Building a Community of Stroke Care

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Patients at Sunnybrook Health Sciences Centre have always had access to exceptional care after experiencing a stroke.  A new initiative has been making that patient experience even better.

Last fall, as a Regional Stroke Centre, Sunnybrook’s stroke services began its implementation of the Toronto Stroke Networks’ Transition Improvement for Continuity of Care (TICC).  This multisite initiative aims at improving communication between acute care, rehabilitation and the community, with the ultimate goal of improving patient experience and outcomes for those living with stroke.

“Stroke recovery is a complex process that involves extensive coordination through the care continuum and over time,” says Beth Linkewich, Director of the North & East GTA Stroke Network and Regional Stroke Centre at Sunnybrook.  “It is critical for us to identify and support transitions with the current changes in service delivery to ensure access to timely and appropriate stroke care, including interprofessional stroke units, intense rehabilitation, and outpatient programs. TICC is the glue that holds the system together.”

“Implementing TICC has helped us strengthen our relationships with rehab facilities around the Greater Toronto Area and makes for a more streamlined transition process from acute care to rehabilitation,” says Jeff Upshaw, patient care manager at Sunnybrook’s Acute Stroke Unit on C4 of the Bayview campus.

The stroke team from Sunnybrook’s newest program area, St. John’s Rehab, also participates in this quality improvement initiative:  “Through TICC, we have been able to open the lines of communication with our acute care partners and therefore ease our patients’ transition through the continuum of care,” says Jennifer Moebs, occupational therapist at St. John’s Rehab’s A3 Neurology and Oncology Rehab Program.

As part of TICC, three pilot projects were introduced in the fall and winter of 2012/2013 to help support transitions through the stroke patient’s care journey.  Each project was developed from the results of interviews conducted with persons with stroke and their caregivers and include the following:

1)      My Stroke Passport: A patient-mediated communication and navigation tool (in the form of a binder) that facilitates seamless, holistic and meaningful care for persons with stroke and their caregivers.  The tool supports patient self-management, education and care collaboration between the patient/caregiver and healthcare providers.  Specifically, it helps patients manage their own care by keeping track of their health, recovery, goals and rehab plans as they move between hospitals and the community. It also includes a resource guide that provides information on stroke-related services.

2)      Knowing Each Other’s Work (KEOW): A series of initiatives for healthcare providers from various disciplines to build on relationships, foster learning, and enhance meaningful collaboration and communication across the system to know each other’s work.  By learning from each other’s practice environments, KEOW enables healthcare providers to deliver the most seamless and optimistic care possible for people living with stroke throughout their journey and across the continuum of care.  The goal is to ensure that essential conversations occur during clinical handover so healthcare professionals at all levels understand what has taken place in order to improve transitions and better meet the needs of persons with stroke and their caregivers.

3)      Peers Fostering Hope: A volunteer program that links stroke patients and their caregivers with peer supporters who have experienced a stroke.  Through a partnership between the Toronto Stroke Networks and the March of Dimes Canada, peers connect with and offer timely support and linkages to persons and caregivers living with stroke, in either acute care or rehabilitation, in an effort to transform the image of stroke to one of hope and possibility.  This one-to-one peer support provides hope, reassurance, and first-hand knowledge of what it is like to experience and live with a stroke.  The process is felt to be reciprocal in that the peers gain self-confidence, reinforcement of coping strategies and personal sense of worth and satisfaction. The value of peer support groups has been shown to have many positive outcomes.

Evaluation of these projects is set to be completed by March 2014 and the results are expected to provide a better understanding of the value and benefits of these programs in order to inform ongoing implementation.

“The anectodal feedback so far has been very positive, suggesting the benefits of the programs are greater than what was anticipated,” adds Linkewich.  “There has been a culture shift towards more collaboration between sites, giving a strong survivor voice and more hopeful optimistic care.”