Meet Maria Maria is 67 years old, and is a caregiver for her husband Raul who has had a moderate stroke.  She has health issues of her own including chronic obstructive pulmonary disease, congestive heart failure and osteoarthritis. She has difficulty walking long distances  and uses a walker to get around.   Maria recently had a flare-up of her condition and was hospitalized for five days. She was able to leave before Raul was scheduled to leave Bridgepoint. Raul had been the one that managed many things around the house including shopping, cleaning and cooking.  They don’t have any children and have a few friends that are neighbours in their apartment building but no formal support network. Maria is worried about whether she can care for Raul after he leaves the hospital and how they will both manage at home.  Maria and Raul live in an apartment in central Toronto and Maria had been driving to visit Raul every day. Maria is on disability because of her health conditions and Raul had been working for the TTC but has recently retired. Maria is worried about how they will manage financially and whether they will be able to afford any extra services they may need. Before Arrival: Maria is relieved that Raul’s needs will be cared for. She is anxious about how Raul will progress and is still dealing with the trauma of Raul’s stroke. Arrival to Rehab: Maria is happy that Raul is at Bridgepoint. She likes the space and finds the team friendly and welcoming. Maria has felt supported by the care providers and has been included in care planning, but sometimes has difficulty understanding some of the information given to her. Maria is worried because the team started talking about Raul leaving the hospital as soon as they arrived. She is worried that Raul will go home too soon and she will be unable to take care of him. Care in Rehab: Maria had a flare up of her COPD and has been hospitalized for 5 days. She is worried about her health and how her husband is coping without her visiting daily. She worries he is lonely and not engaging in as much therapy when she isn’t there to encourage him. She is worried about her own health and how she will recover and whether she will be able to go home before Raul is scheduled to leave Bridgepoint. Transitioning: Maria was able to leave hospital a week before Raul was scheduled to leave, but still hadn’t fully recovered, needing to go home on oxygen. She has been able to visit some days, but some days she is not feeling well enough. Maria is concerned that Raul will be leaving Bridgepoint too soon and is worried about how she will care for him at home. She is worried about the coordination of different home care services and that they won’t be able to receive enough services to care for them both. What if she needs to go to the hospital again? She feels she will need to pay for extra support, but is unsure how they will afford this on her disability income and Raul’s pension. Continuing the Journey Home: Maria has been frustrated around home care services after Raul left Bridgepoint. One of the care agencies did not come and she wasn’t sure who to connect with. She did not know who to call at Bridgepoint to help guide her. Maria is still overwhelmed by everything that has happened. Maria has doctor’s appointments of her own. She isn’t sure how to do it all. She feels isolated since Raul was the one that would help get her out of the house. She doesn’t know who to reach out to and is struggling to cope with her health issues, Raul’s needs and worries about their future.