Community & Long Term Care

Purpose

The Champlain Regional Stroke Network's Community and Long-Term Care portfolio supports health service providers within the Champlain region to achieve better outcomes for stroke survivors and their care partners by helping them to align their services with the Canadian Best Practice Recommendations for Stroke Care. The Champlain Regional Stroke Network's goal is to ensure that all stroke survivors and their care partners are systematically connected with integrated community based services that allow them to return home to their loved ones and personally valued activities.

Context

The Ontario Ministry of Health and Long-Term Care's Patients First: Action Plan for Health Care is a commitment to put people and patients at the centre of the health care system. In support of the action plan, Health Quality Ontario has created the Quality-Based Procedures: Clinical Handbook for Stroke that includes guidance to support recovery in the community. We have work to do in Champlain to make the best recovery possible available to all Champlain stroke survivors and their care partners.

Current projects

Stormont, Dundas & Glengarry Community Stroke Rehabilitation

Stroke survivors and care partners have told us that it is very difficult to arrive home after having a stroke and spending time in the hospital and/or inpatient rehabilitation. Hospitals and rehabilitation providers have told us that they have longer inpatient stays because there are limited outpatient rehabilitation services for patients upon discharge.  The Champlain LHIN has provided new funding for a Community Stroke Rehabilitation (CSR) service for the Stormont, Dundas, Glengarry, and Akwesasne area. If this project is successful, it will hopefully be expanded to cover the entire Champlain region.  The CSR service will see the client within 72 hours of their discharge from the hospital or rehab and will provide up to 8 weeks of therapy.  The client will receive occupational therapy (OT), physical therapy (PT). communication therapy (SLP), nursing and social work as needed.  For those clients who are well enough and can obtain transportation, therapy will be provided at clinic sites in Cornwall (Centre de santé communautaire de l'Estrie) or Alexandria (Hôpital Glengarry Memorial Hospital). If the client is too far away, not strong enough or cannot get transportation, the team will provide therapy at their home. The focus for everyone will be on locating resources and making plans to continue community reintegration after the end of the CSR program. The service is scheduled to begin in January, 2016.

Systematic Referrals to Community Services

Almost one third of the patients hospitalized for stroke in our region are sent home without inpatient or outpatient rehabilitation services. While their stroke may be considered mild in the hospital, it can still result in significant changes or concerns for the patient and their care partners. Appropriate exercise is often recommended as one of the best preventative measures we can take to reduce our risk of having a stroke (or another stroke).  We are starting a pilot project at the Queensway Carleton Hospital to provide improved support for these stroke survivors.  Staff at the hospital will ask patients if they consent to receive phone calls after returning home.  Physicians will complete an exercise prescription if appropriate. The hospital will use the CCAC’s Health Partner Gateway computer system, to send the patient’s contact information to the Stroke Survivor Association of Ottawa or to Heartwise Exercise offered by the City of Ottawa.  Staff from these programs will reach out to the patient by phone, offer more information and invite them to participate in their programs. 

Specialized Stroke Care in Long Term Care

About one quarter of the residents in Ontario's long-term care homes are stroke survivors. Obtaining the most appropriate care and assistance will help these residents have the best possible quality of life. New Orchard Lodge (NOL) is an Extendicare long term care (LTC) residence and home to 111 women. The CRSN team delivered a full day of training to more than 80% of the personal support workers at NOL using the Tips & Tools for Stroke Caregivers curriculum developed by the Heart and Stroke Foundation. NOL identified a stroke team champion for each floor. The champions provide mentorship to the team each day and perform weekly tracking that used to update the resident care plan. Fifteen residents have received specialized stroke care and outcomes have been tracked for 3 – 9 months. The depression rating scale (DRS) is a standard part of LTC assessment. The DRS score improved for 9 of the 15 residents during the tracking period and the average DRS score declined from 2.9 to 2.3. The case mix index (CMI) is an overall measure of the resident’s care needs.  CMI declined for 7 residents, was stable in 5 cases and increased in 3 cases. Improvements were observed in mobility, transfers, fall prevention and meal assistance. Tips & Tools training followed by sustained implementation of specialized stroke care improves the quality of life for stroke survivors residing in LTC facilities. The trends indicating less depression and enhanced ability to complete activities of daily living should be explored with more research on the methods and outcomes of specialized stroke care in LTC homes. The Champlain Regional Stroke Network is investigating strategies to expand this model to additional LTC homes in Champlain.

Client and Family Engagement

We know health care systems work better when they listen to the clients and families that are served in the system. This is a central focus for health care in Ontario as described in the Patients First Action Plan for Healthcare. We are committed to increasing client and family participation in CRSN projects. This is a deliverable in the Champlain LHIN 2015-16 Community Engagement Plan. Please contact us if you would like to get involved in the continuous improvement of stroke services in the Champlain region.

Contact

Please get in touch and let us know what you would like to see improved for stroke survivors and their care partners living in the Champlain region:

Beth Donnelly, CRSN Coordinator for Rehabilitation, Community, and Long-Term Care                                    

Champlain Regional Stroke Network / Réseau régional des AVC Champlain
The Ottawa Hospital – Civic Campus  1053 Carling Avenue, Ottawa, ON K1Y 4E9
tel:     613-798-5555 ext. 14430   email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Contact us

Champlain Regional Stroke Network The Ottawa Hospital - Civic Campus Civic Parkdale Clinic, Main North 1053 Carling Avenue Ottawa, ON K1Y 4E9

Phone: 613-798-5555 x 16153
SPC Phone: 613-798-5555 x 16156