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Bundled stroke care: pilot project

Similar to how a communications company bundles its products, a new bundled care model and team approach for patients recovering from stroke is being tested, with a goal of helping patients transition more smoothly out of hospital and into their homes.

Up until recently, the transition of these patients from one setting to another could sometimes be a confusing and bumpy one due to siloed approaches to care and a lapse in communication between settings.

One Client, One Team: Central and Toronto Central LHIN Integrated Stroke Care is a new provincial approach to integrate care over a stroke patient’s recovery, including a single pathway and team of healthcare providers to cover all the care needs of an individual patient’s hospital care and home care.

As a patient moves throughout the system and back to their home, the majority of their healthcare team remains the same. Services are coordinated around the patient’s needs, resulting in fewer emergency department visits and less risk of being readmitted to hospital.

The aim is to create a seamless experience across the stages of their care as the patient moves between different settings of their care process – acute care hospital, rehabilitation, long-term care or home.

The model includes:

  • Identifying what is important to patients: The Canadian Occupational Performance Measure helps patients identify their goals and rate their performance that is tracked across their recovery, allowing for a more personalized approach to healthcare.
  • Using consistent discharge documentation: My Guide for Stroke Recovery is a stroke passport concept that is being used as a self-management resource for persons with stroke and their families. It has information about upcoming appointments, questions to ask care providers, and resources to support recovery.
  • Warm hand-overs between members of the team: Essential Professional Conversations for Seamless Care are discussions between healthcare providers when there is a transition in care (i.e. when the patient moves from hospital to home) that focus on sharing information to progress care without interruptions and help patients understand what comes next in their care.
  • Care Navigation: A pilot project to understand the navigation functions to help identify and address gaps in the stroke patient’s journey.

The provincial government selected Sunnybrook as the lead organization to support the implementation of this bundled stroke care pilot project, along with five partnering healthcare providers representing acute, home and rehabilitation settings. The team will continue to evaluate the bundled-care model until March 2018.