Enhancing Community-Based Stroke Rehabilitation in Southeastern Ontario: Improving the System of Stroke Care

Timely, enhanced community and LTC rehabilitation services have been provided to stroke survivors in Southeastern Ontario since February 2009 with the launch of an innovative LHIN-funded project. In April 2011, recognizing the critical role this enhanced service plays in both improving stroke survivors' functional outcomes and health system utilization as evidenced by reduced lenths of stay, the LHIN committed to supporting the service as a regional standard in support of best practice in stroke care.

Eligible stroke survivors have and will continue to be considered for enhanced Physiotherapy, Occupational Therapy, Social Work and Speech Language Pathology services for two months following discharge home or to Long Term Care. Objectives of the enhanced rehabilitation services in the community and long term care include:

  • For Stroke Survivors: to improve access to timely enhanced community and LTC rehab services for improved function, emotional support and satisfaction with transition to home.
  • For Health Care Providers: to improve information flow and stroke care expertise.
  • For the Health Care System: to decrease length of stay, Emergency Room visits and hospital readmissions by supporting transition to home for those with new stroke, providing timely enhanced community and LTC rehabilitation support.

The provision of this service upon transition to the community has demonstrated a positive impact on both health system utilization and stroke survivor outcomes. As you will see from the Communique from Oct 2014 below, there has been a sustained reduction in length of hospital stay as well as a sustained reduction in wait times to first scheduled rehab visit in the community. The relative percentage of individuals with stroke being referred to the enhanced program has gradually increased since the initiation of the program.

For further information on this initiative, please contact Gwen Brown, Regional Stroke Community & LTC Coordinator at 613-549-6666 x6867 or Patti Dixon-Medora, Client Services Manager, Community Services, South East Community Care Access Centre at 613-544-8200 x8210.

For training materials in use for this service, please see the Best Practice & Education section of our website.