1. Managing Transition to the Community
The goal of transition management is to facilitate and support seamless patient, family, and informal caregiver transitions across the continuum of care, and to achieve and maintain optimal adaptation, outcomes, and quality of life for the family system following a stroke. This incorporates physical, emotional, environmental, financial and social influences.
West GTA Stroke Network

2. Objectives: By the end of the presentation you will be familiar:
Some of the Canadian Best Practice Recommendations for Stroke Care: Transitions
List at least three community resources that you can refer your clients to
Please note that this brief presentation will highlight only certain portions of the Transitions chapter of the Canadian Best Practice Recommendations. To view the details of this chapter please consult the full Canadian Best Practice Recommendations publication which can be found on the Canadian Best Practice for Stroke Care Website.
In this presentation I will also speak to you briefly about a current initiative that is underway looking at developing the healthline resource to have a comprehensive list of community supports for the stroke client.
Near the end of the presentation, I will also highlight one specific resource in the MH and Central West geography that you as care coordinators should know about and refer your patients to.

3. What does the best practice say regards transitions?
All members of the healthcare team engaged with stroke patients and families are responsible for working together to ensure successful transitions and facilitate a successful return to the community following stroke.
This is a visual diagram developed in by Southwestern Ontario in collaboration with stroke survivors to identify the critical elements important for optimal community reintegration post stroke.

4. Key components of successful transitions include:
Collaborative goal setting between the healthcare team, patients and families
Ongoing education for patients, families and caregivers
Skills training appropriate to needs and goals of patients to facilitate safe transitions
Discharge planning that begins soon after stroke admission and includes all relevant support services, such as home assessments and access to ambulatory and community-based rehabilitation
Ongoing assessment of family and caregiver capacities to provide care for the patient with stroke, their individual support needs and potential burden of care
How many of you are aware that there are best practice recommendations that discuss transition of care? How many of you are familiar with these recommendations? These recommendations are not the responsibility of one member but rather the whole team…..they are the ideal state that the team should work towards.

5. Key components of successful transitions include:
Timely transfer of medical and recovery information between stages and settings of care
Appropriate medical support by primary care physicians and team members, as well as stroke team members and stroke prevention services
Stroke navigators or case managers in place to facilitate transitions of care and ensure continuity of care across settings, as well as appropriate access to needed resources and services; identification of and linkages to community resources
Ongoing surveillance of physical, psychological, social and emotional recovery, coping and adaptation following discharge
Post stroke fatigue and intimacy post stroke
How many of you are aware that there are best practice recommendations that discuss transition of care? How many of you are familiar with these recommendations? These recommendations are not the responsibility of one member but rather the whole team…..they are the ideal state that the team should work towards.

6. Where can I find the stroke best practices:

7. Best Practice Recommendation Patient & Family Education
Patient & family learning needs and goals should be assessed and documented throughout each stage of the continuum
Assessment should include previous information received, information retention, & ongoing learning needs
Based on information received, a formal education/referral plan should be developed
Education should be a combination of verbal, written, and hands on treatment with an emphasis on self management whenever possible
Upon referral to the community program the team members should flag any issues (level of coping, risk for depression, and
other physical and psychological issues, ongoing education needs) that arise and address them and or/refer to appropriate resources. The focus should be both on the patient as well as the family.
Educational content should be specific to the phase of care and readiness of the stroke survivor, family and informal caregiver

9. Best Practice Recommendation Patient & Family Education Resources
Patient Education Across the Continuum Quick Reference Guide content/uploads/2013/10/SBP-Transitions-Patient-Ed- Quick-Reference_4.pdf
Heart and Stroke Prevention Self Management Resources
Taking Action for Optimal Community and Long Term Stroke Care content/uploads/2016/01/ HSF_F15_TACLS_booklet_EN_Final_Linked.pdf
OTN Archived Webcast Learn to Access On-line Stroke Resources

10. Relationship/Sexuality and Fatigue Resources
Stroke Engine info/
Heart and Stroke Foundation: Your Stroke Journey content/uploads/2015/03/YOURSTROKEJOURNEY.FINAL_.EN GLISH..pdf
Fatigue
West GTA Stroke Network Fatigue Fact Sheet Page-FACT-sheet-Fatigue.pdf
Dr. Mark Bayley OTN Archived Webcast on Post Stroke Fatigue

11. Best Practice Recommendation
Discharge Planning
Make sure that the care plan is up to date and defines ongoing patient and family goals
The team revisits and updates the care plan
Discharge planning discussions are initiated as soon as possible

12. Discharge Planning Top Tips
Make sure that client/family knows what will happen after discharge
Use of a discharge planning checklist
Encourage a philosophy of continued activity and stimulation through participation in the community
Refer to community reintegration programs before the patient has left your program
Help the patient and family to problem solve around barriers to accessing these (i.e transport,/community mobility planning, language, toileting independence, fatigue)

13. Best Practice Recommendation Discharge Planning Resources
Discharge Planning Checklist Example (JANINE DO YOU HAVE ANYTHING FROM YOUR JOINT COMMITTEE THAT YOU CAN PRINT OUT AS AN EXAMPLE OR FROM THE PROVINCE?)
My Stroke Passport
Taking Care of Myself: A Guide for When I leave the Hospital
Heart and Stroke Foundation-Your Stroke Journey:
My stroke passport is a resource developed by the stroke foundation developed to compile a contact list for the client after discharge, a list of follow up appointments, an action plan that the client would like to focus on like doing more exercises, feeling more positive, lowering blood pressure, resuming driving. This resource also includes information/reminder the signs of a stroke and that stroke is a medical emergency. This resource also has a section to write down any concerns that the client may have to ask a health care professional involved in their care. Ie. Do you have your list of medications and understand what they are for and when to take them.
Heart and Stroke has many resources: Life after Stroke Handbook and Your Stroke Journey(118 pages) in English, French and Chinese pdf on line. Stroke emergency checklist, healty eating and quit smoking handouts, stroke risk assessment tool
-Taking care of Myself: A Guide for When I leave the Hospital. A guide that helps the client keep track of when to see the doctor and what to ask, take medicines, exercise, eat healthy foods and whom to call with questions.

14. Best Practice Recommendation
Community Reintegration and Community Navigation
Navigating the continuum of care following stroke is challenging for stroke survivors and their caregivers
Patients and families should be provided with information, support, and access to services throughout transitions to the community following a stroke to optimize the return to life roles and activities
Supporting Stroke Families Transitioning Across the Care Continuum

15. How to Find Resources in Your Community: WGTASN Community Resource Book
Bring Community Booklets

16. How to Find Resources in Your Community: CW Healthline Stroke Page
Bring Community Booklets

17. A SPOTLIGHT ON SOME COMMUNITY RESOURCES IN THE CENTRAL WEST
Now I would like to highlight for you one specific resource in the Central West geography that is available to stroke survivors.

18. March of Dimes: Peers Fostering Hope Program and Warm Line

19. Central West Stroke Specific Exercise Program
This program consists of strengthening and balance exercises to reduce your risk of falls and offers a variety of health and wellness topics related to your health
The Stroke Program is supervised by a qualified physiotherapist and delivered by a physiotherapy assistant. By registering for this program, you are taking positive steps to stay independent and healthy!  
For Central West Exercise and Falls Prevention Classes information, please call , ext

20. Halton-Peel Community Aphasia Programs
Supported Conversation Groups offer the opportunity to strengthen communication skills
Groups are not a replacement for individual speech therapy but a complement
The goal of the Aphasia Program is for group members to participate actively in conversation using a variety of communication strategies.
Speech-Language Pathologists, Social Workers, Communication Disorders Assistants and trained volunteers are involved with the Aphasia Programs to help make communication easier

21. Janine.Theben@thp.ca Maggie.Traetto@thp.ca
QUESTIONS?