Break Out Session
TSN Annual Forum Dec 03 2013
Theme 3: Accessing ongoing post stroke care in the community
a) Within your
organizations,
what are you doing
well to collaborate
and link your
patients to ongoing
care in the
community?
- Therapeutic transfers and collaborative meeting: formalized meeting between inpatient and outpatient staff and patient/ family prior to d/c
- In house CCAC coordinators and Community Health Navigators (provide 48 hour f/u phone calls to link to appropriate resources once patient is d/c)
- Linkages with community services – Variety Village, Scotia Bank Learning Centre - In house wheeltrans assessments prior to d/c
- Team collaborates in rounds re: d/c planning, bullet rounds - CCAC, HAL, Tele Homecare, IMPACT, CNAP
- Community Health Navigation Role - Transition Coordinator Role
- Providence – Huddle Review patients - Passport, Peer Support
- Resource Centre – Scotia Bank
- Living with Stroke – Heart and Stroke Foundation (HSF) guest speakers
- North York collaboration – St John/ Sunnybrook – expedite mild-moderate CVA respond quickly to outpatient rehab. Initial phases: looking at barriers, creating flow maps, constant communication
- Lakeridge – outreach campaigns to family med. Revised triage tool, updated referral process. Increased volumes of referrals from community. Strain on Stroke Prevention Clinic (timelines).
- Outreach to community members/ positive public.
- Administer of tPA increase in Durham region. Public awareness. - Not enough programs in community for sustainability/ transitions
- Central LHIN/ Aphasia Institute – staff/ community members don’t know about community resources. Access to care for people with language issues
- RMR – E referral, CCAC
- SMART d/c – meeting with patient/ family (gets family and team talking about goals)
- Aphasic patient – Speech Language Pathologist utilize, entire team supportive care conversation including environmental staff, food services
- Stroke Prevention clinic f/u after d/c
- Depressions Scales redone in SPC as a f/u, also done prior to leaving acute unit
- Nurse practitioner involved in patient education group session – BP, diabetes education D/c checklist, phone calls
b) What resources or
services could be
leveraged to
support ongoing
care in the
community?
- Better transitions from IP to home, could therapy be started in the home before d/c?
- Poor communication between CCAC staff (clinical staff) and hospital staff – equipment needs - *better development of an outreach team
- Better transitions between back from home to rehab, need a 2 way flow of communication re: rehab readiness
- Enhanced therapy services through CCAC
- Are therapists going into the home use to working with stroke patients – accessing therapists with stroke background
- Funding for patients going home for extra support - Funding for eg life line, accessing transportation - Continence management nurses
- Outpatient videofluroscopy
- Accessing reasonable prices continence products – continence supply warehouses - Home modification/ renovations
- Recreational based programming
- Leveraging resources to help prevent cognitive decline - Not working in silos
- Community also has a responsibility/ expertise in offering to the hospitals. Two-way. Peers from the community are a big resource
- Patient/ family centeredness. Eg First Nations community
- Language/ cultural barriers – programs that aims towards these groups - Cognitive impairments and patient education. They are not well integrated - Move away from stroke but also link with Diabetes/ schools/ etc
- E.g. Stroke Expo at North York General Hospital, invited community members - Improving transportation/ access to services (Toronto/ GTA link)
- Social Media – Apps “Stroke Link”, virtual community for patient and families as well as staff in GTA, use of volunteers
- How do you make the family resilient? Stroke survivor group, March of Dimes Canada, Peer support – Peers Fostering Hope, Life after Stroke – HSF, Aphasia version – Linda Leduc HSF
- Medicalized framework – does the patient need to be referred to as a person – transitioning to the community
- Recreation therapy – painting to allow for expressive therapy, blossoming into an identity - Dining out of their room, great idea, dining hall used as rec therapy room
- HELP – friendly visiting, volunteer, training provided, appropriate conversations, understanding stroke better, 16 hours in total
c) How can
collaborations be
enhanced to
ensure a positive
patient experience
while accessing
community
resources and
services?
- More transitional programs to enhance provider – provider communication, consistency of goals/ info - *decrease repetition of info and tighten connections
- Look at other pathways to open up lines of communication between what is happening in the hospital and what is happening in the community (increase transparency of what is available across the LHINs, better transfer of info between HCPs across the continuum)
- Have a consistent way for patients to know what services are available to them and how to access them (ie CNAP, Toronto 211)
- Giving someone a personal contract instead of just giving them an organization to access - Enhancing collaboration will enhance transitions
- Community rounds – each individual therapist meet as a group to round on patients – more collaborations - Red book left with patient that all therapists write in
- Invest in technology to improve communication between therapists
- Community coordinators coming into facilities before patient is d/c to give info on resources - Self-manage – having some control on the plan
- Having patient navigators from onset for transition pieces, separate entity, follow up - Interprofessional teams
- Caregivers are often charge with their own health co morbidities. How do you assist them? - Caregiver burden/ respite
- More community based programs at LHIN level
- Have more standardized programs across GTA/ Toronto – keeping the unique needs of each community intact, outcome vs process
- Have a listing of programs – easy access - Accessing community resources and services - 311 Community resource
- f/u phone call from hospital, outreach program, system navigator, assign a lifelong partner? Setting up people for success
- Knowledge exchange
- Ensure clear concise comprehensive d/c form
- Circle of Care form – community service, people’s info, have it on hand, person gives consent, good for education training, statistics, info
- Document – different languages, aphasia patients
- Interactive Help Line – people go to website and find out info, Warm Line FAQ, live chat line - Aphasic patients – 1 CONS, click, map, friendly to aphasia patients
- More opportunities to get together – identify to get together to talk about issues - TSN – calling out to the community, VCoP using the platform
- Better stroke care as part of the continuum
F
d) rom your
discussions, what
should be the top
2-3 process steps
to ensure ongoing
access to stroke
care in the
community?
- Increase resources for severe stroke and patients with cognitive and perceptual impairments (i.e. access to rehab, access to transportation, support with toileting)
- Look at options for re-entry into the system. (ie patient becomes ready for rehab or declines) and then unable to enter rehab
- Increase resources for psychosocial needs of our patients and families
- In hospital collaboration – once in the community there needs to be collaboration within the community resources
- Patient advocate to coordinate care in community - Use of technology (patient/ family apps etc.) - Funding for interpretation
- Community organizations speaking to hospitals
- LHINs to continue talking to wheeltrans/ adapted transport
- Funding for parking as well. Volunteer drivers (HSFO), like they do in cancer care. Link with other diagnostic groups to share resources/ funds
- Early transition from pt to person into community - Ongoing resources
- Circle of care – can even take it to ER, buddy in community - VCoP – something created for the stroke survivor, expand this - Resource guide
- D/c follow up call – voice to speak to, community navigator - CCAC
- Language line – translator
- TIA TAMS unit – 3 hour window, LOS increase, not calculated in factor of model
