Champlain CVD Prevention & Management 2013-16 Strategy & Action Plan

Taking Action to Prevent Cardiovascular Disease

This is the second Cardiovascular Health plan for Champlain region. The Champlain 2013-16 Strategy and Action Plan is a roadmap for how our partners in primary care, public health, acute care, and community settings will work together to address cardiovascular disease. The plan provides five strategic directions to improve cardiovascular health of Champlain residents and build a a system of excellence in cardiovascular disease prevention that can serve as a model for the province of Ontario and Canada. This plan is driven to a commitment to quality and innovation and to delivering better services to Champlain residents. Most of all it is based on the understanding that collaboration and partnership will be key to our success.

Learn more about this strategy

Cardiovascular Disease

Cardiovascular disease (CVD) is the number one cost driver in Ontario’s health care budget.

$6.8 billion is spent annually in Ontario on the treatment of CVD.

CVD accounts for the largest proportion of health care spending in Ontario including:

  • 20% of acute care hospital costs
  • 15% of home care
  • 10.5% of emergency room visits
  • 10% of medical services
  • 17% of drug expenditures

The Champlain Region of Ontario
Three of Ontario’s hot spots for CVD are found in the Champlain region.

8 in 10 champlain residents live with one or more CVD risk factor:
631,000 residents are overweight or obese
512,000 residents are physically inactive
183,000 residents have high blood pressure
157,000 residents smoke daily
90,000 residents live with CVD
75,000 residents live with diabetes

Our Track Record

In 2007, the partners of the Champlain CVD Prevention Network (CCPN) launched a five year strategy to address CVD prevention and management. The 2007-12 Champlain CVD Prevention Strategy focused on the execution of six large-scale priority initiatives.


The Ottawa Model for Smoking Cessation in Hospitals

The Ottawa Model for Smoking Cessation (OMSC) is an evidence-based approach to treating tobacco use in clinical settings.

OMSC was introduced in all 19 hospitals in the Champlain region.

Since 2007, more than 20,000 Champlain residents who smoke have received support with quitting.


The Champlain Get with the Guidelines Program

The Champlain Get with the Guidelines (GWG) initiative is a hospital-based quality improvement initiative designed to ensure all patients admitted to hospitals with Acute Coronary Syndrome (ACS) and Heart Failure (HF) in the region are treated with best known practice guidelines as the standard of care.

16 Champlain hospitals have signed on as partners in GWG-ACS and GWG-HF.

80% of hospitals are reaching benchmarks for ACS patients.

The Champlain Primary Care Prevention and Management Guideline

The Champlain Primary Care CVD Prevention and Management Guideline was developed as a resource for primary care physicians and health professionals working in the region and contains the latest evidence in preventing and managing heart disease, stroke, diabetes and their associated risk factors. The Guideline is tailored to primary care physicians and includes links to relevant local community resources.

The Guideline has been distributed to more than 1,300 primary care and specialty care providers, with updated versions produced in 2008, 2010 and 2012.

Improved Delivery of Cardiovascular Care (IDOCC) in Primary Care

The Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation program was one of the largest primary care quality improvement projects in Canada.

83 primary care practices and 190 primary care physicians participated in the IDOCC Program.

Measureable improvements in rates of evidence-based CVD practices were documented.

The Champlain Community Heart Health Survey

The Champlain Community Heart Health Survey assessed cardiovascular risk factors among 1,443 adult residents. The survey included, for the first time, an assessment of physical health status of individuals and communities in the Champlain region. The survey involved measures to assess risk factors such as blood pressure, weight, cholesterol, blood sugar, and sodium intake.

The Atlas of Cardiovascular Health in the Champlain District was released in 2005, 2008 and 2011 to summarize the latest information on the burden of CVD and its associated risk factors.


Healthy School-Aged Children Initiative

The Champlain Declaration, a commitment to working together to ensure that Champlain school environments support healthy eating and physical activity on a daily basis, was signed by the Directors of Education from the nine school boards and the Medical Officers of Health from the four public health units in the Champlain region.

More than 1,300 school board administrators, principals, teachers, and parents from across the nine school boards have been reached with Healthy Schools 2020 tools and resources for improving school nutrition environments. Positive changes have been documented in the quality of foods offered in schools along with a decrease in the use of food for fundraising and rewards.

In partnership with the Société santé en français, the Écoles en santé 2020 facilitation program engaged 76 schools in creating local action plans to increase healthy eating and physical activity from the region’s three Francophone school boards.

The Champlain “Give Your Head a Shake” Sodium Reduction Campaign

The “Give Your Head a Shake” campaign was designed to empower Champlain residents aged 35 to 50 years to take action to reduce their daily sodium intake. The bilingual mass media campaign featured quick and easy tips to reduce sodium when buying foods, preparing meals, and eating out.

More than 8,800 campaign ads were seen and heard on TV, radio, print, web and over 100 news stories generated.

The campaign evaluation found Champlain residents exposed to the campaign are more likely to be taking action to reduce sodium.


The Ottawa Model for Smoking Cessation in Primary Care

Building on the hospital program, the Ottawa Model for Smoking Cessation was adapted and introduced in primary care settings across the region.

18 Family Health Teams/Groups have introduced the program into their clinical settings.

Since 2010, more than 10,000 Champlain residents have received support with quitting.

About this Plan

The 2013-16 Strategic builds on the success of the 2007-12 Champlain CVD Prevention Strategy and aims to develop further integration between our partners in public health, primary care, specialty care and acute care settings.

The Champlain Cardiovascular Disease Prevention Network (CCPN) is one of the first multi-sectoral partnerships of its kind in Canada, comprising partners from public health, specialty care, primary care, hospitals, education, community, industry and academia.

Building the Plan

The CCPN 2013-16 strategic planning process was a collaborative effort involving broad representation from Network partner organizations and regional leaders. More than 20 consultation meetings with stakeholders kicked off our strategic planning process and identified five short-listed priority areas.

For each priority area, an Expert Task Group was assembled to develop a detailed report of recommendations. All reports were presented to the Strategic Planning Leadership Committee for assessment and consideration for inclusion in the 2013-16 Strategy and Action Plan.

More than 110 leaders contributed their time, knowledge and expertise by participating as a member of the Strategic Planning Leadership Committee or one of the five Expert Task Groups.

Five Priority Programs

The 2013-16 Strategy builds on the assets and successes achieved in 2007-12 and aims to develop further integration between our partners in public health, schools, primary care, specialty care and acute care settings.

The 2013-16 Strategy and Action Plan will focus on five priorities:

  1. Primary Care CVD Prevention and Management Program
  2. Regional Integrated Heart Failure Program
  3. Regional Smoking Cessation Program
  4. Healthy Schools 2020 Program (Healthy Eating and Physical Activity in Schools)
  5. Healthy Foods in Champlain Hospitals Program

Our Roadmap


To develop an integrated system of excellence in cardiovascular disease prevention for the Champlain region that acts as a model for Ontario and Canada.


To enhance the capacity of stakeholders to work together to deliver integrated, innovative, high quality, evidence-based policies and programs that will improve the cardiovascular health of Champlain residents.

Overarching Aim

Better cardiovascular health, better cardiovascular outcomes, better quality, better value for money.



We will foster strong partnerships with all stakeholders and work together to achieve positive and lasting relationships that breakdown silos and support inter-sectoral solutions.

inveStment ACROSS the COntinUUm Of PReventiOn

We will ensure a balance of investment in upstream prevention and disease management to address the growing burden of CVD in our region.

evidenCe-infORmed innOvAtiOn

We will support the translation and delivery of evidence-based practices and promote innovation.

CAtALyzinG ACtiOn

We will support the delivery of new programs, policies, and services, which can improve the cardiovascular health of our residents.

QUALity And ACCOUntAbiLity

We will foster a culture of quality and accountability.

demOnStRAte vALUe

We will provide Ontario residents with better value for their tax dollars.

deLiveRinG On PROvinCiAL PRiORitieS

We will ensure alignment with Ontario’s Action Plan for Health and deliver solutions to build a stronger health system.


PRimARy CARe Cvd PReventiOn & mAnAGement PROGRAm

Support Champlain Family Health Teams, Community Health Centres and Health Links in improving the delivery of care for the primary, secondary and tertiary prevention of CVD through evidence-based practices and innovative models of collaborative care.

ReGiOnAL inteGRAted heARt fAiLURe PROGRAm

Facilitate a more efficient and coordinated system of heart failure care with the goal of improving quality of care, reducing emergency visits and avoidable admissions/re-admission, and ultimately improving patient outcomes while reducing costs in the health care system.


Ensure more Champlain residents make an aided quit attempt using evidence-based cessation services through a focus on health care, mental health and addiction services, and workplace partnerships.

heALthy SChOOLS 2020 PROGRAm

Expand and strengthen the Healthy Schools 2020 Program to ensure that Champlain schools are equipped with implementation supports to make continued improvements to their school nutrition environments, and to expand the Healthy Schools 2020 program to include physical activity.

heALthy fOOdS in hOSPitALS PROGRAm

Create supportive, healthy nutrition environments in Champlain hospitals so that the healthy choice is the easy choice for staff, visitors, and patients.

Delivering on Provincial and Regional Priorities

Ontario's Health Care Action Plan

In 2012, the Ministry of Health and Long-Term Care released its Health Care Action Plan. The Plan includes three major areas of investment:

Keeping Ontario Healthy

Focus on childhood obesity, tobacco use.

Faster Access to Stronger Family Health Care

Focus on quality and better transitions.

Right Care, Right Time, Right Place

High quality care, timely proactive care, and care close to home.

Health Links

Ontario is investing in better co-ordination of care for high-needs patients such as seniors and people with complex conditions. Health Links will bring together health care providers in a community to better and more quickly coordinate care for high-needs patients.

Health Quality Ontario Strategic Plans

Health Quality Ontario’s Strategic Plan 2012 has identified three key transformational objectives:

Forge partnership and advance integration

among distinct components of the public health and health care system.

Accelerate the use of evidence

to deliver demonstrable improvement in the quality of health services.

Drive a culture of quality, value and accountability

throughout the health care system.

Champlain Integrated Health Services Plan 2013-16

The Champlain Local Health Integration Network’s (LHIN) 2013-16 Integrated Health Services Plan identifies three strategic priorities for an integrated health system:

Build a Strong Foundation of Integrated Primary, Home and Community Care

Integrated health networks and hubs, early identification and management of risk, coordinated services, advanced access to services.

Improved Coordination and Transitions of Care

Integrated discharge planning, information sharing, intensive case management, clinical guidelines and pathways.

Increase Coordination and Integration of Services Among Hospitals

Regional programs, central intake, emergency room initiatives, quality-based procedures.

Public Health Ontario: Taking Action to Prevent Chronic Disease

Tobacco Use

Broaden and extend the integrated tobacco cessation system to include health care and community settings.

Physical Activity

Evaluate daily physical activity, support active transportation.

Unhealthy Eating

Support healthy eating in publicly- funded institutions, implement mandatory menu labeling in food service operations, create an Ontario food and nutrition strategy, include compulsory food skills in curricula.

Build a Capacity for Chronic Disease Prevention

Work Towards Healthy Equity

Ontario's Integrated Vascular Health Blueprint

Population Health and Promoting Healthy Public Policy

Tobacco use, unhealthy eating, physical inactivity.

Understanding and Supporting the Individual and Family Through the Vascular Healthy Journey

Ensure family and patient perspective initiatives incorporated into initiatives.

Improving the Quality and Access to a Continuum of Vascular Services

Tools for primary care providers, a shared care model for collaboration between specialists and primary care, communication tools.

Developing System Enablers and Efficient Use of Resources and Assets

Common standardized clinical guidelines, facilitate flow of information between sectors, proactively supporting primary care providers, providing self- management education, vascular health indicators, provincial targets for quality improvement.