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

2. Map of Champlain LHIN

3. Stormont, Dundas, Glengarry & Akwesasne

4. 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

5. 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)

6. “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

7. 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.

8. 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

9. “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

10. 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

11. 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)

12. 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

13. 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

14. Patient Outcomes

15. Patient Outcomes

16. Patient Outcomes

17. Patient Outcomes

18. 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

19. 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

20. 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

21. “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

22. 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

23. 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.

24. 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

25. 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.

26. 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

27. 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

28. 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.

29. Thank you! For more information
Jeanne Bonnell
Director of Home and Community Care, Champlain LHIN