Central South Regional Stroke Network



Community Partners Roundtable 2019Discussion Questions and Responses for District Outbreak Take a moment to reflect on the ideas generated from 2017 (in your package). What positive changes have you seen in stroke services since then? Have the needs of persons with stroke changed? Has this changed the way you provide service? Let’s revisit the question: “Today, what is our biggest opportunity to improve stroke care in our community?Once again, let’s imagine stroke services in your community in the near future; services are considered “ideal” for everyone. What would this look like? What does it mean for persons with stroke, caregivers, healthcare providers? ------------------------------------------------------------------------------------------------------------Reflection on 2017Gap with transitions due to role + model changes in Brant. (Stroke unit has not landed on a model of service)Community Navigation. (navigate services once home)Positive ChangesImprove Navigation in communityBetter job at connecting with Community PartnerHamilton Community Partners NetworkElectronic Resources. (e.g. Central South, Healthline, Halton Community Information System)Engaging survivors to make aware of resourcesPeers Fostering Hope – offer peer supportSpeak about resourcesDecreased LOS + more efficientDedicated stroke teamsClot Retrieval Therapy (EVT)PFAC – pt inputExpanded windowPublic education (e.g. FAST)Understanding diagnoses, symptoms, + more informationMore happening – better training (aphasia)FLOWImproved patient outcomeEstablished the LHIN Stroke TeamsHelplineMore education for family and providersYounger strokes (different needs, young families/ finances/ vocational issues)Talking more about mental health services for depression (especially challenging for those with aphasia)Linking survivors with survivors – growing and spreadingMore patient and family engagementCommunity training re post – stroke communication through M-PCAP, Halton Peel Community Aphasia Program BIS has a list of com. resources to discharged patients or those that don’t meet criteriaSeveral agencies (MOD, Wellness House, employment services) will complete forms for PWSWW – discharge all appointments listed and set-upCare Dove (WW St. Joe’s) providers can make appointments with other agencies and provide to patientSPC direct booking (HHS) from ED – pt's leave ED with appointmentsPush for dischargeMonarch House – soon will be a piloting intensive aphasia program – focus on return to workAphasia Institute/ MOH making resoucres/ training more accessible and free!Monarch House Waterloo connect with WWRAP MOD follow-up phone calls 3 months, 6 months, 12 months after dischargeNeeds Changed, Service Provision ChangesFee for service (work with insurance)ABA behaviour ( work with BCBA board certified behaviour analysts)D/C pt’s who are going home fasterSeeing more + more complicated pt’sMarginalized cause + youngerPt’s are sicker + more complexIncreased cognitive issues/ cognitive communication impacts new learningTechnology needs to be accessible DATA – common metricsRESEARCH -apps/ tools/ sharing (education for patients) TelehealthYounger sickerSupport system is differentMultiple comorbiditiesReturn to work No income – huge problem + big changeStill a bit siloed – different mental needs how do we meet bothNot much encouragement for the caregivers/ How does the caregiver communicate around the person with stroke whose role changed + how to deal with the person?How do we support the caregiver while in hospital to prepare for the role?When do “Timing It Right”“support Group” - labelNo family supportSystem is not patient- firstSystem hasn’t grown to support increase aging population/ demographicTry creating a System – Integrated System to understand the acute needs – to anticipate those needs + declineWellness House – nimble to adjust + try to meet needs + gear to a particular streamVisited pt prior to PLCThere with medications when pt’s arrived homeVisited home to prevent readmissionBarrier Free access, financial + physicalContinuity of the team + allIdentify + Problem solve financial barrierOther models – what is the best model? Biggest OpportunityCan we make our own MyHealth GPS cards to make patients/ family etc. AwareResources (community services)EquityLTCAffordability (assisted living, RH etc)TransportationHospital to Commuinty TransitionFeedback loop – patientsMore standardized pathwayAccess pertinent info quickly (don’t need to read 100 pages to get it) + communication b/w teamsBetter way to communicate 1 # to callCan’t rely on internetInnovative approach to resourcesRight resource/ Right time/ Right placeMore streamlined + less siloedAge appropriate servicesBuild cross linkagesTherapist – Who to contact, peer + peer connectionsHospital system differentRegional variation + knowing what is availableCommunity NavigationFollow-up supports/ needsHow we give information to patients (i.e. younger generations) Keeping them updatedStill gaps – transportation (especially rural)Those with comm. impairments harder to use transportation services How can PWA arrange own transportationBetter education for service providers to communicate with people with aphasiaCommunity education – how do businesses/ restaurants interact with people with aphasia/ disability (e.g. Tim Hortons – some have stickers on drive thru speakers, if com. impaired please go to window)Connecting the dots...How do we help patients/ GP’s etc know about programsGet our own info on HNHB healthline (eg. Events)Ideal StateCross – continuum app. Capacity including community servicesRegistry for people who have had a stroke + create a networkOngoing cognitive perceptual rehab/ reading + writing 1° preventionInclude family physiciansAccess to LTC + servicesRx at right place + right timeIntegrated + seamlessMore option in community (eg. ADS, OPS, LHIN) Is it an option or is it a continuous!Hub – that has more servicesThere would be services available in a timely wayMISTIE Study – Point person –Case management person + how to ensure resources + connections continued supportOne navigator to follow through patient stroke journey, not just a tool, a personConstant changes in health care systemNo knowledge gaps (re: services)Individualized length of service (e.g. therapy, aphasia programs)MOD peer support program expanded to communityMore opportunities for meaningful life roles for PWSFree pharmacare ................
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