women.
  • 41.4% of seniors live in the rural areas of Nova Scotia, compared to 15.5% nationally.

Source: 2006 Census, Statistics Canada

Stroke survivors often require specialized health services ranging from risk screening and prevention to emergency, acute care, rehabilitation, community re-integration and long-term care (Cameron, 2006). However, care for individuals with most multiple, chronic health problems including stroke is often fragmented and less than optimal. (Clarfield, Bergman, & Kane, 2001) There are excessive burdens not only on stroke survivors and their families but on service providers often acutely aware of system inadequacies. (Lyons, McDonald, MacKay-Lyons & Philips, 1995).

Well-organized, integrated care from prevention to long term care is the general approach for addressing prevention and management of chronic disease (Sulch & Karla, 2000). From a knowledge translation perspective, the thinking is that organized systems of care around an implementation strategy provide the foundation for health system financial investments, human resource coordination and development, and the mechanism for effective uptake of evidence through practice guidelines, training, and research. This approach has been popular for a wide variety of chronic diseases such as cancer, diabetes and Alzheimer's disease.

Countries such as Canada, Scotland, and Australia have initiated evidence-based integrated care for stroke. (Woods, 2001; NHS Scotland, n.d.; Department of Health, 2000; NHS ES, 2006) Although the precise outcomes of complex health systems change, such as integrated care, are methodologically challenging, studies of integrated care have shown improvements in quality of care and patient outcomes and increases in clinical expertise. Integrated care strategies provide a focus for health systems investments, benchmarks and the use of evidence. Cost benefit analyses also support integrated care. (Canadian Stroke Network, 2006) In Scotland, outcomes include population health improvements (e.g., reduced smoking), clinical improvements (e.g. earlier diagnosis and better treatment for cancer, and reduced death rates from stroke), and reduced wait times for treatment and discharge from the hospital (Audit Scotland, 2005). The National Breakthrough Collaborative Improvement project in the Netherlands examines improvement in care in 23 stroke services, including length of stay, information transfer, thromobolysis treatment, after care, protocols and cooperation, and knowledge translation (Minkman, Schouten, Huijman, & Splunteren, 2005).

Service Needs in Rural Communities

Large, better resourced health systems are at the forefront of integrated systems change and it is predominantly an urban concept. (Cameron, J., 2006) Resources in this context refer to specialists across the continuum of care from prevention to community re-integration, care and training coordinators, clinician-researchers, physical infrastructure, champions, and financial resources for research, KT and change. Kodner & Kyriacou (2000) identify 15 factors integral to the development and operationalization of integrated care. However, smaller communities, low resource areas and rural regions also require service. They often have a disproportionate population of older adults (whose children have moved away) and they are often places of respite and retirement and few specialists practice there. Recent urban-rural comparisons of cardio-vascular disease in Canada have generally shown higher prevalence, higher mortality and morbidity from cardio-vascular disease and poorer quality of services in rural Canada (CIHI, 2006). In other words, health service innovations may not be occurring in the locations that need them the most.

Senior's Projected Share of Total Population
Nova Scotia & Canada 1996 - 2016
Senior Health Care is Very Expensive Nova Scotia, 1994

Source: Statistics Canada

Rural Canada: Communities in Transition

  • Population Aging
  • Economic Sustainability
  • Health & Wellness Services
  • Chronic Illness & Disability
    - Lack of services/opportunities
    - Inactivity
    - Caregiver burden

Rural communities have often been cited as having inadequate health human resources, and fewer specialists, geographic challenges in accessing care, and typically are lower-resourced systems for service or organizational change. The need to extend integrated care to rural communities has been well documented (Bird, Lambert, Hartley, Beeson, & Coburn, 1998; Coburn, 2001).

The few studies conducted on the efficacy of rural/small community integrated care have shown positive outcomes. For instance, Bernbabei et al. (1998) implemented integrated health care designed specifically for frail elderly people living in rural communities in Italy. Compared with frail elderly receiving conventional care, the experimental group showed fewer and shorter admissions to hospitals and nursing homes, better physical functioning, reduced cognitive decline, and spent on average $1800 less on health services than those receiving conventional care...but what was different from the urban models? An integrated care approach for the frail elderly was launched in a semi-urban community in Quebec. Individuals receiving the integrated care had a 44% lower risk of institutionalization, and reductions in deterioration of health and caregiver burden (Hébert, Durand, Dubuc, Tourigny, and the PRISMA Group, 2003; Tourigny, Durand, Bonin, Hébert, & Rochette, 2004).

Research on stroke service in rural communities has included telestroke, rapid transport systems for thromobolytic treatment (Silliman, S.L., Quinn, B., Huggett, V., Merino, J.G., 2003); practice guideline usage in emergency departments (Burgin, W.S. et al., 2001) and access to care issues in rural communities in developing countries (Nicoletti et al., 2000). Geographical access to quality care, trained health professionals, getting by in to use through organized care, and payment systems appear to be the four key issues facing rural communities worldwide, although there has not been a plethora of studies specifically related to either global health or rural stroke care.

In summary, the impact of stroke together with opportunities for substantive improvements to prevention and treatment have lead to improved service in many parts of Canada and other countries. In addition, integrated systems of care systems of care have been instituted in many countries. Integrated care is also a promising model for rural communities and lower resource systems although there has been little attention paid to them as large systems have the resources have been the prime venues for improved service. Perhaps a statement of growing attention but the need to figure out how this would work and what the drivers are to stimulate attention to small, rural communities. for case-management) have been shown to improve care, reduce hospital stays and health care costs (Sulch & Karla, 2000), and this decade has brought considerable understanding about the value of rehabilitation in physical and psycho-social functioning.

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Principal Investigator:
Renee F. Lyons, Ph.D.

Term of Project:
February 2001 - 2007

Project Location:
Yarmouth, NS (pop. 9000)
Halifax, NS

Advantages of Integrated Care

Graphic of EKGAccumulating evidence suggests that integrated care across the continuum from prevention to community re-integration is a valuable approach to chronic disease prevention and management. Integrated care refers to the coordination of health services around a patient/family- oriented approach, horizontally between practitioners and organizations that provide services, and vertically between different levels of care from ambulatory to long-term care. (Conrad & Shortell, 1996; De Jong & Jackson, 2001; Leatt, 2002; Plochg & Klazing, 2002)

Stroke is an excellent candidate for this approach due to prevalence, impact and preventability of onset and recurrence. Research, evidence-based guidelines, stroke strategies (e.g,. Canadian Stroke Strategy Swedish), and financial investments have contributed substantively to development most elements of stroke care (e.g. secondary prevention; thromobolysis) and organized systems of care (stroke units). However, in most parts of the world the basic elements of stroke care are still not present, let alone integration, and this is particularly true for rural and low resource health systems. Evidence becomes a major feature in exacerbating health and health system disparities unless mechanisms are in place to raise and level the bar for rural and low resource environments.

Facilitation of systems change via university-community collaborative processes can improve stroke service in such communities, wherein a "third place" is created for contextualizing evidence and improving care.

References

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The American Heart Association Statistics Committee and Stroke Statistics Subcommittee (AHA). (2006). Heart disease and stroke statistics – 2006 update. USA: American Heart Association.

Audit Scotland, 2005. Overview of the performance of the NHS in Scotland 2004/05. Audit Scotland. Scotland: Edinburgh.

Alberts, M., et al. (2000). Recommendations for the establishment of primary stroke centers. JAMA, 283, 3102-3109.

Bird, D., Lambert, D., Hartley, D., Beeson, P., & Coburn, A. (1998). Acute stroke care in non-urban emergency departments. Neurology, 57, 2006-2012.

Burgin, W.S., Staub, L., Chan, W., Wein, T.H., Felberg, R.A., Grotta, J.C., Demchuk, A.M., Hickenbottom, S.L., Morgenstern, L.B. (2001). Prevalence of depression after stroke: the Perth Community Stroke Study. The British Journal of Psychiatry, 166, 320-327.

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Coburn, A. (2001). Models for integrating and managing acute and long-term care service in rural arease. The Journal of Applied Gerontology 20, 386-408.

Conrad, D.A. and S.M. Shortell. 1996. Integrated Health Systems: Promise and Performance. Frontiers of Health Services Management (Fall) 13(1): 3-40.

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Minkman, M., Schouten, L., Huijsman, R., & van Splunteren, P. (2005). Integrated care for patients with a stroke in the Netherlands: Results and experiences from a national Breakthrough Collaborative Improvement project International Journal of Integrated Care, 5, 1-12.

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Tourigny, A., Durand, P., Bonin, L., Hébert, R., & Rochette, L. (2004). Quazi-experimental study of the effectiveness of an integrated service delivery network for the frail elderly. Canadian Journal on Aging, 23, 231-246.

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