Providence Hospital introduces new model of care on Stroke Rehab Unit


For over a year, a group of dedicated staff members in Providence Hospital’s Specialized Stroke Service has been developing a new interprofessional model of care that actively involves patients in their rehabilitation, 24 hours a day, seven days a week.

Through the new model, designed to suit patients in low-tolerance, long-duration rehabilitation, patients are encouraged to take a proactive role in setting goals. This helps the patient’s care team work together to ensure that rehabilitation is part of the patient’s day-to-day life in the hospital, not just when they go for their physiotherapy or speech-language appointments, but when they get in and out of bed, when they get dressed each morning, and when they are walking on the unit, for example.

“Our goal is to enhance the clinical outcomes for our patients as well as their families,” explains director, Patient Care, Carol Jarman. “By becoming more efficient and making the best use of our resources, we can also reduce patients’ length of stay, which will ultimately help the health care system.”

The approach also emphasizes patient-centred care. “Wherever possible, we give patients options with regard to their rehabilitation. It could be a choice on when to have a shower or bath, or the time of day they would like to have therapy appointments. We can’t always accommodate their requests, but we can be more flexible in our routines,” explains Katie Smith, a physiotherapist and member of the interprofessional model of care working group. “Providing patients with choices is empowering and important to a successful rehabilitation.”

The Care Facilitator

Another critical component of the new model is the ‘care facilitator’ role. Under the new model, a care facilitator is assigned to each patient on admission, and acts as the liaison between the patient, family and team members throughout the patient’s length of stay. The care facilitator can be any full-time member of the care team.Smith was one of several staff members from the working group who took on the ‘care facilitator’ role during the pilot project in 2006. “It’s someone the patient can really get to know, so they can talk more openly with about their care plan, especially if they hit any stumbling blocks during their rehabilitation,” she explains.

A recent Patient and Family Satisfaction Survey indicated there was a need to improve coordination and communication within the Specialized Stroke Service, so this new role is expected to help address this challenge. The care facilitator is also the first point of contact for the family. In the event the care facilitator can’t help with a patient or family member’s question, they can direct them to the appropriate person.

“We will evaluate the new model of care after three months, six months and at the end of the year,” says Jarman. Ongoing evaluation of the new model of care will also help ensure best practices are being used.

Customized tools have been developed for the Inter-professional Model of Care to support the team members and care facilitators, as well as to reinforce the model of care’s philosophy, and ensure goals/targets are being met through:

The Roles Video

This is used to promote awareness of the scope of practice of each team member’s profession. Staff interviews are viewed in a video format, where staff speak about what information they can share with the team, and what information they need to know from other professions to more effectively care for patients.

Lanyard Tags

Staff members wear a lanyard tag with messaging that reminds them that rehabilitation continues 24 hours a day, seven days a week.

The Process Map

This map is prominently displayed at the front of each patient’s chart, and follows the patient from pre-admission to post-discharge over a 12-week period. It indicates action items for the care facilitator such as call family for follow-up at the two-week mark, then schedule family meeting at the six-week mark.

Interprofessional Kardex

All professions are featured on this modified version of the kardex used in the Specialized Stroke Program, so that everyone on the team understands who is involved in the patient’s care. It is used to quickly and effectively communicate to staff from shift to shift the basic details, as well as any changes, to a patient’s care and treatment.

Submitted by Providence Hospital’s Specialized Stroke Service.