CSBPR Stroke Systems of Care Framework

Canadian Stroke Best Practices Optimal Stroke Service Framework Overview

The Canadian stroke leaders, including collaboration between the CSBPR advisory committee, Heart and Stroke Foundation, Canadian Stroke Consortium, Canadian Neurological Sciences Federation, CanStroke Recovery Trials Platform  and individuals with lived experience of stroke have developed a framework to drive timely and equitable access to stroke care and services across the continuum of care and facilitate system improvement through the adoption of evidence-based best practices and increased collaboration and integration. Stroke systems of care are driven by national efforts, and planned and implemented at the provincial, territorial and regional levels.

The goals of stroke systems of care are to provide timely and individualized care that is responsive to the needs of individuals with stroke, their family and caregivers, and to optimize short and long-term outcomes for individuals and the health system.  

This may be accomplished by ensuring effective communication and continuity of care across all specialties and phases of care to provide collaborative integrated care, breaking down siloes, reducing delays and creating systems to address inequities based on geography, sex and gender, ethnicity, language, culture and other social determinants of health. 

Within these goals it is recognized that the needs of individuals with stroke and their families are dynamic – they will change over time, and stroke systems need to be flexible and responsive and be able to support individuals with stroke and their families through these shifts. Support and management for individuals with stroke extends beyond the traditional healthcare system; it is imperative that strong collaborative relationships be built across sectors, including community services, education, leisure and vocations. 

There are four components to be considered as part of the Canadian Stroke Systems of Care framework (Figure 1).

Stroke systems of care are defined as a comprehensive, diverse and longitudinal system that addresses all aspects of stroke care within an integrated, organized and coordinated approach. A stroke system spans the continuum of care from primary prevention to end of life.  A stroke system ensures access to evidence-based care and therapies which optimize their survival and recovery.

Stroke systems are built and operate at several levels where planning, funding and operational management occur:

1. Nationally to address priority initiatives and support provincial and territorial work through coordination, content development, and professional communication. Work at this level generally includes establishing partnerships with national agencies including government, health charities, health professional organizations, research funding bodies, and other disease strategies with the goals of collaboration and alignment and strengthening advocacy of overlapping issues. National and international efforts also include increasing public awareness, knowledge sharing, and funding and promoting research. 
2. Provincially or territorially to provide oversight and monitoring of provincial stroke systems of care, identify and address provincial/territorial priority initiatives including health system planning, funding allocations, provincial standardization of best practices, and quality improvement. Work at this level also includes collaboration and alignment with national and provincial/territorial partners such as government, health system partners, health charities, community service planners and providers, and people with lived experience. Provinces and territories also play a critical role in public awareness, prevention and health education. 
3. Regionally and/or locally to provide oversight, monitoring and funding of regional stroke systems of care, and local care delivery across the continuum.  Building partnerships in identifying provincial priority initiatives and aligning regional priorities. Regional and local focus on implementation of best practices, and quality improvement, supporting local public awareness and education, and outcomes for people with lived experience and the health system overall.

Integrated stroke systems take a comprehensive approach to planning and delivering care, encompassing access, assessment, treatment, clinical best practices, data collection, outcome measurement, benchmarking, guideline implementation, service organization, funding, and education.

1. Continuum of Stroke Care and Recovery
The stroke continuum of care in Figure 2 characterizes the stages that the general public and then individuals with stroke generally experience. All individuals in the general public will ideally be aware of risks for stroke and other vascular events and may consider primary prevention through routine healthcare and education interactions. Once a stroke event occurs, individuals with stroke may experience stages from acute care through to end-of-life.  It is recognized that individuals who experience stroke may experience more than one stage simultaneously (e.g., secondary prevention and stroke rehabilitation) or move back and forth between stages over a period of time.

2. Essential Components of a Stroke System
There are key core elements that form the foundation of high-quality stroke systems of care across the continuum and in all settings where appropriate. The five pillars of the original Canadian Stroke Strategy have evolved over time into the current eight essential components of the Stroke Systems of Care framework, presented in Figure 3 and Table 1.

A critical element of the core components in stroke systems of care is accountability for disparities in care experienced by individuals and populations disproportionately impacted by inequities, such as in indigenous, racialized, rural, gender-diverse populations.

These components have matured and progressed over time as stroke knowledge, evidence, practice, technology and care have advanced.  Elements within each component can be applied across the stroke continuum of care (as per Figure 2) where relevant, and all components are inter-related to each other.

3. Settings for Stroke Care and Recovery
Settings for stroke care across the stroke continuum refers to the physical locations where care is delivered to and received by individuals who have experienced a stroke, their families and caregivers across the continuum of care (refer to Figure 2).

These settings may include:

• the prehospital phase with emergency medical services (ambulance), 
• emergency department, acute stroke unit, other acute care hospital wards, intensive care unit (may also be transferred between acute care hospitals with different levels of stroke services  - e.g., small community hospital to a comprehensive stroke centre)
• inpatient rehabilitation units and facilities 
• outpatient clinics (e.g., secondary prevention and rehabilitation clinics) 
• community nursing and health outpost stations (remote/ rural areas)
• a wide range of community-based facilities and services
• complex care
• long-term care
• an individual’s home and place of residence (consider unhoused situations and other challenges)
• respite care facilities/services
• palliative care, hospice care
• virtual healthcare delivery

The essential components of stroke systems should be considered and applied across all settings where relevant with appropriate nuances considered.

4. Ecological Model of Health Adapted for Stroke Systems of Care 
Within stroke systems in Canada, the levels of the ecological model of health systems are also considered in health systems design and implementation (Figure 4). This model considers how individuals interact with increasingly broader levels of their community and environment as they address health behaviour change and experience specific health journeys such as dealing with a stroke event. The model in Figure 4 has been adapted for stroke, with input from system leaders, clinicians, researchers and importantly people with lived experience. It can be used to provide additional insights and considerations when planning and delivering high quality stroke care across the continuum.