Pilot Projects Year II

Transcription

1 STROKE CARE IN LONG-TERM CARE FACILITIES AND THE COMMUNITY Pilot Projects Year II March 2003 Report prepared by Ilsa Blidner Consulting Inc. Contents Background... 1 Stroke Strategy Initiatives in the Community and Long-Term Care Sectors... 2 The Stroke Care Pilot Projects... 3 Stroke Care Pilot Projects Activities and Findings... 4 Lessons Learned... 6 Future Directions Appendix A Goals: Community and Long-Term Stroke Care Appendix B: Logic Model: Community and Long-Term Stroke Care Background Stroke is one of the leading causes of death and adult neurological disability 1, currently affecting 88,000 Ontarians living in the community. 2 Stroke is the third most common diagnosis in long-term care 3 and about 22% of institutionalized adults age 65 or older have had a stroke. 4 As Ontario s population ages, stroke numbers will rise and demands on the system for care will increase. Significant planning and focused efforts are required to offset escalations related to the number of strokes that occur, shortages in health care providers with stroke expertise and the costs associated with stroke. 5 Strategies to prevent and respond to stroke and its after-effects are timely. Ontario s Coordinated Stroke Strategy aims to ensure access to appropriate, timely, quality stroke care for all Ontarians. Begun by the Heart and Stroke Foundation of Ontario (HSFO) as a demonstration project in the fall of 1998, the Stroke Strategy is now supported by the Ministry of Health and Long-Term Care (MOHTLC) with annual funding growing to $30 million. Through focused efforts to reorganize stroke care, it is expected that the incidence of stroke will decrease, resulting in improved stoke patient care and outcomes. The Stroke Strategy s vision is set out in the June 2001 landmark report, Towards an Integrated Stroke Strategy for Ontario. Issued by the MOHTLC and based on the efforts of a Joint Working Group of the MOHTLC and HSFO, the report sets out recommendations for achieving a comprehensive, integrated, evidence-based stroke strategy across the province. Additional recommendations, focused on the development of regional stroke rehabilitation systems and targeted efforts to achieve that end, are presented in A Report of the Stroke Rehabilitation Consensus Panel, produced that same year by the HSFO in consultation with the MOHLTC. The HSFO gratefully acknowledges the Ministry of Health and Long-Term Care for funding the development and production of this report. 1

2 Stroke Strategy Initiatives in the Community and Long-term Care Sectors Since the Stroke Strategy s inception in 1998, developments have occurred in stroke best practices and care coordination in the various components of the care continuum (Figure 1). In the first two years of the implementation phase of the government s commitment to the Stroke Strategy (2000 and 2001), the MOHLTC allocated $350,000 to develop initiatives in the long-term care and community care sectors to ensure stroke survivors transferred from hospital into the community (either to their own home or to a long-term care facility) receive services that optimize their functioning and maximize their quality of life. Year I accomplishments in stroke long-term care and community care sector initiatives included: Formation of a Steering Committee that guided project initiatives and that formalized new working relationships among a broad array of long-term care and community service provider organizations, government and HSFO Affirmation of goals for coordinated stroke care in longterm care and community care (Appendix A) and adoption of a logic model/framework against which to evaluate the success of initiatives (Appendix B) Completion of initial needs assessments Development of resources including Tips and Tools for Everyday Living and Stroke Strategy Case Management; Best Practices for Community Stroke Care; province-wide educational workshops to disseminate the resources; and issuing of a report (October 2001) that outlined these first projects and lessons learned. In Year II of the Stroke Strategy, the MOHLTC provided $330,000 in support of the Strategy s goal to promote stroke best practices in long-term care facilities and in community care. Two primary initiatives were mounted outreach across the province to promote the use of Tips and Tools and Transition Workshops to enhance linkages at the regional level along with additional activities including OACCAC website access to CCAC Case Managers material and production of Tips and Tools supplements and a newsletter. These Year II efforts focused on three main objectives: (1) standardizing best practices; (2) improving patient transition from one component of care to the next; and (3) expanding linkages and partnerships. A parallel initiative aimed at standardizing best practices complemented the Year II initiatives. The publication of Best Practice Guidelines for Stroke Care: A Resource for Implementing Optimal Stroke Care provides regions, communities, organizations and individual health care providers across the continuum with a resource to support delivery of the best possible stroke care. The document, developed collaboratively by HSFO and Regional Stroke Centres, includes 19 evidence-based guidelines for stroke care including proposed care guides, Figure 1: The Continuum of Stroke Care Health Promotion Pre-Hospital Risk Factor Management Acute Care Rehabilitation Community Reintegration Risk Factor Management 2

3 sample protocols, and assessment and measurement tools. It also provides information about stroke prevention; recognition; emergency, acute and rehabilitation care; the management of transitions; and community re-engagement. It is anticipated that the Best Practice Guidelines for Stroke Care will serve as the gold standard for stroke care across the continuum. It will assist Regional Stroke Centres to develop and implement regional stroke plans, and will assist stroke care practitioners to deliver optimal stroke care and to serve as change agents for improved care processes. The Best Practice Guidelines for Stroke Care will be continuously updated to reflect evolving stroke best practices across the continuum. In Year II, the MOHTLC separately allocated $300,000 for five Stroke Care Pilot Projects in the community and long-term care sectors. Built on previous accomplishments in these sectors, the pilot projects sought to develop linkages and partnerships between long-term care providers and other parts of the regional stroke system for advancing best practice approaches. The projects also aimed to identify important lessons learned and to share these broadly across the sectors engaged and through regional stroke networks, in order to support the implementation of best practices. This report draws from the five stroke care pilot projects final reports. It summarizes key project activities, findings, and lessons learned for enhancing coordinated stroke care within the sectors and across the continuum of care. The Stroke Care Pilot Projects Five Stroke Long-Term Care and Community Pilot Projects were conducted across the province, each with a unique focus. The projects were designed to: Develop tools to enhance patient/client transitions to longterm care Continuing Stroke Care in the Community: Transition Management from Community Care Access Centre to Long-Term Care (West GTA Stroke Network) and Enhancing the Transition of Stroke Survivors from Acute Care to Long-Term Care (Toronto West Regional Stroke Network and North and East GTA Regional Stroke Network) Explore resources to enhance stroke care in long-term care facilities Partnerships for Stroke Care in Long-Term Care Facilities (Southwestern Ontario) Identify and provide strategies to support care providers in adult day programs Aphasia Training in Adult Day Programs (Central West/South Central Ontario) Identify strategies to enhance social support for survivors in rural communities Stroke Care in Communities in Rural Eastern Ontario (Southeastern Ontario). The Stroke Care Pilot Projects were developed jointly by Regional Stroke Centres and provincial associations including Ontario Association of Community Care Access Centres (OACCAC), Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS), Ontario Long Term Care Association (OLTCA) and the Ontario Community Support Association (OCSA), all of which provided ongoing input to the pilot projects through their representation on the Steering Committee. Coordinated and managed by HSFO, the projects were initiated in fiscal year As they progressed, all projects were monitored in accordance with the Steering Committee s approved evaluation plan. With the intention of documenting, assessing and sharing lessons learned, projects reported their objectives and achievement of activities, along with recommendations for further developing or sustaining best practices and for coordinating stroke care in the sector. 3

4 Stroke Care Pilot Project Activities and Findings Transitions Two projects examined client transition processes and tools for enhancing these transitions. Both projects, conducted in Toronto regions and the West GTA region, sought to facilitate seamless care for the stroke survivor. The projects are based on the assumptions that seamless care optimizes care continuity and that collaborative working relationships among providers will facilitate seamless care. Both pilot projects provided opportunities for stakeholders to collaboratively examine and improve the system for the stroke survivor s transition. Transition Management from CCAC to Long-Term Care Covering Halton and Peel regions, the West GTA project examined existing practices and transition management processes when the Community Care Access Centre (CCAC) mediates the stroke survivor s move from home-based and hospital-based environments to long-term care. The project convened an Advisory Panel broadly representing the sectors studied and conducted key informant interviews with stakeholders in long-term care facilities, community programs, hospitals, CCACs and with stroke survivors and their families. The findings from the West GTA project highlight the complexity and fragmentation of the transition process. These result in stroke survivors and their families experiencing the transition as abrupt and difficult. Stakeholders, stroke survivors and families identified corrective strategies that include: Improved coordination among care providers Improved and increased transfer of client/patient information Increased family involvement in the transition process More gradual shifts in service levels upon transition to long-term care settings Increased use of client-centred approaches for transition Education of both front-line staff and stroke survivors and families. Recommendations from the project focus on process improvements. Enhancing the Transition of Stroke Survivors from Acute Care to Long-Term Care Two Toronto Regional Stroke Networks, Toronto West and North & East, collaboratively mounted a project to examine and improve the system for stroke survivors transition from acute care to long-term care. An Advisory Committee, representing these Toronto regions long-term care stakeholders, was formed to guide and direct the project. The transition process of clients from acute to long-term care settings was studied through sector-specific (hospital, CCAC, long-term care) group interviews with representative acute and long-term care organizations that had the history and experience in providing stroke care. Through these discussions, stakeholders provided perspectives on the transition process and identified gaps. The project Advisory Committee vetted the interview findings and determined that the pilot project s collaborative work ought to focus on advancing development of a best practice-based communication tool, and recommending process and practice enhancements that would support seamless transition between acute and long-term care. To support a comprehensive plan for transition enhancement, a review of data reflecting discharge disposition of stroke patients by patient residence ( and ) was also conducted. This project resulted in the development and revision of elements of a Communication Template for Stroke Recovery. Designed as a generic communication tool that can be adapted by other regions, the template is structured to be consistent with the framework of Tips and Tools for Everyday Living: A Guide for Stroke Caregivers. Face validity of the template was established during the pilot project and two Regional Stroke Centres are scheduled to proceed with preliminary testing of the template in the spring of The project generated recommendations for further developing collaborations and leadership to improve communication and stroke best practices within the long-term care sector, for implementation of best practices and for policy review. 4

5 Partnerships in Long-Term Care The Southwest region s stroke pilot project examined the organization of long-term care for stroke. An Advisory Group, comprised of long-term care stakeholders and community partners, was formed to provide ongoing input to the study s implementation and to interpret the findings. The project began with a review of the literature and current best-practice approaches for organizing stroke care and resources across the continuum. Then, key informant interviews with representatives of long-term care facilities and community provider agencies, along with stroke survivors and families, explored the potential to reorganize models of care, resources and infrastructure to facilitate enhanced stroke care and to extend collaborative relationships that would foster continuity and coordination of stroke care. The pilot project findings highlight that stroke care arrangements associated with positive patient outcomes such as clustering patients and dedicated stroke teams or units exist in both acute and rehabilitation settings but are less evident in long-term care. Deficiencies in the patient transition process to long-term care and in access to rehabilitation and other support services and resources were noted. Stakeholders identified opportunities to increase collaborative arrangements across the long-term care and community care sectors for enhancing coordinated stroke care. This project resulted in recommendations related to: Increased opportunities for use of available resources in long-term care (e.g., Nurse Practitioners) that would support stroke best practice approaches Establishing a demonstration stroke unit for developing, testing and teaching methods of stroke long-term care Improved opportunities for and access to rehabilitation services Ongoing education to support best practices in long-term care settings Increased use of available data systems for patient/client information transfer that would facilitate transitions and optimize achievement of client outcomes Increased partnerships and collaborative arrangements across the care continuum to foster coordinated stroke care Increased collaborations with service organizations and advocacy groups to advance stroke system improvements. Stroke Community Care Pilot Projects Two Stroke Care Pilot Projects were jointly initiated by the Ontario Community Support Association (OCSA) and Regional Stroke Centres. Both explored opportunities for stroke best practice improvements in community care settings. Stroke Care in Rural Communities The Southeastern Regional Stroke Steering Committee and OCSA s joint Stroke Pilot Project focused on building the capacity for stroke response in rural communities where available resources and health services are limited. Project activities included focus group sessions that enabled stakeholders to identify and develop important linkages across the care continuum and to better understand the prevalence of stroke locally so that appropriately planned responses could be developed. Educational workshops (Work Smarter, Not Harder: Effective Care Giving for Stroke Clients) targeted at community care providers in two rural communities provided stroke care approaches that foster client independence and build on existing abilities (to offset learned helplessness ). And a how to guide was written for leaders organizing a self-help group for stroke survivors and/or caregivers. The project enabled diverse organizations in the rural areas of the region to learn about stroke and its management, to understand resources available and to develop important relationships that participants have taken the lead to sustain. Preliminary feedback on the self-help guide developed during the pilot project indicates it is a valuable and useful tool for rural communities, and stakeholders identified conditions to ensure successful self-help group start-up. Educational workshops brought together diverse rural community agency caregivers, volunteers and staff who reported that the training increased their capacity to better care for stroke clients. 5

6 Aphasia Training in Adult Day Programs The Central West/South Central Regional Stroke Steering Committee and OCSA s joint pilot project focused on identifying and responding to Adult Day Program (ADP) providers needs for education to respond to stroke clients communication difficulties. The project began with a planning meeting of Adult Day Program providers convened to determine the needs for, scope, and format of education for dealing with aphasia. A speech pathologist trainer, an experienced worker in ADP, provided on-site training sessions and also provided telephone and support over the course of the pilot project. The Aphasia Institute provided additional pictographic and video resources. This project s training sessions reached a significant number of staff across various organizations in the Central West/South Central region. Participants evaluations were positive in their assessment of both the planning meeting and the educational sessions. They indicated an increased awareness of the Stroke Strategy, stroke resources and skills to better manage stroke clients. The project produced a model for training and support in the management of aphasia that may be applied by ADP providers in other parts of the province. Lessons Learned The five pilot projects, each unique in focus, yielded important findings and recommendations for furthering the work begun. Noteworthy lessons have been learned from all the pilot projects that can inform advancements in long-term and community stroke care. There are several key themes that resonate across the pilot projects, notably: Long-term care and community sector contexts are complex Available, accessible and appropriate services are important for stroke survivors in long-term care and the community Process improvements are necessary, particularly related to transitions in and out of long-term and community care Education is required to ensure dissemination and uptake of best practices in long-term and community care sectors Relationships and networking arrangements are essential to coordinated stroke care System change, policies and incentives are needed to support these sectors in efforts to ensure optimal care for stroke clients. Long-term care and community sector contexts are complex. The five pilot projects highlight the complexity of the longterm care and community care sectors. This challenges planning and operationalization of stroke care coordinating approaches. For example, there are numerous and diverse long-term care facilities and community organizations providing care to stroke survivors. Facility size varies, as does the level of resourcing. Further, there is a mix of organizations and services; some are privately and some are publicly sponsored. And there are varying regulations in these sectors. Data for planning purposes are not readily available. Stroke admission patterns across long-term care facilities are variable. And admission data do not necessarily reflect the total stroke population; it appears that some long-term care facilities have significant stroke populations and some have few. In addition, client populations in both the long-term care and community sectors are complex. Here, there is need not only to respond to clients presenting with complex conditions, multiple diagnoses and comorbid conditions, but also to address needs of families and caregivers supporting such clients. According to stakeholders who were consulted through the pilot projects, many challenges within the longterm and community sectors are not limited to stroke and are generally pervasive within the sectors. 6

7 Funding cuts are hindering the long-term and community care sectors. Insufficient resources impact the amount of time spent in caring for clients/residents and meeting quality standards, the level and amount of education to ensure evidence-based practice, and the implementation of programs that promote independence and reactivation. These pilot projects provided opportunities for stakeholders across the continuum and for stroke survivors and their families to better understand the issues and complexities of long-term and community care. Together, they devised local and regional approaches to support best practice stroke care. These projects increased the awareness of the Stroke Strategy, created a focus on system improvements in the longterm care and community sectors and engendered enthusiasm to further the work. An emphasis on optimal, best practice based stroke care in the long-term and community sectors may serve as a catalyst for overall improvements in the quality of care in these settings. Available, accessible and appropriate services are important for long-term care and community-based stroke survivors. The pilot projects underscore the need to ensure stroke survivors have access to an appropriate range of available services and supports. Client-centred services that will optimize stroke survivors outcomes and quality of life ought to be equally available to community-based survivors and to longterm care residents. Limited access to timely therapy and low levels of rehabilitation therapy in long-term care are particular issues of concern. Some evidence suggests that residents with rehabilitation potential in long-term care facilities may be undertreated. It is evident in the acute phase of care that some stroke clients may be slow to recover. These clients may transition to long-term care without an appropriate trial of rehabilitation and may not receive levels of rehabilitation care in long-term care settings that will optimize outcomes. Increased access to slow stream rehabilitation is advocated. These pilot projects also point to the need for increased opportunities to assess and improve stroke survivors functioning. This includes ensuring appropriate involvement of physiotherapy, occupational therapy and speech/language therapy in the care of stroke survivors in both long-term care and community settings. And it also includes the opportunity for long-term care stroke residents to transition back to specialized rehabilitation, if required. The pilot projects underscore the need for community therapists and for support staff (i.e., adjuvant staff, program aides and restorative aides) to have adequate time with stroke residents and for occupational therapists to have an expanded role in stroke care. These pilot projects indicate that formalized criteria for rehabilitation services in long-term care are lacking. There is need for a formal, standardized process for prioritizing rehabilitation needs (e.g., stroke severity, rehabilitation potential). Long-term care residents who suffer a stroke while living in long-term care should have access to timely acute care and to rehabilitation therapy immediately following the stroke. Process improvements to support such transitions are important. Acknowledging the issue of limited resources in the long-term care sector generally, the pilot projects put forth approaches that optimize the use of existing resources. Various models of care are proposed, all centred on client needs and grounded in a philosophy of restorative care. For example, current approaches for the care of geriatric and cognitively impaired populations that are focused on quality of life improvements might be extended to stroke populations. Another opportunity exists in an extended role for Nurse Practitioners currently working in long-term care as advanced practice nurses, consultants, educators, counselors, advocates and role models. They provide an opportunity to improve stroke care and to champion advances in the sector. Sharedcare approaches are proposed to enable care providers to efficiently meet stroke clients needs. The Central West/South Central region s community care pilot project produced an aphasia training model that might easily be extended from community to long-term care settings. Two pilot projects concluded that clustering of stroke clients in long-term care might be a reasonable option for facilities with sizeable stroke populations. Clustering presents the potential benefits of increased stroke resident critical mass (important for development of providers skills and expertise in stroke care) and of increased access to rehabilitation services. These pilot projects suggest that clustering of residents might centre on restorative care/reactivation; it may be feasible to link stroke with other conditions where a restorative focus is in place. 7

8 Lessons Learned continued Process improvements are necessary, particularly related to transitions to and from long-term and community care. Several of the pilot projects reinforce the need to ensure continuity of care for stroke survivors as they transition across the continuum of care. Limited and incomplete clinical/plan of care information, limited information flow across care settings, and service disruptions occur when clients must quickly transition to long-term care. The move from one setting to another, usually mediated by CCACs, activates processes that are not consistently linked. The pilot projects identified process improvements and opportunities for improving transitions. The pilot projects confirm the need for standardized information to flow with clients and the need for standardized data to enable planning and evaluation. The Home Care RAI form, now being implemented in other settings, is remommended to ensure standardization of information for CCAC client placement. The MDS 2.0, an assessment and care planning tool, is recommended to ensure a standardized and consistent base of information for planning and evaluation of client, organization and system level issues. Standardized, sufficient and accurate information including stroke survivor s functional level and therapies required ensures care continuity and permits initiation of appropriate therapy. The pilot projects advocate the use of formal protocols to facilitate the transition process. The Communication Template, developed through the Toronto pilot project as a generic template that can be adapted and operationalized locally, focuses on elements of a care plan that will facilitate the flow of information. This process improvement approach complements the HC RAI tool. The Southeastern Ontario community care pilot project produced a how to guide for stroke self-help group start-up. This resource highlights opportunities for both staff-driven and volunteer-driven approaches and builds capacity for a local response to stroke. Strategies and supports that encourage stroke survivors independence are important. The projects also identified the need for pre-admission stroke management planning in long-term care settings and the importance of processes that are client-sensitive. For example, staff in long-term care facilities might meet with residents prior to admission; providers in settings across the continuum might be identified as liaisons to ensure communication about the stroke client and connectivity across settings. The pilot projects results suggest that smoother transitions are achieved when team approaches are used. The MOHLTC s current clustered stroke unit funding model will ensure that each Regional Stroke Centre engages a Stroke Case Manager (1 F.T.E.). Among other responsibilities, the Stroke Case Manager will: develop and coordinate transition plans for patients/clients and families throughout the stages of care and within and across the continuum; ensure an interdisciplinary approach that is attentive to evidence-based standards and patient-focused care; and facilitate repatriation and access to rehabilitation and stroke resources within the region. Other important supports identified by these pilot projects are readily accessible, and comprehensive inventories of stroke services and supports, available locally and regionally, are accompanied by an approach for promoting awareness of these resources. Education is required to ensure dissemination and uptake of best practices in long-term and community care sectors. Stroke requires specialized care by staff that are specially trained and experienced. Education is important to ensure standardized and coordinated approaches to care in long-term and community settings. These pilot projects point to the need for increased educational opportunities and training for staff in long-term and community care settings, focused on all aspects of stroke care and best practices. There is also an identified need to better understand the roles of hospital, CCAC, long-term care and community providers in the transition and care processes. Tips and Tools and other HSFO resources for stroke management are seen as valuable educational tools. The pilot projects identified additional content areas for inclusion and strategies for disseminating/educating within regions. Specific strategies to support and reinforce learning are recommended. Outreach stroke consultants or teams might provide follow-up on call support in regions. Experience 8

9 from these pilot projects indicates that the use of local experts ensures sustainability of learning. Providers value this approach and report increased confidence and skill. Other strategies to reinforce learning might include website use; dissemination of existing information and research generated by stroke regions; grand rounds to discuss case studies of stroke survivors who transitioned to long-term care; and continuing and new partnerships with university and research centres to further develop education programs. It is expected that stroke regions will take the lead in devising educational programs to meet local needs. Formalized functions and dedicated resources will be required for education that supports best practice stroke care. There is a need to ensure that education strategies are linked and it is anticipated that each stroke region s Education Coordinator will, with funding provided by the MOHLTC, ensure regional needs are met through efforts that coordinate and coalesce education offerings. Relationships and networking arrangements are essential to coordinated stroke care. It is evident from the pilot projects that collaborative relationships among stakeholders across the continuum contribute to stroke care improvements. Increased mutual awareness of issues, challenges and opportunities within the sectors permits the development of a common language for advancing stroke best practices. Increased linkages among acute care, rehabilitation, longterm care and community sectors are needed. Specific formalized relationships might be forged (e.g., among CCAC case managers, hospital stroke teams and long-term care facilities) to improve transitions and foster best practices. Enhanced structures and processes to advance best practices across the continuum rely on stakeholders who are willing to come together to promote system change. Working Groups and Advisory Groups formed for these pilot projects brought together various stakeholders in new relationships to tackle practical issues in their regions. All projects highlight their participants enthusiasm for the new relationships that were forged. They recognized the expertise of each sector across the continuum and that each is an important contributing partner for advancing stroke care. Pilot project results indicate that stakeholders are committed to continued collaborative efforts to improve stroke care in the long-term care and community sectors. For example, further work to test the "Communication Template" will bring together various organizations across several Toronto regions. The pilot projects identified the need to change the image of long-term and community care that all stakeholders across the continuum need to better understand long-term and community care, and the role of and expertise within these sectors. It is recommended that stroke champions in the long-term and community care sectors who raise the profile of stroke have the opportunity to advocate for best practices in long-term care and keep attention focused on long-term and community care generally. System change, policies and incentives are needed to support these sectors in efforts to ensure optimal care for stroke clients. Changes are required to support improvements in long-term and community care, in transitions and in the quality of life for stroke survivors and their families. The mix of long-term care facilities, community organizations and varying funding approaches challenges the operationalization of approaches to coordinate care across the various settings. To achieve client-centred and coordinated care, stakeholders from across these settings must be engaged in policy and program formulation discussions. A number of the pilot projects underscore the need for services that optimize resident/client function and outcomes. Appropriate policies are therefore required to: Ensure restorative philosophies and care models are embraced and supported Refocus incentives on care in the most appropriate place, to ensure that funding allows for the most appropriate services to be provided and that care continuity rather than bed occupancy remains the priority Enable client absences from long-term care if other care settings are appropriate for stroke survivors to achieve gains Ensure flexibility in long-term care placement timelines for stroke survivors Ensure funding for therapies within the long-term care envelope Enable shared-care approaches (e.g., permit extended community day program stays to give stroke survivors an adjustment period in their transition to long-term care Further develop campuses of multi-level services that could ease stroke survivor transition (e.g., combined seniors apartments, retirement and long-term care facilities) and ensure processes are in place to enable access to such campuses. 9

10 Future Directions The pilot projects were successful in a number of ways. They contributed to increased awareness of, and application of, stroke best practices; they forged new relationships within the long-term/community sectors and across the continuum; and they produced new templates and tools to ensure stroke care continuity and to meet stroke survivors needs. These projects offer important groundwork and insights for extending project learning province-wide, and for regions to develop sustainable plans for stroke care through the community reintegration component of care. Over the next year the Stroke Strategy, through continued projects within the regions, will build on these best practice approaches, will focus on education to support widespread uptake of best practices and will develop strategies that can be sustained in these sectors. Footnotes 1 Towards an Integrated Stroke Strategy for Ontario. Report of the Joint Stroke Strategy Working Group. June National Population Health Survey, 1996/97. 3 PriceWaterhouseCoopers, Report of a Study to review levels of service and responses to need in a sample of Ontario long-term care facilities and selected comparators. 4 Towards an Integrated Stroke Strategy for Ontario. Report of the Joint Stroke Strategy Working Group. June Ibid. 10

11 A P P E N D I X A GOALS: COMMUNITY AND LONG-TERM STROKE CARE Ensure coordinated stroke care in the long-term care sector that is part of an integrated, regional stroke system Ensure resources developed for disseminating best practices are accessible to frontline workers Develop relationships for best practice ongoing stroke care within the long-term care sector Develop partnerships between continuing stroke care providers and other parts of the regional stroke system Encourage leadership within the long-term care sector with respect to the Ontario Stroke Strategy Apply the ongoing lessons learned, to ensure success 11

12 A P P E N D I X B LOGIC MODEL: COMMUNITY AND LONG-TERM STROKE CARE OBJECTIVES Standardize use of stroke best practices Improve patient information (flow and quality) for critical patient transition points Expand linkages and partnerships among providers ACTIVITIES Communication strategy Dissemination of resources (tools/ approaches) developed in Year I Targeted education and training (providers & family) Workshops Advisory network Electronic formats Feedback to inform ongoing planning of best practice approaches and dissemination Joint planning of care guidelines, pathways, tools by institution and communitybased providers Application of tools to ensure information transfer OUTCOMES Communication strategy Strategy for linking rehab experts in institutions with front-line providers in LTC facilities and the community Consultative approaches for developing and disseminating stroke best practices and for linking with other initiatives Stroke champions in the longterm care sector Strategy to ensure connectivity between LTC and regional stroke centre Increased reach Increased knowledge Increased uptake and use of tools Increased awareness of plan for stroke strategy Improved processes of care and approaches for care coordination Increased use of standard approaches/pathways Continued improvements in care Increased participation of range of providers in network relationships Increased awareness among stakeholders of issues across settings Increased stroke leadership and champions in long-term sector Increased competence (best practice stroke care) Increased collaboration in stroke care across regions Increased coordination of care across the continuum Responsive system of stroke care Optimized life participation for survivor/patient 12