Navigation & Transitions

Patient Journey Map

Connecting stroke survivors and families to relevant social supports and services is critical to ensuring a successful transition home and continuing community reintegration.  Navigating this complex web of services can be challenging and many health care providers (HCP) may be involved in a navigation role at any point in the stroke survivor’s recovery journey.  Working in collaboration with partners from across the continuum the Stroke Network of Southeastern Ontario has developed this navigation page to help HCP access local, regional and provincial resources to help in communicating with clients and families and connecting to resources.

Additional resources can be found under the Community Supports tab

Navigation Tools- Facility-Specific Provider Supports and Resources

For more information about the following resources, please email Shelley Huffman at 

  • Patient Oriented Discharge (POD)- KHSC
  • Patient Care Order Set (KHSC)
  • Acute Stroke Best Practices Reminder Checklist (KHSC)
  • Brockville General Hospital (BrGH) Post-Stroke Patient Safety Checklist
  • KHSC Post Discharge Screening Questionnaire
  • Therapy Specific Hospital to Community Forms