1. 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)

2. 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

3. Where we started….

4. 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

5. 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)

6. 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

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

8. 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

9. 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.

10. 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

12. Program Delivery Assumptions
1. Therapy sessions 1 hour in length
visits/week, 10 weeks (QBP 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

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

14. Outpatient Service Team Predictor
DRAFT

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

16. Questions? Full report available later Spring 2018!
For further information: Janine Theben,
Shelley Huffman,