1. Fast Track Stroke Outpatient Program
Megan Wormald & Jean Liu

2. Outline Outline Rationale Program Description & Eligibility Criteria
Services Offered and Goals Addressed
Transitions of Care
Case Studies
Statistics and Patient Satisfaction Survey Results
Cost Effectiveness Analysis
Successes
Telepractice
Lessons Learned
Megan

3. Stroke Network & Stroke Best Practice Rationale
Stroke Network led an initiative across the Toronto Central and GTA LHINs to enhance efficiency and access to stroke rehabilitation
The GTA Rehab and Stroke Network recommended enhanced outpatient rehabilitation to accommodate more people with mild strokes – freeing up inpatient capacity for moderate and severe strokes
Early access to high intensity outpatient rehab

4. Fast Track Program: Initial Goals
Facilitate timely outpatient access while supporting reduced Length of Stay (LOS)
Improve transitions and continuity of care
Transition TWH patients with mild stroke to TRI Fast Track Program
Start therapy within 5 days of referral
Provide access to High Intensity Outpatient Stroke Rehab

5. What is the Fast Track Program?
High Intensity Short Duration Stroke Outpatient Program
Flexible with intensity of therapy
Ranges from 1 to 5 times a week
Maximum period of up to 4-5 weeks
Timely access to outpatient therapy
within 5 days
Interprofessional approach to patient care

6. Program Eligibility Criteria
Over 18 years of age
Recent confirmed diagnosis of ischemic or hemorrhagic stroke
Must be medically stable
Alpha FIM on referral shows a projected motor and cognitive total score of 80 or above (for external referrals – TWH & TGH)
Acute care can safely discharge client home, with appropriate referrals completed/initiated
Be medically and physically and mentally stable in order to attend regularly and actively participate in therapy
Has clearly identified rehab goals
The client requires one or more services (PT, OT, SLP, SW)
The client is able to secure reliable transportation
The client is able to independently toilet self, or have a caregiver who can attend with client to assist with toileting while at Toronto Rehab

7. Fast Track Team Members
Physiatrist
Dr. Denyse Richardson, Dr. Alex Lo, Dr. Emily Tam
Physiotherapists
Kathy Mileski (0.5 FTE)
Jean Liu (0.6 FTE)
Occupational Therapist
Geoff Law (1.0 FTE)
Speech Language Pathologist
Joanna Wong (1.0 FTE)
Social Worker
Alice Lee (0.2 FTE)

8. Services Offered Access to:
Neuropsychiatry
Neuropsychometry testing
Community Resource Worker
Chaplain
ABI/Stroke Education Group
Fitness Group
Circuit Group
PROPEL Group
Mindfulness Group
Pool therapy
Perturbation training
Cardiopulmonary Exercise Test (CPET) clinic
Peers Fostering Hope Program
Videofluroscopy
Started offering Telepractice for SLP and SW services

9. Typical Goals Addressed
Return to driving
Return to work
Improve mobility & ADLs
Community Reintegration
Improve communication and swallowing
Manage mood
Connect with community services (financial, transportation, housing)

10. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

11. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

12. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

13. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

14. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Referred via E-Stroke
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

15. Upon discharge from Fast Track…

16. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

17. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

18. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

19. Case Study #1 Case Study #1 75 year old male
Referred from acute care with right ischemic stroke
Alpha FIM 106
Streamed directly to Fast Track
Started within 5 days of inpatient discharge
Required OT & PT services
Discharged to Stroke Day Hospital (DH)
Started DH within 9 days

20. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

21. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

22. Case Study #2 Case Study #2 48 year old female
Referred from acute care with left ischemic stroke
Alpha FIM 110
Streamed directly to Fast Track
Started within 2 days of acute care discharge
Required OT, PT, SW & SLP services
Referred to neuropsychometry, Cardiac Rehab & Community Programs

23. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

24. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Stroke Day Hospital
(University Centre)
4-8 weeks
Neuropsychometry
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Cardiac Rehab
(Royal Victoria Hospital)
12 Weeks ?
Fast Track Program
4 weeks
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(Pilates)
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

25. Case Study #3 Case Study #3 38 year old female
Referred from acute care with bilateral ischemic strokes
Alpha FIM 67; Admit FIM 44
LOS 42 days; 6 days saved from target LOS
Discharge FIM 119
Streamed to Fast Track
Started within 4 days of inpatient discharge
Required OT, PT, SLP, SW, Fitness group
Referred to Stroke Day Hospital
Delayed start due to client’s travel plans(2 months)
Referred to Cardiac Rehab post Stroke Day Hospital

26. Transitions of Care/Patient Flow
Stroke Day Hospital
(University Centre)
4-8 weeks
Stroke Day Hospital
(University Centre)
4-8 weeks
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Internal Referral (Inpatient Rehab Unit)
early discharge OR support complex discharge by target date
Cardiac Rehab
(Rumsey Center/TWH)
6 months
Cardiac Rehab
(Rumsey Center/TWH)
6 months
2 month break
Fast Track Program
4 weeks
Fast Track Program
4 weeks
External Referral
(UHN acute care)
TGH and TWH
Community Programs
(TIME Program, YMCA, Aphasia Institute, etc.)
Stroke Outpatient
(Rumsey Centre)
4-8 weeks

27. Fast Track Population Fast Track Statistics 55% are under age 65
79% have had an ischemic stroke
Year 2017
Median wait time is 4 business days
Number of inpatient days saved = 237 days
Total of 123 referrals received
Acute UHN referrals = 81
Internal TRI referrals = 42

28. Referrals for 2017

29. Services Required
% of Patients
Service Required
Jan Dec 2017

30. Patients Requiring Further Outpatient Therapy
% of Patients
Jan Dec 2017

31. Continuity of Care
In 2017, 50% of patients required further outpatient therapy
Referrals to Stroke Day Hospital, Rumsey Centre or other facilities are completed before discharge to provide seamless transitions
Community-based programs such as Cardiac Rehab, TIME Program, Variety Village, Aphasia Institute & other day programs referrals are made as needed
1 SW overlap between Fast Track and inpatient, and previously 1 PT & SLP (now PT only) overlapped between Fast Track and Stroke Day Hospital which helps with transitioning
Since inpatients, Fast Track and Stroke Day Hospital clients are all seen on the same floor, this helps with transitions across programs

32. Patient Satisfaction Survey Results

33. What our patients are saying…
“I had an excellent team who cared about my needs, recovery and well being. It paid off, I reached most of my goals and am on my way to meeting all of them. Thank you.”
“I was able to start immediately after discharge from inpatient treatment. I didn’t have to wait”
“It is truly appreciated how quickly therapy was arranged. I was impressed at how quickly I was discharged from inpatient and admitted into Fast Track. Staff and therapists were all phenomenal. Transitioning from one therapist to another was seamless!”

34. Fast Track Cost-Effectiveness Analysis
Economic evaluation of the FT program was completed by physiatrist, Dr. Alan Tam in 2017
Conclusions:
TRI able to move patients through inpatient rehab faster, thus, increasing inpatient capacity without increasing the number of physical beds
Likely a cost-effective method of delivering High Intensity Rehab (HIR) after acute stroke
FT can be implemented to support early discharge and drive down LOS in inpatient settings
FT does require resources; health care savings are found in the decrease in the # of ALC days in acute care

35. Fast Track Cost-Effectiveness Analysis
Successes
Able to provide high intensity rehab (average 3-4 times a week)
Able to decrease number of admissions to inpatient, Stroke Day Hospital and Rumsey Stroke Outpatient
Able to save inpatient LOS (237 days)
Earlier supported transitioning for those at high risks (eg. high falls risk, swallowing)

36. SLP Telepractice Telepractice
Purpose: to maintain timely access to outpatient services for those who are unable to access rehab services closer to home
Started with SLP services. SW added
Use Ontario Telemedicine Network (OTN) – a video conference platform
Patient requires a computer/laptop/tablet, internet access, and a webcam and microphone and speakers
Adapted assessment and therapy to work on screen
What’s next:
Add OT services
Develop information and step by step training sheet

37. Lessons Learned Lessons Learned
Changed our admission criteria to allow single service due to need
Flexibility with provision of care to suit our client needs (telepractice)
Not everyone benefits from early access to high intensity rehab
Location in the same office for collaboration and communication is essential
Establishing relationships with referral sources is crucial

38. Thank you!