Champlain Regional Stroke Rehabilitation System

The Champlain Regional Stroke Rehabilitation System is designed by healthcare professionals working in stroke rehabilitation in the Champlain Local Health Integration Network (LHIN) with guidance from the Canadian Stroke Best Practice Recommendations for Rehabilitation (2015) and Quality-Based Procedures: Clinical Handbook for Stroke (December 2015).  The System was created to encourage healthcare providers in our region to deliver stroke care according to best practice. The Algorithm and the recommended processes built into it help acute care and rehab teams, with patients and families, determine the most appropriate sub-acute discharge destination for stroke survivors.  The Service Standards for Inpatient and Outpatient Rehabilitation programs are meant to guide the provision of stroke rehabilitation in our LHIN.

All of the Champlain Regional Stroke Rehabilitation System supporting documents were updated in June 2016 and can be downloaded near the bottom of this page.

 

Patient Flow Algorithm - Ensuring Stroke Patients Receive Approprate Sub-Acute Care Using the AlphaFIM®

The Patient Flow Algorithm is implemented in the acute care setting to ensure patients arrive at the most appropriate setting after their acute hospital stay.  One key component of the Algorithm is theAlphaFIM® instrument, which is used in Champlain and across Ontario as a major factor in deciding what level of sub-acute care is most appropriate for stroke patients.  

 

The AlphaFIM® is a standardized method of assessing burden of care in the acute care setting.  It is completed on or by day 3 after admission (target day 3, admission is day 1) and is used to project a full FIM score (the FIM, or Functional Independence Measure, is an assessment used in the rehabilitation setting).  By using the AlphaFIM® score and following the Algorithm, the acute care team ensures the patient follows the trajectory of care most appropriate for their individual needs.  

 

The decision to refer to one service (e.g. rehabilitation) over another (e.g. community support services) is not always straightforward to make.  The acute care and rehab teams must work with patients and families to determine the most appropriate care trajectory.  In addition to the AlphaFIM® assessment, the System has designed and recommended processes around the decision nodes (pink diamonds) in the Algorithm:

 

1. Significant Deficits - it is recommended that  all stroke patients who score >80 on the AlphaFIM® are referred to the Speech Language Pathologist and the Occupational Therapist so that the assessments needed to identify mild (non-obvious) deficits can be completed.  Supporting documents are: criteria indicating a referral to the Speech Language Pathologist and criteria indicating referral to the Occupational Therapist.  Patients who are assessed by SLP and/or OT and subsequently discharged home can be provided with these information sheets: Info about Communication and/or Info about Cognition and Perception.

2. Needs Met as Outpatient - every effort should be made to address barriers to the patient receiving outpatient rehabilitation (e.g. finding transportation services).  A complete recommendation guide is available to guide the decision to refer to outpatient or another sub-acute service.

 

 

 

PTFLOW2016 

 

 

Service Standards 

Service Standards are written for both Inpatient Rehabilitation with Stroke Expertise and Outpatient Rehabilitation with Stroke Expertise and should be used to guide the provision of stroke rehabilitation in the Champlain LHIN.  The Service Standards reflect Quality-Based Procedures: Clinical Handbook for Stroke (December 2015) and Canadian Stroke Best Practice Recommendations for Rehabilitation (2015) but are not meant as a replacement for either of the two documents.  Rehabilitation programs should be familiar with and follow the recommendations in both QBP and CSBPR.  The Service Standard documents offer recommendations from the CRSRS Working Groups for topics on which the CSBPR and QBP differ in their recommendations.

A checklist is available for both Inpatient and Outpatient Service Standards to facilitate review of the services delivered at the programs and can be used to identify opportunities for improvement.  By defining service standards for the two stroke rehabilitation services, we have advanced the mandate of providing equitable stroke care within our region.

 

 

RESOURCES - CLICK ON THE LINKS BELOW TO DOWNLOAD YOUR COPY

Patient Flow Algorithm (2016)

Identifying Deficits in Mild Stroke Patients (Significant Deficits): A process guide for acute stroke units

Referral Indicators for SLP

Referral Indicators for OT

Patient handout - Communication Deficits

Patient handout - Perceptual and/or Cognitive Deficits

Patient Care Needs Can be Met as Outpatient & Patient can Access Outpatient Services

Service Standards - Inpatient Stroke Rehabilitation

Checklist - Does your organization meet inpatient stroke rehabilitation service standards?

Service Standards - Outpatient Stroke Rehabilitation

Checklist - Does your organization meet outpatient stroke rehabilitation service standards?

 

 

Background - Creating the Champlain Regional Stroke Rehabilitation System

Development and Approval of the Champlain Regional Stroke Rehabilitation System Project Charter

A Champlain Regional Stroke Rehabilitation (CRSRS) Project Charter was written in 2012 with the purpose of advancing the goal of designing and establishing a comprehensive regional stroke rehabilitation system.  The goal for the regional stroke rehabilitation system was to rapidly triage patients with residual deficits to an objectively defined and publicly funded rehabilitation service according to the Canadian Best Practice Recommendations for Stroke Care.

The CRSRS Project Charter was signed by the Champlain Local Health Integration Network (LHIN) and CEOs of hospitals providing acute and sub-acute stroke care in our region and was approved by the CRSN Steering Committee and the Rehab Network of Champlain (RNOC) in 2013.  Work on CRSRS 2.0 was underway during 2013 and 2014; the results are outlined in the sections below.  Note that the CRSRS will be updated to reflect new Canadian Best Practice Recommendations for Stroke Care, the Quality-Based Procedures: Clinical Handbook for Stroke, and other resources, evidence, or recommendations as these documents are released.  The existing CRSRS 2.0 reflects the most recent information available up to the time of approval, that is June 2014.

Champlain Regional Stroke Rehabilitation System 2.0

In June 2014, the CRSN Steering Committee and the Rehab Network of Champlain (RNOC) approved the CRSRS 2.0.  

Under the direction of the CRSN-RNOC Stroke Rehabilitation Sub-Committee, two working groups were tasked with further defining the patient flow algorithm.  Specifically, the working groups were tasked with defining "significant cognigive, perceptual, communication deficit" (first decision node/diamond on the left of the patient flow algorithm),  "patient care needs can be met as outpatient and patient can access outpatient services" (second decision node/diamond), and developing service standards for Inpatient Rehabilitation with Stroke Expertise, and for Outpatient Rehabilitation with Stroke Expertise.  The resulting information can be found by clicking on hyperlinks in this paragraph.  These and other resources related to the CRSRS are also available for download at the bottom of this page.  

Bruyère Continuing Care and The Ottawa Hospital have agreed to pilot the CRSRS in the future.

 

Questions or comments?

Beth Donnelly, Champlain Regional Stroke Rehabilitation Coordinator:

bThis email address is being protected from spambots. You need JavaScript enabled to view it.

613-798-5555 extension 14430

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