Vascular Health Strategic Aim TAG Vascular English

For vascular disease, the prevalence is high, the risk of developing the disease is high, the cost to the health and quality of life of people with the disease is high and the cost to the health care system is high.

With the overarching goal of Living Healthier at Home - Advancing integrated systems of care to help Central East LHIN residents live healthier at home, the Central East Local Health Integration Network (Central East LHIN) 2016-2019 Integrated Health Service Plan (IHSP 4) will guide, direct and inspire health system change.

Through the engagement process for the LHIN's 2016-2019 Integrated Health Service Plan, patients, caregivers and providers identified where improvements to the health care system are required as the system continues to improve the vascular health of people to live healthier at home by spending 6,000 fewer days in hospital and reducing hospital readmissions for vascular conditions by 11% by 2019.

Who is this Priority Population?

Generally speaking, vascular disease includes: cardiovascular (heart disease); cerebrovascular (brain disease) including vascular dementia and stroke; and, peripheral vascular disease presenting in areas of the body such as kidneys, arms and legs. Vascular diseases remain the leading cause of preventable death in adult Canadian men and women. Nine out of every ten Canadians over age 20 have at least one risk factor for vascular disease, while, one in three have more than one risk factor.
Many of the modifiable risk factors are prevalent in the Central East LHIN population including overweight/obesity (51%); physical inactivity (48%); type 2 diabetes (5.8%); and, smoking (16%).

Within the Central East LHIN, 17% of residents have multiple chronic conditions which makes vascular disease management more complex and can lead to higher hospital re-admission rates. In 2014-15, over 23.2% of patients with Congestive Heart Failure (CHF), 15.3% of Cardiovascular and 10.2% of Diabetes clients were readmitted to hospital within 30 days of discharge, suggesting, that despite significant vascular health advancement over the last nine years, improvement is still needed.

Building on Key Accomplishments

Integral to achieving the aim and improving vascular health is the Central East LHIN Vascular Health Coalition, formed and funded by the Central East LHIN to improve the organization, coordination and delivery of vascular health services for residents in the Central East LHIN. Making a direct contribution to reducing hospitalization and promoting vascular health, the Coalition and health service providers from across the LHIN surpassed by more than 45%, the aim of reducing the impact of vascular disease on local residents set for the system in IHSP 3.

The following are a number of vascular health priority projects and investments which have contributed to and will continue to contribute to achieving our Vascular Health Aim:

Regional Cardiovascular Rehabilitation and Secondary Prevention (CRSP) Program (Implemented)

  • strategy reducing morbidity/mortality related to cardiovascular disease
  • provides a regional integrated service utilizing harmonized referral criteria, centralized referral, acceptance and booking for patients with established vascular disease at high risk for cardiovas-cular complications
  • to deliver the program locally there are 12 sites distributed throughout the Central East LHIN
  • Applied Health Research Question (AHRQ) will help identify knowledge gaps; including providing data, analyses and knowledge translation intended to better understand the impact of patients enrolled in the Central East LHIN’s CRSP

Chronic Disease Self-Management Training (Implemented)

  • empowers people to develop new tools and skills to break the cycle of symptoms that can result from chronic conditions

Diabetes Education Programs (Implemented)

  • providing comprehensive management for people with diabetes through interdisciplinary teams of health professionals
  • increasing physician engagement and community outreach and collaboration

Stroke Report Card (Implemented)

  • Central East LHIN was a “top performer” for key performance indicators: prevention of stroke, acute stroke management, stroke rehabilitation, measuring above provincial benchmark (2013/14 Stroke Report Card and Stroke Progress Report) and a low performer in other indicators

Teleophthalmology (Implemented)

  • engaging individuals with diabetes who live in the Central East LHIN Health Link communities with the purpose of preventing complications and vision loss
  • increasing the number of people with diabetes in the Central East LHIN receiving the recommended annual screening for diabetic retinopathy

Centre for Complex Diabetes Care (CCDC) (Implemented)

  • providing individuals with complex diabetes health needs with a single point of access to specialized inter-professional teams using a coordinated approach as they move through the health care systems

Diabetes Service Coordination and Quality Improvement (Implemented)

  • Centralized Diabetes Intake Referral Program - improving standardized, equitable access to care
  • Diabetes Education Program - increasing physician engagement and community outreach and collaboration

Vascular Health Physician Lead (Implemented)

  • builds and establishes strong collaborative relationships between service providers across Health Link communities in order to drive quality improvement and adoption of best practices in diabetes /vascular care and management
  • promotes the integration and coordination of diabetes and vascular health services and resources
  • supports coordination engagement, planning and outreach in partnership with related initiatives of the LHINs, service providers and provincial associations

Telehomecare (In development)

  • a time-limited intervention which provides in-home monitoring for clients through technology, supported by a registered health care provider
  • supports primary care providers to provide needed monitoring and self-mangement coaching to patients

Unplanned hospital readmissions are common, expensive and often preventable. Strategies designed to reduce readmissions will target patients at high risk and those programs that support vascular clients to transition between the hospital, primary care and other community providers. This will include continuing to support initiatives that focus on better clinical management before hospital discharge, improved case manage-ment, and adequate discharge planning and follow-up care, and adequate home care services.

Through strong inter-sector action between hospital, primary and specialty care, the Central East CCAC and community organizations in partnership with patients, their families and caregivers, there are continuing opportunities for supporting vascular clients across the continuum of care. Through Health Links, collaborations and partnerships can be initiated or expanded; the role of primary and specialty care can be highlighted and developed, including advancing screening and treatment for vascular disease; and, service integration opportunities can be identified and pursued.

Learn More

To track the system's ongoing progress against this Strategic Aim, please visit the Central East LHIN Performance page.

For more information on these accomplishments, please contact the LHIN at centraleast@lhins.on.ca or any LHIN-funded Health Service Provider