Community Stroke Rehabilitation Program Presenter(s) Jeanne Bonnell Date 2018 March 21

Map of Champlain LHIN

Stormont, Dundas, Glengarry & Akwesasne

Creating the Community Stroke Rehab Program Strategic and Operational goal of Champlain Regional Stroke Network Collaborative effort over 12 months Reviewed: literature; similar programs in other Local Health Integration Networks (LHIN), provinces, countries; Quality Based Procedure recommendations Working Group and Patient Focus Groups informed service delivery model HSIP to LHIN with CCAC as lead service provider and numerous partners

Program Overview Key Elements Specialized community stroke rehabilitation service Offered both in-home and/or community clinic Interdisciplinary stroke rehab team Core team: OT, PT, SLP, SW, PTA/OTA Additional comprehensive training for stroke expertise Supported by Care Coordinator, Rapid Response Nurse, RD etc. Strong partnerships maintained with local hospital rehab teams (e.g. knowledge transfer, shadowing, facilitated transfer)

“Years ago it felt like we left the hospital and set adrift when more rehab is desperately wanted and needed.  The difference now is like night and day. I can’t believe how many positive comments I hear from stroke survivors about this program.” – Steve, Leader of the Alexandria & Area Stroke Survivors Group

Patient voice integrated pre and post implementation Input from local stroke survivors before implementation: 2 focus groups (French and English) Stroke survivor was a member of the working group Strong support for program. Emphasized importance of therapy in clinic to encourage people to get out of the house when possible.

Post implementation focus group of stroke rehab patients Great feedback re program and therapists Caring, flexible, knowledgeable and inclusive Great communication amongst team members Program delivers close to home, fills huge need in community Need for reduced duplication of assessments Need better communication/information sharing with hospital and Physicians

“As a family, we got to know what to do [at home and after the program ended]” – Spouse of Patient in Program “I believe that the therapists went above and beyond helping me to return to my normal life.” – Patient in the Program

Building Stroke Expertise Training of the stroke rehabilitation team was based on learning areas identified for stroke care. Review of Canadian Stroke Best Practice Recommendations Completion of on-line modules: brain anatomy and physiology, stroke prevention Shadowing experienced stroke rehabilitation therapists Training in Stroke specific assessments Supported Conversation workshop Training to support self-management Consultation and training with Champlain Regional Stroke Best Practice team Establishment of relationships for mentoring

Service Delivery At enrollment, patients are: Visited by the Rapid Response Nurse visit (48h) Evaluated by the Therapist Team Lead (1wk) Assessed by Interdisciplinary Stroke Rehab Team Therapy is provided over 8 – 12 weeks Setting therapy goals (individualized treatment plan) 1-2 visits per week/discipline At discharge: patients are linked with community support services where possible/appropriate (e.g. stroke exercise program, stroke survivors group)

Service Delivery Outcomes Outputs April 2016– Mar 2017 # of referrals 76 Median # of days to first visit (rapid response) 2 Median # of days to first therapy visit 5 % receiving services in home only % receiving services in clinic only % receiving services both in home and clinic visits 24% 13% 66% Average # (Median #) therapy visits per patient who completed program 31 (33) Proportion of patients who received each type of therapy   Occupational therapy 90% Physiotherapy 73% Speech and Language therapy 56% Social Work 25% Median Length of Stay 74 days

Patient Outcomes Preliminary outcomes measures showing overall improvement in all outcome measures including: Canadian Occupational Performance Measure (COPM), Stroke Aphasic Depression Questionnaire (SADQ) or Stroke Aphasic Depression Questionnaire (PHQ-9), and Reintegration to Normal Living Index (RNLI). Average Outcome Score Improvement: COPM: Performance 2.9 point improvement on 10 point scale Satisfaction 4.3 point improvement on 10 point scale SADQ & PHQ-9: average number of patients depressed pre 32%, and post 18% RNLI: 20% improvement 100 point scale

Patient Outcomes

Patient Outcomes

Patient Outcomes

Patient Outcomes

System Outcomes Expected Appropriate length of stay meeting QBP targets In acute care at Cornwall Community Hospital (CCH) In stroke rehab at Highland Glengarry Memorial Hospital Reduction in Alternate Level of Care days at CCH, others Appropriate sub-acute setting Reduced discharges to long term Care and complex continuing care Increase in number of patients to outpatient stroke rehab Increase of severe stroke survivors in inpatient stroke rehab

Relationships/Partnerships Built Shadowed Bruyère’s outpatient rehabilitation team Glengarry Memorial Hospital inpatient rehabilitation team Shared an SLP and a SW with Glengarry Memorial Hospital Regular contact and feedback loop with referring hospitals Established connections with Champlain Regional Stroke Network Best Practice Team Imbedded in and working with team at Centre de santé communautaire de l'Estrie – Cornwall Impactt Center at CCAC – assessing Jintronix system as Rehabilitation Tool within the clinic/home setting

Facilitating Team Communication Weekly rounds – Therapists divided into 2 teams for ease of communication and scheduling Internal LHIN therapy share common documentation and communication systems Support of team administrative assistant and rehabilitation assistant

“The Community Stroke Rehab Program has been indispensable in helping transition stroke survivors and their families post in-patient rehab back into community living. The collaborative work between the rehab teams, in hospital and CCAC, has been the key in developing an effective continuity and quality of care for our patients who have suffered a stroke” Chantal Mageau-Pinard, Stroke Rehabilitation Manager, Glengarry Memorial Hospital

Admission Criteria Diagnosis of recent stroke Discharged from hospital and residing within the Stormont, Dundas, Glengarry region and Akwesasne (Ontario) area Medically stable As a guideline, Patients admitted directly from acute care should have a discharge AlphaFIM® > 80. Ability to learn and retain information Endurance/tolerance of 30 – 60 min of therapy Able to attend therapy alone or a caregiver is available to attend therapy sessions if assistance is required

Lessons Learned When delivering rehab in community, must be flexible with scheduling Flexibility between home and clinic is ideal – almost every Patient had a mix of visits – Right Care in the Right Place at the Right Time Build in regular team education and planning sessions especially in the first year but needed ongoing Weekly rounds allow for informed team moving in same direction Social Work is a key player in the rehab process. When needed, involved longer than originally thought.

Continuing to Learn and Adapt Patients and families or caregivers enjoy the opportunity to connect with others “going through the same thing”. The CRSN and HCC are liaising with March of Dimes Canada and the local Stroke Survivors Support Groups to build their support group and ensure that patients and families or caregivers of the Program are linked to it Introduced group information/therapy sessions for patients and caregivers and have individuals come together in larger community room for joint sessions with other patients and Stroke survivors where appropriate. Group session titles: General information on Stroke; Driving; Emotions & Adjustment; Finances and Community Resources

Continuing to Learn and Adapt - 2 Are consider introducing a Stroke Navigator person/role into the CSR Program. An information package including Program information, the Post- Stroke Checklist, and other important information is now sent to physicians when patients are enrolled in the program. Improved the access to patient information from referring hospitals Creation of an information sheet for referred patients and provide to referring hospitals. Information will be posted online so it is easily accessible for patients and families or caregivers that are referred.

From Pilot to Regional Program Spread the community inter-disciplinary stroke rehab team model across the region Identify key hubs for the stroke team teams Build stroke expertise within stroke rehab team Continue to engage and involve Stroke Survivors across the region Establish stroke community clinic sites Engage community partners Assess local services, patient proximity and patient population

Renfrew County Community Stroke Program Renfrew County Community Stroke Program begins March 26th Clinic based out of Pembroke Regional Hospital Will work side by side hospital outpatient team, with hospital stroke rehab team one floor up Goal to become one big seamless team with pre-discharge check-ins and coordinated discharge home assessments as needed Shared team learning events

Growing Other regional partners are now stepping up to the plate. All partners allowed stroke clinic on site at no extra cost. Team works around existing schedules Next phase will be Prescott Russell then the Ottawa area to coincide with regional sub-acute review plan once approved.

Thank you! For more information Jeanne Bonnell Director of Home and Community Care, Champlain LHIN Jeanne.Bonnell@lhins.on.ca