Building a community of stroke care

Patients at Sunnybrook 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."

The stroke team from Sunnybrook's newest program area, St. John's Rehab, also participates in this quality improvement initiative.

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.

One of those projects includes 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.