approximately two in every three health dollars in Canada is taken up by the treatment of chronic conditions

Since its formation in the 1950s, the Heart and Stroke Foundation of Ontario (HSFO) has struggled with these issues. Our programs and focus have evolved over time. Fifty years ago, printing really nice brochures telling individuals how to better manage their risk factors was standard operating procedure. Today, new thinking and technologies have left that approach in the dust. Although providing information to individuals and patients remains an essential bedrock of our programs, we have recognized that chronic disease prevention and management requires action on several fronts.

In this talk, I’d like to focus on three specific ways in which the HSFO has responded to the changing landscape of chronic disease prevention and management. These four areas can be summarized under the general categories of system change, mass media, interactive, user-centred resources and primary care reform.

Systems Change

The idea of systems change is not really new and dates back to the 1960s, when the HSFO partnered with the Wellesley Hospital to create the first Cardiac Care Unit in Ontario. But this effort was essentially a demonstration project, and there was little or no effort to influence the organization of cardiac care at the systems level. In fact, for many years, aside from tobacco regulation where we worked extensively with other organizations as part of a united front, the HSFO shied away from targeted advocacy efforts, focusing almost exclusively on core activities of research and public and professional education.

During the late 1990s, however, the development of thrombolytic therapy for acute ischemic stroke led us to seriously re-examine our traditional priorities. Thrombolytic therapy offered one of the first substantive treatments for ischemic stroke in medical history. But because of the narrow treatment window of three hours, to be effective, thrombolytic therapy required a “perfect storm” of concomitant changes: physician acceptance of the new therapy, procedures and policies for rapid pre-hospital and emergency department identification, triage, diagnosis and treatment, and improved public awareness of the urgent nature of stroke. If any one area lagged behind the other, there could be inefficiencies or even chaos.

As a result, the HSFO threw itself into the task of creating a system of organized stroke care for Ontario that was patient-centred, crossed the entire continuum of care and was structured to ensure the delivery of optimal care, regardless of geographic location. This meant developing new capacities, particularly in the area of advocacy and government relations.

Mass Media

The campaign for organized stroke care also brought about changes in another key area: the use of mass media for health promotion and public education. Like many not-for-profits, the HSFO had traditionally relied upon public service announcements to get its messages to the public. In fact, for years it was Foundation policy to not pay for advertising. In an age of mass media, this can be problematic.

For the Ontario Stroke System to work, it was and is essential to increase the public’s awareness of the warning signs of stroke and the urgency of activating emergency medical services. The most efficient way of achieving this goal has been mass media; specifically, television advertising. The Stroke Strategy propelled the HSFO into developing expertise in mass media advertising. Other programs, such as the Heart&Stroke’s online Blood Pressure Action Plan™ (BPAP), have expanded this work into new media (i.e. digital advertising).

By measuring and refining our mass media plans, the HSFO has vastly expanded its ability to reach Ontarians with health promotion, prevention and management messages. However, we recognize that communications to build awareness and knowledge is only the first step in promoting chronic disease prevention and management.

Interactive Prevention and Management Resources

Which brings me to the third area where the HSFO has undergone substantive change over the past decade: the use of interactive media. Seventy two percent of Ontarians now have internet access. Whereas our website provides a tremendous amount of information on both prevention and management for information seekers, it also goes further. Our interactive consumer e-health tools of the BPAP and the Heart & Stroke Risk Assessment™ (H&SRA) utilize the Transtheoretical Model of Change offer users an opportunity to not only identify their risk factors but to make, or move closer to, behaviour change. These online tools are supported by an ongoing email followup service and an interactive self-management portal that engages users to monitor and track their progress and success. Resources such as the online risk assessments, email service and interactive self management portal are interactive, flexible, user-focused and user-driven. They empower and enable people to make lifestyle changes and take charge of their own health. They are light years away from the era of brochures tackling individual risk factors.

Moving to a user-centred approach is also helping to break down organizational boundaries previously traditional in the health promotion field. In 2002, for example, the HSFO partnered with the Centre for Addictions and Mental Health (CAMH) in order to address alcohol in the BPAP and H&SRA. Respondents who report alcohol consumption in excess of the low risk drinking guidelines are seamlessly streamed into a CAMH alcohol risk assessment to receive more detailed information. Interactive health resources must be driven by the needs and concerns of users, and these do not necessarily conform to diagnostic categories. As noted in the recent report by the Health Council of Canada, greater than one-third of people with chronic health conditions also report having multiple long-term health problems and certain conditions tend to cluster. The risk and prevention factors we focus upon (such as diet, physical activity, smoking, weight and blood pressure) are important to many chronic diseases and conditions. As a result, this year we added a question to the online risk assessments asking participants about other chronic conditions. This not only provides users with a more comprehensive and well-rounded assessment of their risk factor profile, but will enable us to link them with reputable sources of information (such as the Cancer Society, the Arthritis Society, the Diabetes Association, etc.). The interactivity and linking capacity of the Internet means that each organization does not have to develop all of the resources needed to address the needs of users. By linking with multiple health organizations, we can go “out of the box” of our own specialized field and ensure that people receive information relevant to the totality of their health, all in one assessment and action plan and not simply in relation to one chronic condition.

This process of broadening from a cardiovascular to a chronic disease focus will undoubtedly continue and expand in the future. For example, in 2008 HSFO will be launching a new tool to address the issue of obesity and the need for healthy weights. Such a tool has relevance far beyond the confines of any one chronic condition.

Primary Care Reform

The HSFO continues to take action at the forefront, recognizing that prevention and management for chronic disease conditions such as high blood pressure (hypertension) require more focused action in primary care. High blood pressure is a prevalent chronic condition and the number one reason for primary care visits. And the complications of untreated hypertension are many: stroke, heart attacks, congestive heart failure, chronic renal disease, dementia, and more. Hypertension, when it co-exists with diabetes mellitus, increases the risk for cardiovascular disease by 75%.

Similar to our past efforts to create organized stroke care via the Ontario Stroke System, we are mobilizing efforts and enhancing inter-professional collaboration in eleven communities across Ontario to improve the quality and consistency of hypertension care and management as a model for chronic illness care. Health care providers are given an evidence-informed toolkit developed by the HSFO. The toolkit makes it easier for them to consistently provide care aligned with best practice guidelines and engage and work with patients to improve their self-efficacy. The toolkit combines technology, practice support and inter-professional education, reflecting several key areas of the Ontario Chronic Disease Prevention and Management Framework: delivery system design, information systems, provider decision support and personal skills and self-management support.

As an organization, HSFO is committed to improving the health and well-being of Ontarians. We invite others to join us in this continuing and evolving journey.

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