The following document was directed to the North East LHIN.

The following document was directed to the North East LHIN. If you require any further details into the information presented here please feel free to contact Jenn Fearn, Regional Rehabilitation Coordinator, Northeastern Ontario Stroke Network at jfearn@hrsrh.on.ca or (705) 523-7100 ext 1718.

Northeastern Ontario Stroke Network Hôpital régional de Sudbury Regional Hospital 700 Paris St. Sudbury, ON P3E 3B5 Phone: (705) 523-7100 ext. 1586 Fax (705) 523-7170 www.neostrokestrategy.com Date: February 17, 2009 To: Northeastern Ontario Stroke Care Stakeholders From: Jenn Fearn Northeastern Ontario Regional Stroke Rehabilitation Coordinator Darren Jermyn - Northeastern Ontario Regional Stroke Program Manager Re: Northeastern Ontario Stroke Network s 2008 Regional Rehabilitation Report Card Dear Stakeholder: Please find enclosed the Northeastern Ontario Stroke Network s Regional Rehabilitation Report Card. This report summarizes the stroke rehabilitation performance at the four North East hospitals that are formally part of the Ontario Stroke System. The region s Enhanced District Stroke Centre is located in Sudbury and the three District Stroke Centres are in Sault Ste. Marie, North Bay and Timmins. In the 2007 Ontario Consensus Panel on the Stroke Rehabilitation System report there were 20 stroke rehabilitation standards put forward. As part of our strategic plan, our District Stroke Centres were asked to evaluate their performance against each of the Panel s standards. A common grading system was developed to use across the four facilities. The staff at each District Stroke Centre (DSC) evaluated their facility s level of engagement on each standard and assigned a score accordingly. Four individual rehabilitation report cards were created, and from these common themes and an overall regional score was determined on a visual grading scale. The enclosed report (which is also available electronically at www.neostrokestrategy.com) depicts the DSC s performance scores for each of the standards in three different formats: 1) a regional score for each standard; 2) a side-by-side overview of the DSC s scores; and 3) individual report cards for each of the DSCs. The standards for the first two reports are presented in order of performance to allow for easier identification of overall engagement. In reviewing these documents a few common regional threads emerge: Minimal engagement exists with respect to the provision of stroke rehabilitation in the following areas: o Ambulatory (outpatient) Care The region is unable to provide screening assessments, appropriate treatment intensity or access to an interprofessional team with stroke care expertise. For the limited ambulatory services that do exist, the rehabilitation services are not accessible within the appropriate timeframes. o Acute Care Stroke survivors in acute care do not have access to rehabilitation assessments within the appropriate time frame nor do they receive the recommended intensity of therapy. o Access There is not equitable access to the same level of rehabilitation services regardless of where the stroke survivor lives. Also, no DSC provides reassessment of the stroke survivor s needs at regular intervals upon discharge from hospital.

Northeastern Ontario Stroke Network As a region there is moderate engagement when looking at the maximum wait time to access inpatient rehabilitation services however only one of the four sites has access to a physiatrist and a psychologist. Although there is not an explicit regional stroke rehabilitation service provision model in place, this standard is being approached across the North East through the work of the North Eastern Ontario Rehabilitation Network (NEORN). The North East shows increased engagement (but not yet fully engaged) in the areas of: o Education The stroke survivor, family and caregiver are to be provided with education across the continuum as well as the interprofessional team would have access to stroke education. o Rehabilitation Opportunities and Environment While hospitalized, stroke survivors with a moderate or severe stroke as well as those stroke survivors in a CCC or ALC environment are to receive stroke rehabilitation services as appropriate to their needs. All stroke survivors who would benefit from inpatient rehabilitation should be cohorted in a geographically defined unit with a stimulating environment. o Treatment Approaches Stroke survivors are to be assessed with standardized valid assessment tools and their therapy should include the use of novel tasks and the integration of functional activities into their daily routine. o Inpatient Rehabilitation The North East inpatient rehabilitation units have an interprofessional team with stroke care expertise however as previously stated only one DSC has access to a physiatrist or a psychologist. This team develops rehabilitation plans with input from the stroke survivor, their family and caregivers. o System Navigation Although there are limited community supports/services in the North East, the interprofessional team facilitate linkages to these for stroke survivors, their families and caregivers as they are discharged from hospital. The one standard where full engagement exists in the North East is that of the inpatient reassessment of moderate or severe stroke survivors at regular intervals. Unfortunately, although the stroke survivor may be assessed as ready for inpatient rehabilitation their transfer could be delayed due to the previously mentioned excessive wait times. In summary, the results of this review demonstrate that the NEO Stroke Network can make positive changes in the areas of stroke education and the implementation of best practice stroke care. However, it is beyond our scope to demonstrate change in many of the standards that relate directly to rehabilitation bed deficits (42% in the North East 1 ); human resource issues; and the overall funding allocation for rehabilitation in acute inpatient stroke care and ambulatory services. We also feel the regional system of rehabilitation care across the continuum could be enhanced greatly through a strong rehabilitation network with dedicated resources. Accordingly, we are hopeful that the concept of NEORN will be viewed by the NE LHIN as an appropriate Integration Strategy project to support. It is our intention to repeat this grading process in two years time to demonstrate any changes in the level of engagement with respect to the Rehabilitation Consensus Panel s standards. If you have any questions with respect to this report, or wish to discuss stroke rehabilitation issues further, we would be more than happy to speak with you either at an in-person meeting or by telephone. Sincerely, Jenn Fearn Darren Jermyn jfearn@hrsrh.on.ca djermyn@hrsrh.on.ca (705) 523-7100 ext. 1718 (705) 523-7100 ext. 3138 1 Fearn J. The Current State of Hospital Based Stroke Rehabilitation in Northeastern Ontario, January 31, 2007

Regional Score for Each Standard

NEO Regional Score for the Stroke Rehabilitation Standards Report Card Organized by Score, 2008 Standard Regional Score Standard Summarized 2 X Ambulatory or home-based screening Ax within 2 weeks for all stroke survivors not admitted to inpatient rehab bed 3b X Periodic reassessment of rehab needs of the stroke survivor at regular intervals upon D/C (6wks, 3 mos, 1 yr) 18b X Maximum wait time for ambulatory & home-based stroke rehab should be no more than 5 days from Rehab Ready and referral 7a X acute X Mild stroke survivors discharged to the community will be provided with ambulatory services for 1 hour of each appropriate therapy, 2 to 5X/wk as tolerated and indicated by patient need Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) - in Acute Care 9b X Community rehab (i.e. home-based or ambulatory) will provide the stroke survivor with access to an interprofessional team with stroke expertise 1 Acute stroke patients(pts) will have an early initial rehab Ax within 24-48 hours; no weekend delay 13 X Equitable access to same level of rehab services regardless of where stroke survivor lives 10 Post-acute care will be delivered using a collaborative practice model. The interprofessional team will include a physiatrist 18a Max. wait time for inpt stroke rehab should be no more than 2 business days from Rehab Ready and referral 19 Explicit regional stroke rehabilitation services provision model in place 9a X Inpatient rehab will have an interprofessional team with stroke care expertise 11 X Repetitive and intense use of novel tasks and integration of skills from therapy are reinforced in daily routine 6 Interprofessional team develops a rehab plan with stroke survivor & family based on severity of stroke, needs & goals, home environment, etc. rehab unit X X X X X Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) - in the Rehabilitation Unit 7c Rehab Ready severe stroke pts will receive the frequency and duration of therapy they can tolerate up to the same targets as moderate stroke pts 12a Interprofessional team has access to stroke education 4 X Mechanism to access or reaccess rehab, if clinically indicated, regardless of time elapsed 5 X Standardized valid assessment tools 8 X All stroke pts will be cohorted in a geographically defined stroke rehab unit with stimulating environment 12b X Stroke survivor, family, caregiver provided with education across continuum 14 X Rehab Ready moderate or severe strokes will have inpt stroke rehab opportunity if they have rehab goals 15 X Pts in a CCC or ALC or LTC environment should have access to stroke rehab services 17 X Interprofessional teams will facilitate linkages for stroke survivors and their family/caregivers after discharge to services in the community including: - Physical help, caregiver training and education, psychosocial counselling where needed - Linkages to community services (driving, peer support etc.), access to primary care practitioners, case management or other system navigation service, respite care, etc. 3a X Moderate or severe stroke pts reassessed at regular intervals 16 NA Home-based rehab service based on CCAC Stroke BP guidelines 20 NA Clinical & service utililization data will be used for planning & ensuring equitable access to rehabilitation Legend Minimal engagement of the parties that should be involved, work may be occuring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA)

Side-by-Side Overview of the District Stroke Centres' Scores

Standard Standard Summarized NBGH TDH SAH HRSRH 2 Ambulatory or home-based screening Ax within 2 weeks for all stroke survivors not admitted to inpatient rehab bed 3b Periodic reassessment of rehab needs of the stroke survivor at regular intervals upon D/C (6wks, 3 mos, 1 yr) 18b Maximum wait time for ambulatory & home-based stroke rehab should be no more than 5 days from Rehab Ready and referral 7a acute Mild stroke survivors discharged to the community will be provided with ambulatory services for 1 hour of each appropriate therapy, 2 to 5X/wk as tolerated and indicated by patient need Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) - in Acute Care 9b Community rehab (i.e. home-based or ambulatory) will provide the stroke survivor with access to an interprofessional team with stroke expertise 1 Acute stroke patients(pts) will have an early initial rehab Ax within 24-48 hours; no weekend delay 13 Equitable access to same level of rehab services regardless of where stroke survivor lives 10 Post-acute care will be delivered using a collaborative practice model. The interprofessional team will include a physiatrist 18a Max. wait time for inpt stroke rehab should be no more than 2 business days from Rehab Ready and referral 19 Explicit regional stroke rehabilitation services provision model in place 9a Inpatient rehab will have an interprofessional team with stroke care expertise 11 Repetitive and intense use of novel tasks and integration of skills from therapy are reinforced in daily routine 6 Interprofessional team develops a rehab plan with stroke survivor & family based on severity of stroke, needs & goals, home environment, etc. rehab unit Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) - in the Rehabilitation Unit 7c Rehab Ready severe stroke pts will receive the frequency and duration of therapy they can tolerate up to the same targets as moderate stroke pts 12a Interprofessional team has access to stroke education 4 Mechanism to access or reaccess rehab, if clinically indicated, regardless of time elapsed 5 Standardized valid assessment tools 8 All stroke pts will be cohorted in a geographically defined stroke rehab unit with stimulating environment 12b Stroke survivor, family, caregiver provided with education across continuum 14 Rehab Ready moderate or severe strokes will have inpt stroke rehab opportunity if they have rehab goals 15 Pts in a CCC or ALC or LTC environment should have access to stroke rehab services 17 Overview of the Four NEO District Stroke Centres Stroke Rehabilitation Standards Report Cards Organized by Score, 2008 Interprofessional teams will facilitate linkages for stroke survivors and their family/caregivers after discharge to services in the community including: - Physical help, caregiver training and education, psychosocial counselling where needed - Linkages to community services (driving, peer support etc.), access to primary care practitioners, case management or other system navigation service, respite care, etc. 3a Moderate or severe stroke pts reassessed at regular intervals 16 Home-based rehab service based on CCAC Stroke BP guidelines 20 Clinical & service utililization data will be used for planning & ensuring equitable access to rehabilitation Legend Minimal engagement of the parties that should be involved, work may be occuring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA)

Individual Report Cards from the District Stroke Centres North Bay General Hospital Timmins and District Hospital Sault Area Hospital Hôpital régional de Sudbury Regional Hospital

North Bay General Hospital (NBGH) Stroke Rehabilitation Standards Report Card, 2008 Standard Standard Summarized Comments Acute stroke patients(pts) will have an early initial rehab Ax within 24-48 hours; no weekend delay Rehab team consulted on standard orders include: SLP, PT, OT, Discharge Planner, Dietitian, and Nurse Clinician. Admissions to acute stroke unit are assessed by physiotherapy within 24 hours from Monday to Friday, 8 am at 4pm. Other disciplines prioritize these referrals amongst other hospital referrals. One profession often communicates need for urgent assessment to other relevant professionals, depending on potential discharge date and severity of stroke. Lack of professionals (OT and SLP) limit the attainment of this standard. No weekend coverage. Therapists are aware of the urgent need to assess the patient but often only screen due to a lack of time and resources. 2 Ambulatory or home-based screening Ax within 2 weeks for all stroke survivors not admitted to inpatient rehab bed All d/c clients get referred to the Stroke Prevention Clinic if the Stroke Orders are used, however no allied health professionals take part in the assessments. 3a Moderate or severe stroke pts reassessed at regular intervals No formal tool used. However, the multidisciplinary team feel that they recognize when the client is rehab ready. 3b Periodic reassessment of rehab needs of the stroke survivor at regular intervals upon D/C (6wks, 3 mos, 1 yr) The client is not brought back at regular interval for reassessments due to limited resources (lack of sufficient positions). 4 Mechanism to access or reaccess rehab, if clinically indicated, regardless of time elapsed The referral for inpatient rehab is available on the hospital website and needs a physician signature. The referral for outpatient rehab also requires a physician referral. Bed utilization is a limiting factor to access or reaccess a rehab bed. Outpatients don't receive many requests to reassess likely due to the knowledge that they have limited therapy time. 5 Standardized valid assessment tools Nursing are using the CNS and other professionals are using a variety of other assessments. Covering staff might not have specific stroke rehab training. The physiotherapists that work in outpatients have mostly ortho training and have little training in stroke rehab. 6 Interprofessional team develops a rehab plan with stroke survivor & family based on severity of stroke, needs & goals, home environment, etc. Acute reports that the therapy staff don't attend the multidisciplinary rounds due to lack of resources. However, they communication via various methods. A formal rehab plan is often lacking due to inability to meet as a team. Rehab indicate that they review the rehab plan on a weekly basis but not a central concise and standardized manner. Outpatients never attains this standard as the service is set-up as a individual service not as a multidisciplinary service. 7a Mild stroke survivors discharged to the community will be provided with ambulatory services for 1 hour of each appropriate therapy, 2 to 5X/wk as tolerated and indicated by patient need The length of the outpatient sessions are 40 minutes and pts are typically seen twice weekly. acute Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) Unable to meet standard on acute unit. rehab unit Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) PT is able to meet this standard most of the time, but OT and SLP are only occasionally able to meet this standard. 7c Rehab Ready severe stroke pts will receive the frequency and duration of therapy they can tolerate up to the same targets as moderate stroke pts Unable to meet on acute care, able to meet on rehab and unable to meet in outpatients. Barriers to meeting are lack of human resources. 8 All stroke pts will be cohorted in a geographically defined stroke rehab unit with stimulating environment The current issue remains that the physical space is limited but they are doing the best possible and are excited to move in the new hospital in 2010. 9a Inpatient rehab will have an interprofessional team with stroke care expertise This is occuring however the team does not have access to a physiatrist or psychologist. 9b Community rehab (i.e. home-based or ambulatory) will provide the stroke survivor with access to an interprofessional team with stroke expertise No interdisciplinary team in outpatients (single service delivery model - physio and OT available but limited knowledge of stroke care as the clinic treats mostly ortho related medical problems.) Legend Minimal engagement of the parties that should be involved, work may be occuring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA) for NBGH 1

NBGH Stroke Rehabilitation Standards Report Card, 2008, continued Standard Standard Summarized Comments 10 Post-acute care will be delivered using a collaborative practice model. The interprofessional team will include a physiatrist Rehab indicated that they meet the standard most of the time, even if they don't have a psychologist or physiatrist. Services are not readily available (long wait times and not local) but referrals are made nonetheless. Outpatients are unable to meet, as there is no interdisciplinary team. They refer on to other services as needed. 11 Repetitive and intense use of novel tasks and integration of skills from therapy are reinforced in daily routine Acute care meets half the time due to nursing availability, rehab feels they meet the standard most of the time but want to improve on consistency of practice, outpatients unable to meet due to lack of interdisciplinary team. 12a Interprofessional team has access to stroke education Acute responded that able to meet most of the time, shift work and reluctance of staff to attend due to staffing situation; rehab responded: meet most of the time on rehab and feel education is a high priority and have reasonable access through various mediums but clinician's time is limited; unable to meet on outpatient as no interdisciplinary team and requests for training are for ortho based learning as this is the most common type of problem seen. 12b Stroke survivor, family, caregiver provided with education across continuum Met most of the time for acute - clinician available Mon-Friday, mild stroke might not be seen before d/c home. Met standard most of the time on rehab - need more information for volunteers, need more specific community groups (aphasia group stopped due to lack of SLP). Not met in outpatients as they don't have the access to family (patients are dropped off), time (therapy session limited to 40 minutes). 13 Equitable access to same level of rehab services regardless of where stroke survivor lives Standard met in acute care but patients might need to be redirected to another DSC when the CT is down in North Bay. Standard of care is facilitated with the use of pre-printed orders but some physicians are reluctant to use them. Met standard in rehab, even consider keeping client longer is services are limited in home community. Not met in outpatients - due to limited therapy time, frequent cancellation of appointments by outpatients services due to therapist being reassigned to cover on inpatient units, scheduling of community transportation with changing appointments. Referrals are being prioritized according to geographical location and out of town referrals are low priority. 14 Rehab Ready moderate or severe strokes will have inpt stroke rehab opportunity if they have rehab goals Met the standard most of the time on acute and limitation is bed availability. On rehab, met the standard always but did indicated that bed availability has an impact. 15 Pts in a CCC or ALC or LTC environment should have access to stroke rehab services Standard met - clients are routinely admitted to rehab from CCC or an ALC bed. 16 Home-based rehab service based on CCAC Stroke BP guidelines NA for NBGH. 17 Interprofessional teams will facilitate linkages for stroke survivors and their family/caregivers after discharge to services in the community including: - Physical help, caregiver training and education, psychosocial counselling where needed - Linkages to community services (driving, peer support etc.), access to primary care practitioners, case management or other system navigation service, respite care, etc. Occasionally being met as clients being d/c home from acute are likely high functioning. The assessment of these high functioning clients is not being thoroughly completed by all disciplines therefore services might not be offered. standard being met most of the time by rehab - they refer to the available services but at times are not informed of new services and that all services are not offered in community (i.e. rec therapy). Occasionally met in outpatients, again not an interprofessional service and time is limited. They do refer to CCAC if they see the need. 18a Max. wait time for inpt stroke rehab should be no more than 2 business days from Rehab Ready and referral Met most of the time on rehab and barriers are bed availability, and discrepancy in determining rehab readiness (screening results from acute care versus rehab varies at times). 18b Maximum wait time for ambulatory & home-based stroke rehab should be no more than 5 days from Rehab Ready and referral Occasionally being met as they don't have dedicated staff for stroke rehab on out-patient. Every attempt is made for the referrals that are labeled urgent to be seen ASAP. 19 Explicit regional stroke rehabilitation services provision model in place In acute care, met most of the time, protocols and timely access to beds, if bed is not available then orders/protocols are being followed off the unit. On rehab unit, met most of the time on rehab however the gap is having the resources to reassess daily/weekly by all treating staff. In outpatients met occasionally as unable to reassess due to lack of human resources and time. 20 Clinical & service utililization data will be used for planning & ensuring equitable access to rehabilitation NA for NBGH - this standard is directed at the LHIN. There is a calculated deficit of 42% for the appropriate number of designated rehabilitation beds in NEO. Legend Minimal engagement of the parties that should be involved, work may be occuring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA) for NBGH

Timmins and District Hospital (TDH) Stroke Rehabilitation Standards Report Card, 2008 Standard Standard Summarized Comments Acute stroke patients(pts) will have an early initial rehab Ax within 24-48 hours; no weekend delay Monday to Friday 90% of our stroke patients are seen with in 24-48 hours except if they have a medical condition that inhibits an assessment however there are no assessments done on the weekend due to a lack of human resources. 2 Ambulatory or home-based screening Ax within 2 weeks for all stroke survivors not admitted to inpatient rehab bed There is no such program in place at this time. Many patients are referred to CCAC which is then serviced on a need priority basis. On the whole all our stroke patients are seen in our Secondary Stroke Prevention Clinic are assessed by our NP within two weeks but no allied health assessments are done at that time. 3a Moderate or severe stroke pts reassessed at regular intervals Patients are reassessed regularly and a rehab application is filled out in order to give the heads up with respect to a potential rehab candidate. 3b Periodic reassessment of rehab needs of the stroke survivor at regular intervals upon D/C (6wks, 3 mos, 1 yr) A formal stroke specific outpatient 'recheck' or 'follow-up' clinic does not exist at TDH or through CCAC. No overarching coordinated process exists. 4 Mechanism to access or reaccess rehab, if clinically indicated, regardless of time elapsed There is a mechanism in place to reaccess rehab via patients family physician, CCAC or self referral. It is questioned how aware the patients and family physician are of this process. 5 Standardized valid assessment tools Our nursing staff utilize the CNS tool; our Stroke Nurse Clinician, NP and stroke physicians utilize the NIHSS; our rehab staff utilize FIM, and the Chedoke-McMaster Stroke Assessment tool; and implementation of the TOR-BSST is under way. 6 Interprofessional team develops a rehab plan with stroke survivor & family based on severity of stroke, needs & goals, home environment, etc. The Multidisciplinary team assesses the stroke survivor individually, the gap is bringing the team together and formulating smart goals by utilizing the Goal Attainment Scale as an effective tool. 7a Mild stroke survivors discharged to the community will be provided with ambulatory services for 1 hour of each appropriate therapy, 2 to 5X/wk as tolerated and indicated by patient need TDH unable to provide this level of care. Lack of funding for human resources is the key issue and there is a large deficit of SLP services. To compensate there is a priority list which is based on the patient's needs. acute Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) Due to lack of staffing on the acute unit at TDH this does not occur. rehab unit Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) This does occur on the rehab unit at TDH with the exception of the provision of SLP. 7c Rehab Ready severe stroke pts will receive the frequency and duration of therapy they can tolerate up to the same targets as moderate stroke pts This does occur on the rehab unit at TDH with the exception of the provision of SLP. 8 All stroke pts will be cohorted in a geographically defined stroke rehab unit with stimulating environment All stroke patients are not cohorted in a geographically defined stroke rehab unit. However improvement has been made by clustering the stroke rehab patients on the same floor and in the same wing. 9a Inpatient rehab will have an interprofessional team with stroke care expertise This is occuring however the team does not have access to a physiatrist or psychologist. 9b Community rehab (i.e. home-based or ambulatory) will provide the stroke survivor with access to an interprofessional team with stroke expertise Outpt stroke rehab (ambulatory) at TDH consists of services from PT, OT and SLP - other members of the core clinical interprofessional team with stroke expertise should include PT, SW, nursing and a physician. Legend Minimal engagement of the parties that should be involved, work may be occurring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA) for TDH 1

TDH Stroke Rehabilitation Standards Report Card, 2008, continued Standard Standard Summarized Comments 10 Post-acute care will be delivered using a collaborative practice model. The interprofessional team will include a physiatrist The interprofessional core team lacks a physiatrist and the team does not have access to a psychologist. Patients with complex seating issues are sent to Sudbury. 11 Repetitive and intense use of novel tasks and integration of skills from therapy are reinforced in daily routine Effort is made by the rehab team to communicate this to the families and nursing staff but there are still gaps noted - the process must be improved. 12a Interprofessional team has access to stroke education Staff is made aware of educational oppurtunities but as time goes on the cost is forever rising, due to distance we require up to two days for travelling when driving and the air fares are quite expensive. Our staff have taken advantage of the NEO educational fund but their expenses are certainly higher than our southern counterparts. 12b Stroke survivor, family, caregiver provided with education across continuum Part of our Stroke Nurse Clinician's role is to accompany the patient from ER to rehab, the Secondary Stroke Prevention Clinic (SSPC) does teaching as well, and our Stroke Survivor Social (Community Stroke Support Group) is in place. 13 Equitable access to same level of rehab services regardless of where stroke survivor lives Due to our 10 bed unit which we are anxious to increase to a 20 bed unit and the vast territory we cover this can be challenging. 14 Rehab Ready moderate or severe strokes will have in pt stroke rehab opportunity if they have rehab goals TDH performs well with respect to this standard. 15 Pts in a CCC or ALC or LTC environment should have access to stroke rehab services TDH performs well with respect to this standard. 16 Home-based rehab service based on CCAC Stroke BP guidelines NA for TDH. 17 Interprofessional teams will facilitate linkages for stroke survivors and their family/caregivers after discharge to services in the community including: - Physical help, caregiver training and education, psychosocial counseling where needed - Linkages to community services (driving, peer support etc.), access to primary care practitioners, case management or other system navigation service, respite care, etc. TDH performs fairly well with this as our social worker works closely with patients to facilitate their discharge into the community, however this is challenging as our community has large gaps (i.e. psychosocial counselling, respite services). 18a Max. wait time for in pt stroke rehab should be no more than 2 business days from Rehab Ready and referral Due to bed availability this is an issue, there is no home based rehab and we have a long waiting list. 18b Maximum wait time for ambulatory & home-based stroke rehab should be no more than 5 days from Rehab Ready and referral Wait time is greater than 5 days for OT, PT and SLP. 19 Explicit regional stroke rehabilitation services provision model in place TDH is a member of the North Eastern Ontario Rehabilitation Network (NEORN) and this standard is being approached across the Northeast for all rehabilitation services - it is an extensive goal which will require significant time and effort to achieve. 20 Clinical & service utilization data will be used for planning & ensuring equitable access to rehabilitation NA for TDH - this standard is directed at the LHIN. There is a calculated deficit of 42% for the appropriate number of designated rehabilitation beds in NEO. Legend Minimal engagement of the parties that should be involved, work may be occurring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA) for TDH

Sault Area Hospital (SAH) Stroke Rehabilitation Standards Report Card, 2008 Standard Standard Summarized Comments Acute stroke patients(pts) will have an early initial rehab Ax within 24-48 hours; no weekend delay Average wait for stroke patients to access service in acute care is 24-48 hours Monday to Fridays (includes OT/PT/RD/SW and SLP). There is no weekend coverage at this time. 2 Ambulatory or home-based screening Ax within 2 weeks for all stroke survivors not admitted to inpatient rehab bed Currently a formal stroke specific outpatient 'recheck' or 'follow-up' clinic does not exist at SAH or through CCAC. 3a Moderate or severe stroke pts reassessed at regular intervals While in SAH the moderate to severe stroke client is reassessed in acute care daily to ensure that they are appropriate for admission to our short term intensive rehab unit. Once the stroke survivor is in the community it is the responsibility of the community health care professionals to determine if a reassessment is appropriate and refer accordingly. 3b Periodic reassessment of rehab needs of the stroke survivor at regular intervals upon D/C (6wks, 3 mos, 1 yr) As mentioned under 'Standard 2' - currently a formal stroke specific outpatient 'recheck' or 'follow-up' clinic does not exist at SAH or through CCAC. No overarching coordinated process exists. 4 Mechanism to access or reaccess rehab, if clinically indicated, regardless of time elapsed There is a mechanism in place to access or reaccess the short term rehab available at the SAH. It is a physician to physician acceptance either from in town or the surrounding district. Physicians from the surrounding area will contact the hospitalist and the arrangement is made through case management. To access the Regional Rehab centre in Sudbury we are required to complete the application and we have had limited to no success in having our patients accepted for long term rehab in Sudbury. 5 Standardized valid assessment tools In the past year training has occurred (NIHSS, TOR-BSST, CMSA and CAHAI) and further education (AlphaFIM and training more individuals on NIHSS & TOR-BSST ) is planned for this year. A videoconference was also given by the NEO Stroke Network to inform clinicians of the Panel's recommended outcome measures. 6 Interprofessional team develops a rehab plan with stroke survivor & family based on severity of stroke, needs & goals, home environment, etc. SAH performs well with respect to this standard. 7a Mild stroke survivors discharged to the community will be provided with ambulatory services for 1 hour of each appropriate therapy, 2 to 5X/wk as tolerated and indicated by patient need Outpatient (outpt) PT is able to meet this standard, OT can provide 2X/week while SLP would not be able to meet this frequency due to lack of SLP resources. acute Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) At SAH - In Acute Care - Moderate stroke patients DO NOT currently always receive the recommended duration and intensity of therapy due to staffing levels and caseload demands. (Links with 'Standard 1' comments). rehab unit Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) At SAH - In the Intensive Rehabilitation Unit (IRU) - Moderate stroke patients DO receive the recommended duration and frequency of treatment for OT and PT but not always for SLP. 7c Rehab Ready severe stroke pts will receive the frequency and duration of therapy they can tolerate up to the same targets as moderate stroke pts Severe strokes are admitted to IRU and receive the same services as moderate strokes and will remain on that unit as long as they are making gains in their therapy. Once the team feels the patient has reached a plateau and cannot be discharged safely to home or retirement home - the mechanism for transfer is initiated for Complex Care Unit or ALC unit to await placement. 8 All stroke pts will be cohorted in a geographically defined stroke rehab unit with stimulating environment SAH presently performs well with respect to this standard. However, cohorting on the acute stroke unit may be impacted in the future due to bed demands. 9a Inpatient rehab will have an interprofessional team with stroke care expertise SAH performs well with respect to this standard however the team does not have access to a physiatrist or psychologist. 9b Community rehab (i.e. home-based or ambulatory) will provide the stroke survivor with access to an interprofessional team with stroke expertise Outpt stroke rehab (ambulatory) at SAH only consists of PT, OT and limited SLP - other members of the core clinical interprofessional team with stroke expertise should include SW, nursing and a physician. Decreased availability of services in the community has a negative impact on SAH. Legend Minimal engagement of the parties that should be involved, work may be occurring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA) for SAH 1

SAH Stroke Rehabilitation Standards Report Card, 2008, continued Standard Standard Summarized Comments 10 Post-acute care will be delivered using a collaborative practice model. The interprofessional team will include a physiatrist SAH performs well with respect to this standard except for lack of a physiatrist. 11 Repetitive and intense use of novel tasks and integration of skills from therapy are reinforced in daily routine SAH has identified some growth opportunities for nursing staff to meet this standard. 12a Interprofessional team has access to stroke education The NEO Stroke Network provides ed.opportunities for the interprofessional team through various training opportunities (Nursing Best Practice Workshops, Chedoke courses, NIHSS, TOR-BSST, etc) and provides funding assistance for clinicians taking part in stroke related education. The Heart and Stroke Foundation of Ontario has prepared a Stroke Rehab Resource Guide for clinicians as well. The barrier is being able to release staff for education due to lack of clinical staff. 12b Stroke survivor, family, caregiver provided with education across continuum Stroke RNs follow pt from ED through to D/C from hospital - provide extensive ed. and risk factor management for pts and family; IRU - pt and family ed. program; provide ed. for mild stroke and TIA pts D/C from acute care. Also, over the next year education opportunities highlighting communicating with an aphasic stroke survivor will occur. 13 Equitable access to same level of rehab services regardless of where stroke survivor lives SAH accepts stroke patients from NEO communities outside of Sault Ste. Marie. It is hoped that the Northeastern Ontario Rehabilitation Network will be able to assist in clarifying the boundary issues that arise between the NEO hospitals with designated rehab beds. 14 Rehab Ready moderate or severe strokes will have inpt stroke rehab opportunity if they have rehab goals SAH performs well with respect to this standard. 15 Pts in a CCC or ALC or LTC environment should have access to stroke rehab services OT, PT and SLP is available for CCC and ALC and LTC if clinically indicated and motivated patient however not as a specialized stroke service. 16 Home-based rehab service based on CCAC Stroke BP guidelines NA for SAH. 17 Interprofessional teams will facilitate linkages for stroke survivors and their family/caregivers after discharge to services in the community including: - Physical help, caregiver training and education, psychosocial counselling where needed - Linkages to community services (driving, peer support etc.), access to primary care practitioners, case management or other system navigation service, respite care, etc. SAH facilitates linkages effectively prior to the stroke survivor being discharged from either inpatient or outpatient services. However once the stroke survivor is in the community there is no formal system navigation available - this links with 'Standard 3b' which identifies the absence of a formal followup process. 18a Max. wait time for inpt stroke rehab should be no more than 2 business days from Rehab Ready and referral SAH inpt. stroke wait time is no more than 2 business days from Rehab Ready to referral. 18b Maximum wait time for ambulatory & home-based stroke rehab should be no more than 5 days from Rehab Ready and referral SAH has limited outpatient services with OT/PT and SLP can be variable. 19 Explicit regional stroke rehabilitation services provision model in place SAH is a strong member of the North Eastern Ontario Rehabilitation Network (NEORN) and this standard is being approached across the Northeast for all rehabilitation services - it is an extensive goal which will require significant time and effort to achieve. 20 Clinical & service utililization data will be used for planning & ensuring equitable access to rehabilitation NA for SAH - this standard is directed at the LHIN. There is a calculated deficit of 42% for the appropriate number of designated rehabilitation beds in NEO. Legend Minimal engagement of the parties that should be involved, work may be occurring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA) for SAH

Hôpital régional de Sudbury Regional Hospital (HRSRH) Stroke Rehabilitation Standards Report Card, 2008 Standard Standard Summarized Comments Acute stroke patients(pts) will have an early initial rehab Ax within 24-48 hours; no weekend delay Average wait in days for stroke patients to access service in acute care (SJHC-4BC) for 2007/2008 YTD: Physiotherapy (PT) 2.13; Occupational Therapy (OT) 3.27; Social Work 3.86 (SW); Registered Dietitian (RD) 1.64; Speech Language Pathology (SLP) 3.76 (for swallowing issues only as there is no dedicated FTE for communication issues in acute care). A formal proposal for enhanced Allied Health staff has been forwarded to HRSRH Senior Management team by E&M Program. 2 Ambulatory or home-based screening Ax within 2 weeks for all stroke survivors not admitted to inpatient rehab bed Currently a formal stroke specific outpatient 'recheck' or 'follow-up' clinic does not exist at HRSRH or through CCAC. HRSRH Rehabilitation Program is currently examining the feasibility of developing such a service for all rehabilitation patients discharged from IRU. However, the proposed mandate of the follow up clinic, if established, would not encompass the HRSRH stroke population not admitted to a rehabilitation bed. Therefore this need would still be unmet for this population. 3a Moderate or severe stroke pts reassessed at regular intervals While in HRSRH Dr. Graham regularly reassesses the moderate and severe stroke pts to determine if they are appropriate for admission to IRU. Once the stroke survivor is in the community it is the responsibility of the community health care professionals to determine if a reassessment by Dr. Graham is appropriate and refer accordingly. 3b Periodic reassessment of rehab needs of the stroke survivor at regular intervals upon D/C (6wks, 3 mos, 1 yr) As mentioned under 'Standard 2' - currently a formal stroke specific outpatient 'recheck' or 'follow-up' clinic does not exist at HRSRH or through CCAC. No overarching coordinated process exists. 4 Mechanism to access or reaccess rehab, if clinically indicated, regardless of time elapsed Mechanism is a referral to Dr. Graham's office or IRU. It is questioned how aware professionals in the community are of this process. 5 Standardized valid assessment tools In the past year training has occurred (NIHSS, TOR-BSST, CMSA and CAHAI) and further education (AlphaFIM and training more individuals on NIHSS & TOR-BSST ) is planned for this year. A videoconference was also given to inform clinicians of the Panel's recommended outcome measures. 6 Interprofessional team develops a rehab plan with stroke survivor & family based on severity of stroke, needs & goals, home environment, etc. HRSRH performs well with respect to this standard. 7a Mild stroke survivors discharged to the community will be provided with ambulatory services for 1 hour of each appropriate therapy, 2 to 5X/wk as tolerated and indicated by patient need No outpatient (outpt) SLP services are available at HRSRH. HRSRH neuro outpt OT and PT unable to provide this level of care with current staffing complement. acute Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) At HRSRH - In Acute Care - Moderate stroke patients DO NOT currently receive the recommended duration and intensity of therapy due to staffing levels and caseload demands. (Links with 'Standard 1' comments). rehab unit Survivors of a moderate stroke will receive a minimum of 1 hr of direct therapy time for each relevant core therapy for a minimum of 5 days/wk (based on needs and tolerance) At HRSRH - In the Intensive Rehabilition Unit - Moderate stroke patients DO receive the recommended duration and frequency of treatment. 7c Rehab Ready severe stroke pts will receive the frequency and duration of therapy they can tolerate up to the same targets as moderate stroke pts Severe strokes are admitted to IRU for a 2 week trial period and will remain on unit if gains are being made otherwise they will be deemed ALC and transferred to await placement. 8 All stroke pts will be cohorted in a geographically defined stroke rehab unit with stimulating environment HRSRH presently performs well with respect to this standard. However, cohorting on the acute stroke unit may be impacted in the future due to the revised HRSRH admission process. 9a Inpatient rehab will have an interprofessional team with stroke care expertise HRSRH performs well with respect to this standard. 9b Community rehab (i.e. home-based or ambulatory) will provide the stroke survivor with access to an interprofessional team with stroke expertise Outpt stroke rehab (ambulatory) at HRSRH only consists of PT and OT - other members of the core clinical interprofessional team with stroke expertise should include SLP, SW, nursing and a physician. Decreased availablity of services in the community has a negative impact on HRSRH. Legend Minimal engagement of the parties that should be involved, work may be occuring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA) for HRSRH 1

HRSRH Stroke Rehabilitation Standards Report Card, 2008, continued Standard Standard Summarized Comments 10 Post-acute care will be delivered using a collaborative practice model. The interprofessional team will include a physiatrist HRSRH performs well with respect to this standard and is fortunate to have the only physiatrist in NEO as part of the team. 11 Repetitive and intense use of novel tasks and integration of skills from therapy are reinforced in daily routine HRSRH performs well with respect to this standard. 12a Interprofessional team has access to stroke education The NEO Stroke Network provides ed.opportunities for the interprofessional team through various training opportunities (Nursing Best Practice Workshops, Chedoke courses, NIHSS, TOR-BSST, etc) and provides funding assistance for clinicians taking part in stroke related education. The Heart and Stroke Foundation of Ontario has prepared a Stroke Rehab Resource Guide for clinicians as well. 12b Stroke survivor, family, caregiver provided with education across continuum Stroke RNs follow pt from ED through to D/C from hospital - provide extensive ed. and risk factor management for pts and family; IRU - pt and family ed. program; new STEP Program - provides ed. for mild stroke and TIA pts D/C from acute care. Also, over the next year education opportunities highlighting communicating with an aphasic stroke survivor will occur. 13 Equitable access to same level of rehab services regardless of where stroke survivor lives HRSRH accepts stroke patients from NEO communities outside of Greater Sudbury. It is hoped that the Northeastern Ontario Rehabilitation Network will be able to assist in clarifying the boundary issues that arise between the NEO hospitals with designated rehab beds (ie should a patient from Englehart come to HRSRH or go to North Bay General Hospital?). 14 Rehab Ready moderate or severe strokes will have inpt stroke rehab opportunity if they have rehab goals HRSRH performs well with respect to this standard. 15 Pts in a CCC or ALC or LTC environment should have access to stroke rehab services OT and PT is available for CCC and ALC however not as a specialized stroke service and SLP for communication issues is not available. LTC access to rehab is NA for HRSRH. 16 Home-based rehab service based on CCAC Stroke BP guidelines NA for HRSRH. 17 Interprofessional teams will facilitate linkages for stroke survivors and their family/caregivers after discharge to services in the community including: - Physical help, caregiver training and education, psychosocial counselling where needed - Linkages to community services (driving, peer support etc.), access to primary care practitioners, case management or other system navigation service, respite care, etc. HRSRH facilitates linkages effectively prior to the stroke survivor being discharged from either inpatient or outpatient services. However once the stroke survivor is in the community there is no formal system navigation available - this links with 'Standard 3b' which identifies the absence of a formal follow-up process. 18a Max. wait time for inpt stroke rehab should be no more than 2 business days from Rehab Ready and referral Jan. - Dec. 07 - avg. 4 days (HRSRH NRS stroke data). ALC issues result in delays as IRU may not be able to transfer patients awaiting placement to another floor resulting in the Rehab Ready pts admission being delayed. 18b Maximum wait time for ambulatory & home-based stroke rehab should be no more than 5 days from Rehab Ready and referral No SLP outpt services. Wait time for an acute stroke patient over the past year for either neuro outpatient PT or OT was from 4 to 8 weeks. 19 Explicit regional stroke rehabilitation services provision model in place HRSRH is a strong member of the North Eastern Ontario Rehabilitation Network (NEORN) and this standard is being approached across the Northeast for all rehabilitation services - it is an extensive goal which will require significant time and effort to achieve. 20 Clinical & service utililization data will be used for planning & ensuring equitable access to rehabilitation NA for HRSRH - this standard is directed at the LHIN. There is a calculated deficit of 42% for the appropriate number of designated rehabilitation beds in NEO. Legend Minimal engagement of the parties that should be involved, work may be occuring on the standard however less than 40% of the standard is being met Moderate engagement of the parties that should be involved, 40 to 90% of the standard is being met The majority of the parties are engaged and at least 90% of the standard is being met Not applicable (NA) for HRSRH