Community & Long Term Care

Community Reintegration Leadership Team (CRLT)

The Community Reintegration Leadership Team (CRLT) is a community advisory committee for the Stroke Network of Southeastern Ontario and includes persons with stroke, family members and community service providers.  The CRLT began following a community consultation in 2007 and has a goal of supporting initiatives and actions that would help with community reintegration following a stroke.  A promise was made to the stroke survivors and families who participated in the initial 2007 consultation that the SNSEO would continue to provide updates on the activities of the CRLT.  As a consequence, the CRLT releases Biennial Reports summarizing changes during each reporting period.

For further information,  please contact Sandra Liu, Regional Community & Long Term Care Coordinator with the Stroke Network of Southeastern Ontario at 613-549-6666 X 6867 or by email at

*NEW* Smart Tips for Stroke Care- a healthcare provider's guide

"Smart Tips for Stroke Care- a healthcare provider's guide to caring for persons with stroke" is a new resource that highlights common changes due to stroke and strategies for managing these changes. The resource is designed for Personal Support Workers (PSW) working in Long Term Care in Ontario, however anyone interested in stroke care can benefit from using this resource, including PSWs in the community, family members, etc.

The guide covers 15 stroke care topics, each a single page (double-sided) and includes custom illustrations to support the information. The guides are designed to be a quick way to get the information you need. Each Smart Tips topic may be used individually or as part of a series. The Smart Tips can be downloaded and printed for free as a full document or individually according to staff and organizational needs.

Click here to access Smart Tips for Stroke Care!

The Brain, The Body and You Workshop Series

This 4-module interprofessional, continuing education workshop series is designed for regulated and unregulated frontline care providers caring for stroke survivors and other complex client populations in the community, long-term care and other care settings. This continuing education program can be easily individualized by selecting the particular module(s) needed to meet the identified learning needs. The 4 module topics include:

Stroke Care - Prevention to Life after A Stroke (Updated May 2021)

Mobility, Transfers and Positioning (Updated May 2021)

Speech, Communication and Swallowing (Updated May 2021)

Cognition, Perception, behavior and mood (Updated May 2021)


You may use this education program or its materials within any existing educational settings or the workplace. 

Tips & Tools for Everyday Living: A Guide for Stroke Caregivers: Putting It Into Practice: Video Series

Six education videos have been developed by stroke care champions in Southeastern Ontario. These videos are designed to complement popular sections of the Tips and Tools for Everyday Living: A Guide for Stroke Caregivers (2010) and education programs currently underway across Ontario and Canada. Five of these videos are designed for front line staff and one has been developed for family and community education.

Front Line Healthcare Staff Education Video Series:

Recognize & React to the Signs & Symptoms of Stroke for Health Care Providers


Meal Assistance & Hydration

Cognitive, Perceptual & Behavioural Problems


Family & Community Education:

Recognize & React to the Signs and Symptoms of Stroke

Best Practice Stroke Care Plans for Long Term Care Homes

Provincial Release of Updated Best Practice Stroke Care Plans for Long Term Care Homes (LTC)

In long-term care (LTC), 21.3% of residents have had a stroke1 and stroke is the third most common diagnosis in LTC residents.2 In fact, stroke is believed to be one of the leading causes of transfer of elderly individuals to LTC facilities.3 More than 10% of patients who have experienced a stroke require long term care and twenty percent of stroke survivors who are identified as having moderate or severe impairments following stroke are discharged to a LTC Home or to Complex Continuing Care.4,5

In 2015, the Heart & Stroke Foundation released the best practice resource, Taking Action for Optimal Community & Long Term Stoke Care©. In response to this release, a working group of Long Term Care (LTC) Home representatives and members of the Ontario Stroke Network reviewed the best practice Stroke Care Plans (initially released in 2012) to ensure continued alignment with this best practice document and current LTC practices and regulations. The LTC Stroke Care Plans were updated again in March 2020 and are intended to enable all Ontario LTC Homes to incorporate best practice stroke care into resident care planning.  Twelve LTC Stroke Care Plans have been developed:

  • Activities of Daily Living
  • Behaviour Change
  • Bladder and Bowel Continence
  • Cognition
  • Communication
  • Depression
  • Leisure
  • Mobility, Positioning & Transfers
  • Nutrition, Hydration & Swallowing
  • Pain
  • Perception
  • Skin Care & Hygiene

The Stroke Care Plans can be accessed through the CorHealth website. This will also link you to additional documents (i.e. Background, FAQs, Implementation Tips, Stroke Best Practice Care Plans for LTC slide deck) to support implementation of the Stroke Care Plans. Sandra Liu, the Regional Stroke Community & LTC Care Coordinator for the Stroke Network of Southeastern Ontario is available to support implementation, to answer any questions you may have and to assist with educational needs. Sandra can be contacted at or by phone at (613) 549-6666 X 6867.  

1Continuing Care Reporting System, CIHI, 2014-15
2PriceWaterhouseCooper, 2001
3Statistics Canada, 2010
4Stroke Evaluation Report, 2012, Ontario Stroke Network and the Institute for Clinical Evaluation Sciences
5Heart and Stroke Foundation of Ontario, 2011

Southeast Healthline

This database provides links to resources for stroke survivors, caregivers, and healthcare providers.

Taking Action for Optimal Community and Long-Term Stroke Care (TACLS)

This resource replaces the Tips and Tools for Everyday Living Manual. It is closely linked with the HSF Canadian Stroke Best Practice Recommendations and is an evidence-based resource that provides guidance around how to provide safe care for people who have had a stroke and are living in community and long-term care settings. Developed primarily for healthcare workers such as personal support workers, health care aides, home care attendants, and rehabilitation assistants, it can also be used by organizations engaged in education or orientation for these healthcare providers, and any other healthcare professionals who work with people who have had a stroke and their families.

Click here to link to the TACLS section of the Stroke Best Practices website

Educational Posters

These educational posters are available 'on loan' at no cost in Southeastern Ontario for display at your location in Long Term Care. They are available in both wall mount and table top display formats (table top panels can be provided) as well in a handout format. The posters have been developed for the education of frontline care providers and are formatted to provide critical learning points in a highly visual way.

The poster topics include:

To access posters for display in Southeastern Ontario, please contact Sandra Liu Regional Stroke Community & LTC Coordinator (Stroke Network of SEO) at 613-549-6666 x6867 or by email Please advise Sandra of the length of time you would like the display poster and arrangements can be made to retrieve the poster.

Community Stroke Rehabilitation Program

Eligible stroke survivors will be considered for enhanced Physiotherapy (PT), Occupational Therapy (OT), Social Work (SW) and Speech Language Pathology (SLP) services through Home and Community Care following discharge home. Note that for stroke survivors discharged to Long Term Care (LTC), PT will be provided by the LTC Home with enhanced OT, SLP and SW being provided through Home and Community Care.

Community and Long Term Care Resource Listing

This resource listing provides supports and services which may be of interest to persons who have experienced a stroke, their caregivers, and their health care providers. The listing includes embedded links where available. There are two separate documents: One for healthcare providers and one for clients and their families. 

Canadian Stroke Community-based Exercise Recommendations

The Canadian Stroke Community-based Exercise Recommendations have been recently updated and include current evidence for exercise providers to plan and implement their programs. The Canadian Stroke Community-based Exercise Recommendations Update 2020: A Resource for Community-based Exercise Providers(link is external), is an evidence-based resource designed to help safely incorporate exercise programs in the community for individuals who have experienced a stroke. 

The Canadian Stroke Community-based Exercise Guidelines are available under Guidelines & Recommendations

Best Practice (BP) Bloggers

BP (Best Practice) Bloggers are myth busting newsletters that provide evidence-based information on various care issues, including stroke care, to the long-term care sector. The Stroke BP Bloggers were created in collaboration with Mary-Lou van der Horst (Director, Schlegel Centre for Learning, Research and Innovation in LTC) and originator of the BP Bloggers.

Blood Pressure Tool Kit

This toolkit is designed to assist Personal Support Workers (PSW) and other health care team members to acquire the practical knowledge and skills to support blood pressure management and to build the capacity to work collaboratively with the health care team and resident/client to optimize blood pressure management. This program is meant to be individualized depending on the needs of the learner and in accordance with the employer/client’s guidelines. The Learning Plan is divided into two modules each of which can be used independently of the other (Module #1: The Basics of Blood Pressure & Supporting the Patient and Module #2: How to Take Blood Pressure). The toolkit may be used by educators or as self-learning modules.

The Tool Kit includes:

  1. Learning Plan
  2. Module 1 "The Basics of Blood Pressure and Supporting the Patient" provides a theoretical overview of blood pressure including hyper- and hypotension, risks for hypertension, impacts of hypertension and role of the care provider.
  3. Case Studies (Module 1) – Three case studies have been developed to support learning. Each case study has a participant and a facilitator version. The case study questions are designed to demonstrate achievement of the evaluation criteria.
  4. Module 2 "How To Take Blood Pressure" provides a practical, visual learning tool to introduce care providers to blood pressure measurement.
  5. Resources – This provides a comprehensive resource listing.
  6. Evaluation Surveys

Registered Nurses Association of Ontario (RNAO)

RNAO resources include best practice recommendations for transitions, stroke care, self-management, smoking cessation, client-centred care, oral health and continence.

Oral Health Videos for Long Term Care

Members of the SHRTN Oral Health Community of Practice have produced 13 education webinar-based videos on various oral health topics for long-term care.