Community Stroke Rehabilitation Program: Service Changes to meet Client Needs

Since February 2009 the South East LHIN Home and Community Care (formerly SE CCAC) has provided timely, home-based rehabilitation services for those discharged from hospital with new stroke. Since its inception, the program has continued to evolve in response to feedback from clients, caregivers and health care providers as well as evaluative data.  This year, several changes have been implemented:

  • Change to the name of the program from Enhanced Community-Based Rehabilitation Services for Stroke Survivors to Community Stroke Rehabilitation Program (CSRP)
  • Change to name of transitional meeting between client/caregiver, inpatient Occupational Therapist and community Occupational Therapist from Discharge Link meeting to Community Rehab Planning meeting
  • Extension of program duration from 8 weeks for OT, PT and SLP to 12 weeks.  SW services will continue to be offered for up to 12 weeks.
  • Change to format of Community Rehab Planning meeting allowing therapists working in rural and remote locations to meet with the inpatient OT by phone. In some cases an alternate therapist lead for this meeting may be approved by the Care Coordinator.
  • A pilot evaluating the benefits of integrating Rapid Response Nurse (RRN) visits is underway for those discharged home from acute care in Kingston and Belleville.  Expansion of the pilot to Brockville is expected this fall. 

Five information sessions were held across the South East in early 2018 to provide a refresh on the CSRP including recent changes.  Sessions were delivered jointly by Home and Community Care and the Stroke Network teams. Over 100 health care providers participated from hospital and community settings including Care Coordinators, Rapid Response Nurses and Community Rehabilitation Providers.  

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