Presented by: Shelley Huffman (on behalf of PIWP Group) Community and Outpatient Stroke Rehabilitation Provincial Integrated Work Group Presented by: Shelley Huffman (on behalf of PIWP Group)

Who we are…. Janine Theben, Rehabilitation Coordinator, West GTA Stroke Network (Co-Chair) Shelley Huffman, Rehabilitation Coordinator, Stroke Network of Southeastern Ontario (Co-Chair) Lyndsay Butler, Rehabilitation Coordinator, Southwestern Ontario Stroke Network Donna Cheung, Stroke Program Coordinator, Southeast Toronto Stroke Network Margo Collver, Community and Long Term Care Coordinator, Southwestern Ontario Stroke Network Esme French, Regional Stroke Rehabilitation Specialist, NWO Stroke Network Beth Linkewich, Director, Regional Stroke Centre and North and East GTA Stroke Network Darlene Venditti, Rehabilitation Stroke and Community Coordinator, Central South Regional Stroke Network Amy Maebrae-Waller, District Stroke Coordinator, Lakeridge Health, Central East Stroke Network Maggie Traetto, Community and Long Term Care Coordinator, West GTA Stroke Network Beth Donnelly, Rehabilitation and Community Long Term Care Coordinator, Champlain Stroke Network Gail Avinoam, Regional Stroke Education Coordinator, Toronto West Stroke Network Kathryn Yearwood, Clinical Specialist, Stroke Services, Corhealth Linda Kelloway, Senior Strategist Stroke, Corhealth

Where we started….

Priority Initiatives – Goals Collect, create and share tools and resources to assist in implementing and delivering QBP Phase II : Community /OP Rehab Support regions/organizations to be able to conduct needs analysis for outpatient and/or community based stroke rehabilitation services at regional level. Priority Initiatives – Goals

Interviews of Comprehensive Outpatient Rehabilitation Sites (10 sites) Program Elements Part A Implementation of QBP (facilitators and barriers) Part B Sustainability and Impact Part C Interviews of Comprehensive Outpatient Rehabilitation Sites (10 sites)

What we learned Referral sources (post acute and rehab) Eligibility criteria Length of Stay (patient specific, ranged between 4 – 12 weeks Commonalities: Assessment/screening tools used Processes for community reintegration Variation: What we learned

Challenges Lack of Communication/Coordination Lack of Resources Individual Patient Factors/Patient Complexity

Impact of co-location of referring sources and the OP Program Importance of a Dedicated Care Coordinator/Stroke Navigator Service Delivery Model Professional Development 1. Team Setup, Functioning and Composition Within Team Cross Continuum Technology 2. Communciation 3.Creative Use of Resources 4. Patient Centredness 5. Partnerships Facilitators

Examples: Grand River Hospital- Freeport Campus Neuro Rehab Clinic - fast track scheduling system for stroke entry to their clinic ( Care Dove) - allows clinicians from acute and rehab facilities to set up patients with their initial assessment prior to discharge Bridgepoint Active Healthcare - Sinai Health Systems created a Priority Setting Guide for patient to assist them in focusing on their top priorities allowing patient to optimize their therapy time. Also uses a follow-up visit 4 weeks post discharge to support community re-integration. Providence Healthcare initiated a partnership with Variety Village to create the Rehab to Community Transition program to support patients as they transition from formal rehabilitation to ongoing self-management and community-based exercises. St Joseph’s Care Group supports communication with external partners by participating in a bi-annual Stroke Transition meeting, a meeting which brings together acute, inpatient rehabilitation and outpatient/community rehabilitation providers.

Demands Analysis for Community Stroke Rehabilitation Reviewed work from around the province Principles in planning Key elements in planning Volume Predictor Service Team predictor – outpatient, in home, hybrid Demands Analysis for Community Stroke Rehabilitation

Program Delivery Assumptions 1. Therapy sessions 1 hour in length 2. 2.5 visits/week, 10 weeks (QBP 8- 12 weeks, 2-3 visits) 3. Modelling for PT, OT, SLP, SW, Care Coordination/Navigation 4. Allow for linkages and flow between programs 5. 100% will receive PT and OT 6. 50% will receive SLP 7. Direct therapy provision FTE (vs paid FTE) 8. Different level of Direct therapy provision for in home providers

Annual Patient Volume Predictor Example: Volume of 500 Acute Stroke = 260 patient who require CSR

Outpatient Service Team Predictor DRAFT

Decision Making Algorithm Considers key patient centred questions Started with RCA Community Referral tool

Questions? Full report available later Spring 2018! For further information: Janine Theben, janine.theben@thp.ca Shelley Huffman, shelley.huffman@kingstonhsc.ca