Introduction: The North Vancouver Recreation Commission (NVRC), on behalf of the City and District of North Vancouver, has developed an innovative health partnership supporting healthy living and physical activity in North Vancouver through the creation of the Healthy Living Program in 2007. The Healthy Living Program is a collaborative community partnership which addresses the needs of North Shore residents affected by or at risk for cardiometabolic disease by bridging the gap between the Health Care System and Municipal Recreation Services and providing education, encouragement, support and accessibility to health care specialists and supervised exercise and rehabilitation programs. The partnership brings together the strengths and resources of the Recreation Commission, Lions Gate Hospital, Vancouver Coastal Health and the community-based North Shore Cardiac Rehabilitation group. Background The North Vancouver Recreation Commission s mission is to build healthy individuals, families and communities through municipal recreation. The NVRC s strategic plan is focussed on enhancing recreation opportunities and participation and working together to expand partnerships with community groups and other agencies. These organizational priorities were the foundation upon which the unique partnership for the Healthy Living Program was developed. The Healthy Living Program is an innovative response to the growing demographic affected by cardiometabolic disease (high blood pressure, diabetes, high cholesterol, obesity). 14.5% of the 190,000 residents In North & West Vancouver are over the age of 65, the highest seniors ratio of any B.C. health region. It is estimated the total population with significant risk factors for cardiometabolic disease is over 56,000. (BC Government statistics, 2003/2004). Increasingly, municipal recreational services are shifting towards working to assist people with health limitations to become more active, and stay active. Cardio metabolic disease describes a continuum of health dysfunction. It begins with poor lifestyle (coupled with genetic susceptibility) eventually leading to risk factors such as hypertension, high cholesterol, diabetes and obesity. In the absence of lifestyle changes and/or medical intervention, these risk factors can lead to increased rates of target organ damage such as heart disease, stroke and chronic kidney disease. Cardio metabolic disease places an enormous burden on the healthcare system. The B.C. government estimates that the top 10% of healthcare service utilizers account for over 50% of total service costs ($750 million dollars/year) 1. The majority of these costs are linked to the medical management of chronic conditions such as cardiometabolic disease. Medical research has established that a healthy lifestyle which includes regular physical activity and balanced nutrition is highly associated with decreased risk of developing cardiometabolic disease. In addition, lifestyle change is considered first-line therapy in the management of cardiometabolic disease. Despite the dramatic impact a healthy lifestyle has on the above listed chronic conditions, and despite the employment of highly trained, multi-disciplinary healthcare professionals, the healthcare system has had limited success in effecting lifestyle change. Part of the problem lies in the fact that the healthcare system is, for the most part, designed for acute care. This has resulted in the centralization of healthcare expertise within hospitals. The expanded chronic care model (see Appendix 1) suggests that a more community based approach is needed in order to effectively manage chronic disease. Municipally run community recreation centres take a community based approach with multiple sites designed to serve their immediate community. For example, in North Vancouver there are 8 major Community Recreation Centres run by the City & District of North Vancouver, but only one community hospital. Many of these community sites have exercise facilities and employ exercise physiologists and recreation experts. Furthermore, these sites are able to accommodate group education and discussion. 1
The partnering of municipal recreation centres with local health authorities and hospitals allows partners to benefit from the each other s strengths: healthcare offers medical expertise while recreation centres offer infrastructure, community access and capacity and trained exercise staff. This forward thinking and cooperative partnership process was the genesis for the Healthy Living Program - an innovative solution for increasing access to healthcare, rehabilitation services, and physical activity programs. Healthy Living Program The Problem: A missing link Prior to 2007, the North Vancouver Recreation Commission (NVRC) operated a cardiac exercise program with no official affiliation with Lions Gate Hospital (LGH). Although the program attracted enthusiastic participants, it lacked appropriate integration with hospital services. Meanwhile at LGH, patients who had been discharged following a cardiac event were receiving up to 4 weeks of health education (which included a walking program), from a cardiac home care nurse. In addition, the hospital was running a diabetes education program focusing on nutrition and medical management, and offering nutritional counselling to cardiac event survivors during their hospital convalescence. The critical missing link in this otherwise excellent set of rehabilitation services was the absence of long term follow-up and linkages to community based exercise and rehabilitation programs, which has been shown to be one of the best predictors of adherence to lifestyle change. 2 The Solution: Complimentary Partners Late in 2006, Dr. Kevin Mcleod (Internal Medicine), with support and assistance from Kinesiologist Min Naruki-van Velzen, NVRC administration, proposed the concept of The Healthy Living Program to North Vancouver s City and District Councils. The program received support from both Councils. By February 2007 The Healthy Living Program had been founded as a partnership between LGH, NVRC, Vancouver Coastal Health (VCH) and North Shore Cardiac Rehab (NSCR. In addition to these four main partners, the pharmaceutical industry stepped forward with an unrestricted grant for an educational lecture series. In general terms the partners contribute the following: NVRC: funding for Exercise Specialist positions, management of exercise programming VCH/LGH: direct funding for Nurse support and provision of dietary, cardiac, diabetes, and psychological services offered through existing programming at LGH. NSCR: Maintaining an active membership which goes towards recapturing some of the cost of program staffing. NSCR also fundraise for capital purchases, and organizes social and educational events. Community groups Health System: Medical / Disease Expertise Healthy Living Program Municipal Community Recreation Centres Infrastructure Community Design Lifestyle Expertise At risk population within community 2
The Healthy Living Program The Vision Statement To create a partnership that links municipal recreation services with hospital based disease prevention and care To reduce morbidity, mortality, and disability from cardiovascular disease through education, prevention, rehabilitation, and aggressive disease management including exercise. To ensure patients know their vascular risk, know the treatment targets to reduce their vascular risk, and understand how to arrive at those treatment targets, i.e. the necessary lifestyle and behavioral changes as well as the necessary pharmacologic interventions. Program Objectives: 1. Maximize use of existing NVRC programs and services and expand Lions Gate Hospital s cardiac rehabilitation program to provide a centre of excellence for both primary and secondary prevention for North Shore area residents. 2. Undertake a patient self management approach to preventive care. Emphasize chronic disease management principles and patient education to help improve physical activity, encourage better lifestyle choices, weight loss, and medication compliance. 3. Provide local physicians with education opportunities and community resources for their high risk patients to help prevent future disease and additional stress on the health care system. 5. Serve as an educational tool for local area residents by providing seminars, small group courses, and customized exercise programs. Provide the community with a yearly patient centered conference on healthy living. 6. Collect data on local patient outcomes to improve the body of cardiac research on primary and secondary prevention, thus providing health care decision makers with valuable information about their local population. Program Operational Model: The Healthy Living Program s operation model ensures customized care and follow up for each client (see Appendix 2 for flow chart). Clients are usually referred to the program through their general practitioner or a specialist doctor; however self referrals are also accepted. Once the referral is received, the client is contacted for a comprehensive intake assessment. Intake assessments are done in a medical office; the client sees a nurse, kinesiologist, and physician in a single visit. Once medical history, risk factor profile, and exercise stress testing is completed, the team and the client work together to devise a plan which will reduce cardiometabolic risk. Clients have access to a wide range of supervised exercise programs. High-risk clients are referred to the hospital based supervised exercise programs, moderate risk clients are referred to supervised exercise classes at a local community recreation Centre and low-risk clients are provided with tools and information for their own self-directed exercise program utilizing North Vancouver Recreation Commission fitness classes and walking programs. Clients also receive referrals for dietary and health education, smoking cessation consultation and counseling and are encouraged to attend biweekly evening discussion groups at Lions Gate Hospital. Topics include the Psychological Impact of Heart Disease, Exercise and Heart Disease, Risk Factors, etc. Three months after joining the Healthy Living Program a follow up appointment is conducted. This involves fitness testing and blood work as well as a review of lifestyle and clinical targets compared against entry data. Depending on test results, the client will be provided with a personal maintenance plan which can be managed outside of the hospital setting with the support of a local recreational facility. 3
Budget: In order to maximize accessibility, every effort was made to ensure program costs were reasonable. This was accomplished by following the following principles: 1) Maximize the use of existing services and facilities before creating new ones. 2) View the patient as a partner by creating a membership fee structure through NVRC 3) Partner with all stakeholders to spread the program costs 4) Use information technology to create efficiencies The primary operation cost is related to staffing the program. Each partner is responsible for staffing a particular discipline. Discipline FTE Hours/Week Approximate Annual Cost Funding Partner Program Director 0.75 30 $47,000 NVRC Exercise Specialist Instructors 0.73 29 $45,250 NVRC Exercise Instructors 0.3 12 $15,600 NVRC Nursing 0.4 16 $33,300 LGH/VCH TOTAL $140,850 In addition, the partners provide extensive in-kind contributions. NVRC provides exercise facilities, front office and administration services, office supplies, equipment maintenance, meeting room space and marketing support. VCH and LGH provide gym and auditorium space, office equipment and software technology, clerical support and facility maintenance. The NSCR has donated equipment to the program. It should also be noted that dietary and psychological counseling is offered through existing services (LGH and Canadian Mental Health Association), with no new costs to the patient nor to the system as a whole. Cost Recovery Program participants purchase NVRC fitness memberships in order to join the exercises classes run by the NVRC. Based on March 2009 registration data it is projected that approximately $94,000 will be recovered in 2009 from membership fees. This accounts for approximately 87% of the costs NVRC incurs to run the program. Outcomes: NVRC and its Healthy Living Program partners are committed to promoting enduring healthy lifestyle change and disease prevention goals that benefit the entire community through improved quality of life, reduced health care costs and a more active lifestyle. The program improves access to health services for those who need it most, and reduces barriers to participation in physical activity programs for the at risk population who would not normally utilize municipal recreation services. The concepts of evidence based practice and outcomes driven change was paramount in the program s design. As a result, the importance of collecting data was viewed as a top priority when the program was initialized. The backbone to this objective is the secure electronic medical record and database (Plexia Medical Systems). Far more than a simple database, this system allows staff anywhere in the community to access client s medical information as well as chart and communicate with team members instantly via the secure website. In fact, the program is almost paperless. Some key statistics to date: Since 2007, 505 people been seen for an intake assessment By January 2010 there will be a total of 11 classes spread over 5 sites in North Vancouver. At present there are more than 175 active members in the supervised programs and countless other who have either graduated out of supervised programming or joined other NVRC programs at Community Recreation Centres. Based on an early sampling of patients, we report a 48% increase in fitness as measured through exercise stress testing which is a predictor of all cause and cardiovascular mortality 3. 4
Program participants report a high level of satisfaction. Many individuals have shared stories of how the program has changed their lives by improving their health and wellness and level of activity. At eight weeks post surgery I started the Cardiac Rehab classes at Lion s Gate Hospital. The main benefits were: having a fixed and regular program to get me out of the house and active; the supervision of trained health experts who gave me the confidence to exercise harder than I probably would have done on my own; access to a range of exercise equipment. I then continued in a community based program (in a recreation centre) which had an added social benefit. Stuart MacRitchie aged 56 Future Opportunities Expanding Partnership The current partnership model between the North Vancouver Recreation Commission (representing the City & District of North Vancouver) Vancouver Coastal Health, Lions Gate Hospital and North Shore Cardiac Rehab has been collaborative and successful. Future plans include working with West Vancouver to expand the partnership. Applying the Model to other Disease Areas The program structure and content would benefit a multitude of other chronic disease such as lung disease, mental health, and liver disease; however, to this point we have not formally opened our door to these populations. The NVRC is currently in talks with Vancouver Coastal Health s Chronic Disease Services Team to see how the Healthy Living Program model could be applied to better serve these patient groups. Sharing Best Practices The program design has been studied by St. Paul s Hospital, Vancouver General Hospital and the City of Vancouver and is being used as a directional template for initiating a similar partnership in other communities -a true testament to the success of the design! Increased Evaluation & Measurement Compiling satisfactory outcome data is challenging due to the labour intensive nature of tracking down intake data from pre-existing records. The program has applied for a research grant in order to free up resources to compile a complete intake data set. Publishing Results: The program team plan to publish the following papers to share the program results: The effect of the Healthy Living Program on global cardiometabolic risk as measured by Framingham Risk Score The effect of the Healthy Living Program on risk factors (lipid profile, blood pressure, weight, waist circumference, glycemic control, etc) The cost/patient, and indirect estimate of cost/quality life year saved. Conclusion Our communities are aging and experiencing higher rates of chronic disease. At the same time, more residents are in need of services to support their health management and physical activity needs while dealing with or recovering from major illness and chronic disease. Although the expertise for managing the challenges of chronic disease exists, hospital based initiatives cannot fully address these challenges due to barriers which included lack of infrastructure and an inability to reach into the communities they serve. Municipal recreation facilities are positioned to serve and engage the broad community with the infrastructure and staffing to provide physical activity, rehabilitation and other health management programs at a local level. The Healthy Living Program helps to build a healthier community by providing innovative, cost effective, community based programs delivered through a collaborative partnership. 5
APPENDIX 1 References: 1) http://www.health.gov.bc.ca/cdm/research/levels_of_cost.pdf 2) Lear SA, Spinelli JJ, Linden W, Brozic A, Kiess M, Frohlich JJ, Ignaszewski A. The Extensive Lifestyle Management Intervention (ELMI) after cardiac rehabilitation: a 4-year randomized controlled trial. Am Heart J. 2006 Aug;152(2):333-9 3) Mora S, Redberg RF, Cui Y, Whiteman MK, Flaws JA, Sharrett AR, Blumenthal RS. Ability of exercise testing to predict cardiovascular and all-cause death in asymptomatic women: a 20-year follow-up of the lipid research clinics prevalence study. JAMA. 2003 Sep 24;290(12):1600-7. The Expanded Chronic Care Model 6
APPENDIX 2 Program Operational Model: Referral Intake/Follow-up Assessment Higher risk Hospital Exercise Low-Mod Risk Self Directed NVRC Fitness Classes Walking Programs Mod-Low Risk NVRC Community Exercise Classes (Supervised) Follow-up at three months 7
APPENDIX 3 Letters of support from the Mayors of the City of North Vancouver and the District of North Vancouver. 8
APPENDIX 4 Partner Contact List North Vancouver Recreation Commission Bernie Blake, Coordinator of Fitness, Health & Wellness 604-983-6317 / blakeb@northvanrec.com Min Van Velzen, Healthy Living Program Director (604) 417-0629 / velzenm@northvanrec.com Vancouver Coastal Health / Lions Gate Hospital Karin Olson, Director of Coastal HSDA, 604-984-5925 / Karin.olson@vch.ca Sandra Edelman, Manager of Healthy Living & Community 604-904-6453 / sedelman@vch.ca Dr. Kevin McLeod, Internal Medicine 604-904-0810 / kevin_mcleod@mac.com North Shore Cardiac Rehab Ed Kry, President, North Shore Cardiac Rehab 604-929-3006 / edkry@shaw.ca 9
APPENDIX 5 Program Photos by James Rolston Program participant at Lions Gate Hospital graduating from the Hospital Program to the Community Recreation Centre Class all smiles! Mixing exercise and fun - the right Perscription! Supervised exercise at John Braithwaite Community Centre 10
APPENDIX 5 Program Photos by James Rolston Program Participants are monitored closely by a dedicated staff team. Memorial Community Recreation Centre Assessment & Follow Up Program Intake & Assessment 11
APPENDIX 5 Program Photos by James Rolston Program special event Parkgate Community Centre: Moderate Low Risk Class Lions Gate Hospital Higher risk class participants 12