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 to Support Client Education

Stroke Information Package for Patients and Families- listing of included resources

Patient Journey Map

Stroke Support Groups

Stroke Specific Exercise Programs

Aphasia Supportive Conversation Groups & Programs

Community Stroke Rehab Program – Client Brochure

Return to Work Toolkit- detailed info located under "Community Supports"

Driving After Stroke

Your Stroke Journey Check-In

Your Stroke Journey- links to the Heart and Stroke Foundation website

Support for Caregivers of Persons Living with the Effects of Stroke

Home and Community Care Support Services South East

Southeast Healthline


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