For more information on Toronto Stroke Networks Initiatives please contact your Regional Stroke Network and/or click on the embedded links.
Access to Hyperacute Care in Toronto
Description: The vision for this initiative is that all eligible patients receive timely best practice hyperacute care at the right place to improve outcomes. Many organizations are still not meeting best practice standards for hyperacute care. Organizations have inconsistently and with varying success, implemented walk-in and inpatient code stroke protocols. The TSNs are planning to support implementation and standardization of the process to enable identification of walk-in and inpatient code stroke patients resulting in better outcomes. The TSNs intend to collaboratively develop standard tools, resources and education that can be adapted locally and facilitate the execution of hyperacute care at the right time and the right place.
Click here to learn more about Access to Hyperacute Care in Toronto.
Setting: Cross continuum
Automatic Acceptance & Bed Offers
Description: All patients with AlphaFIM® 40-80 (referred ≤ 7 days post stroke) should receive an automatic bed offer for high intensity rehab. Future work will focus on automatic acceptance/bed offers for all patients (with rehab goals) and a centralized referral intake system to support flow of patients through the continuum of care.
Click here to learn more about the Automatic Acceptance & Bed Offers initiative.
Setting: Acute and inpatient rehabilitation
Building Capacity in Psychosocial and Hopeful Care: Education and Knowledge Translation Program
Description: An evidence-informed, multi-modal education and knowledge translation program for healthcare providers working in stroke care. The purpose of this initiative is to improve the life experience of persons with stroke and their families/caregivers through focused attention on psychosocial care and promoting a culture of hopeful care.
Click here to learn more about the Building Capacity in Psychosocial & Hopeful Care initiative.
Setting: Cross continuum
Canadian Occupational Performance Measure© (COPM©)
Description: The Canadian Occupational Performance Measure© (COPM©) is both a patient reported outcome measure (PROM) and a patient reported experience measure (PREM). It focuses on the patient’s most important needs and measures the most relevant outcomes for the patient. It detects change in a patient’s self-perception of their task and activity performance over time, and supports evidence-based practice. The COPM© can improve the patient’s experience by supporting the clinician’s ability to establish a positive relationship with the patient. The COPM© is being implemented across the continuum from acute care to inpatient and outpatient rehabilitation. The COPM© is utilized to help patients identify their goals and rate their performance and satisfaction to support their recovery journey. The Toronto Stroke Networks (TSNs) are monitoring and reporting on the completion of COPM© to understand patient outcomes using standardized language and to support seamless transitions for the patient.
Click here to learn more about the COPM© initiative
Setting: Cross continuum
Cognitive Orientation to daily Occupational Performance (CO-OP)
Description: CO-OP is is a performance-based, problem-solving approach that enables skill acquisition through a process of strategy use and guided discovery. CO-OP was initially implemented at 5 rehabilitation sites using an evidence-informed knowledge translation approach to facilitate increased access to rehabilitation for persons with stroke and cognitive impairment. CO-OP implementation has been expanded to include acute care, an integrated stroke unit and outpatient rehab.
Click here to learn more about the CO-OP initiative.
Setting: Acute care, Rehabilitation
Community Forum
Description: The Toronto Stroke Networks will be hosting a Community Forum on June 8th, 2022. Community stroke care providers will be invited to attend sessions that will provide education and practical ways to incorporate various community stroke best practice initiatives, tools and resources into their practice.
Click here to learn more about the TSNs Community Forum initiative.
Setting: Community
Essential Professional Conversations (EPCs)
Description: The Essential Professional Conversation (EPC) initiative grew from two previous initiatives: Transitions Improvement for Continuity of Care (TICC) and Knowing Each Other’s Work (KEOW). EPCs are enhanced verbal exchanges between health care providers about patients at the time of the patients’ transition between programs or sites. The goal of EPCs is to facilitate continuity of care and promote hope at an uncertain time for the patient and their family/caregivers. Resources related to EPCs including an orientation e-learning module are available on the EPC page of TSN’s Virtual Community of Practice (click here). These are cross-continuum resource suitable for use by any site.
Click here to learn more about the Essential Professional Conversations initiative.
Setting: Cross continuum
Framework for Implementing Sustainable Change
Description: The Toronto Stroke Networks’ (TSNs) Framework for Implementing Sustainable Change was developed and refined through a series of sessions with regional stakeholders using human-centered design principles. Knowledge obtained from design thinking, prior implementation of TSNs’ initiatives and the Gailbraith’s Star Model analysis were integrated into the framework. A concurrent review of relevant literature was completed to ensure the framework reflected best practice.
The Framework for Implementing Sustainable Change is comprised of three components: self-reflection and collaboration, the implementation cycle, and human factors. Utilization of this framework will facilitate regional implementation of initiatives that support best practice in stroke care.
Click here for more about the Framework for Implementing Sustainable Change initiative.
Setting: TSNs' Team
Guide for Stroke Recovery (GSR)
Description: The Guide for Stroke Recovery (GSR) is a self-management and education resource for persons with stroke and family/caregivers to promote understanding of common issues after stroke and prevention of recurring strokes. This resource is available in PDF format in the following languages: English, Italian, Portuguese, Punjabi, and Simplified Chinese. The GSR website is based on the book and provides practical support through videos, tips and strategies and links to relevant community resources. Two workshops have been developed to support healthcare providers:
- GSR workshop: This 1.5 hour workshop equips clinicians with knowledge and skills to: introduce the GSR and describe its value to persons with stroke, families/ caregivers; support persons with stroke to manage their care and recovery with the use of the GSR; and support patient education, goal setting, transitions of care, and community reintegration.
- Choices and Changes – Utilizing the Guide for Stroke Recovery: Application of the Guide for Stroke Recovery has been integrated into a provincially recognized education framework and workshop, ‘Choices and Changes: Motivating Healthy Behaviours’. This full-day workshop equips clinicians with knowledge and skills to motivate change in patients/clients for better health outcomes.
Click here to learn more about the GSR initiative.
Setting: Cross continuum
Integrated Care for Stroke: System Planning
Description: Leveraging the learnings from the Integrated Funding Model Pilot Project, this work focuses on developing and implementing a system-level approach to integrated funding for stroke. This initiative involves working with system stakeholders across the continuum of care on a geographical hub model, where each hub includes inpatient rehab, outpatient rehab (regular and early supported discharged streams), and home-based rehab (regular and early supported discharge streams). The goal is to create a sustainable stroke care system where outcomes are shared across stakeholders and equitable access and quality stroke care for our patients is maintained
Setting: Cross continuum
Integrated Stroke Care: Automatic Acceptance and Centralized Bed Offers
Description: All patients with AlphaFIM® 40-80 (referred ≤ 7 days post stroke) should receive an automatic bed offer for high intensity rehab. Future work will focus on automatic acceptance for all patients (with rehab goals) to support flow of patients through the continuum of care.
Click here to learn more about the Automatic Acceptance and Bed Offers initiative.
Setting: Cross continuum
Integrated Stroke Care: eStroke Inpatient to Outpatient Referral Pathway
Description: To build an eStroke referral pathway in RM&R for EXTERNAL inpatient to outpatient rehab.
Click here to learn more about the eStroke Inpatient to Outpatient Referral Pathway initiative.
Setting: Cross continuum
Orientation to Stroke Care in Toronto
Description: The Orientation to Stroke Care in Toronto has been created for all new staff working in stroke care. It is a checklist found on the TSNs Virtual Community of Practice (VCoP) that provides high level information and resources available in Toronto’s stroke system.
Click here to learn more about the Orientation to Stroke Care initiative.
Setting: Cross continuum
Patient & Family Experience Questionnaire
Description: The Patient and Family Experience Questionnaire (PFEQ) was implemented in 2017 to help us better understand the experiences people have as they access the system of stroke care in Toronto. In order to capture reflections on the entire experience in the stroke system, the PFEQ is targeted for dissemination when the majority of care is complete (e.g. in secondary stroke prevention clinics and outpatient rehabilitation settings). The PFEQ is available in both paper and online format. Aphasia-friendly versions are also available.
Click here to learn more about the Patient & Family Experience Questionnaire initiative.
Setting: Outpatient Rehabilitation, Secondary Stroke Prevention Clinics, and Community Services
Regional Access to Stroke Unit Care
Description: The vision for this initiative is to Improve patient outcomes by ensuring all persons with stroke have access to stroke unit care across Toronto . It has been shown that individuals who receive stroke unit care have lower mortality rates, reduced impairments and improved quality of life. These benefits are seen in older and younger patients, men & women, and in people with different types of strokes and varying severity. However, In Toronto there is inconsistent access to stroke unit care and there is a widening gap in access compared to provincial performance.
Click here to learn more about the Regional Access to Stroke Unit Care.
Setting: Cross continuum
Standards of Care
Description:As a platform for continuous quality improvement, the Standards of Care resource was created in 2019 and is intended to provide an overview of key stroke best practices and how these practices have been implemented across the continuum in Toronto. The vision for Standards of Care is “to be accountable leaders and innovators, continuously creating and achieving shared best practice standards of excellence in stroke care that are accessible across geographical boundaries".
Click here to learn more about the Standards of Care initiative.
Setting: Cross continuum
Stroke Core Competency Framework (SCCF)
Description: The Stroke Core Competency Framework (SCCF) is an accessible, comprehensive self-assessment tool that will help healthcare providers identify specific learning objectives to support stroke best practice implementation. The SCCF can be used by both new and experienced healthcare providers working across the continuum of stroke care. It was revised provincially and has been adapted for use within the Toronto Stroke Networks.
Click here to learn more about the Stroke Core Competency Framework
Setting: Cross Continuum
Stroke Prevention
Description: The Regional Secondary Stroke Prevention Working Group collaborates on supporting the implementation of best practices as per Ontario’s Stroke Prevention Clinic (SPC) Core Elements and co-developing standardized processes, where applicable, to support equity, access and care to secondary stroke prevention services in Toronto.
Click here to learn more about the Stroke Prevention initiative.
Setting: Stroke Prevention
Stroke System Performance
Description: Stroke System Performance was developed to integrate the data collection and analysis within the TSNs to support system level planning. It includes data from the following:
- Integrated Care Data and Reporting Framework: facilitates accountability for the implementation of best practice integrated stroke care within our regional system.
- eStroke
- Provincial Stroke Report: opportunity to see trending data
The data analysis will also provide the opportunity for organizations to compare themselves to their peers and see the impact of their quality improvement initiatives at the Standards of Care site visits.
Click here to learn more about the Stroke System Performance initiative.
Setting: Cross-Continuum
Supporting Stroke Best Practices in Primary Care
Description: The TSNs are engaging, building and strengthening partnerships with our Primary Care stakeholders in order to inform, promote and support stroke best practice implementation in this area of practice.
Click here to learn more about the Stroke Best Practices in Primary Care initiative.
Setting: Primary Care
The Integrated Care Data and Reporting Framework
Description: The Integrated Care Data & Reporting Framework was developed to support a standardized approach to data reporting and monitoring at a system and regional level. This facilitates accountability for the implementation of best practice integrated stroke care within our regional system. As well, the timely data collection provides the opportunity for organizations to compare themselves to their peers and see the impact of their quality improvement initiatives.
Click here to learn more about the Data and Reporting Framework
Setting: Cross continuum
TSNs Annual Collaborative
Description: The Annual Collaborative is an annual event held by the TSNs, which brings together Healthcare Providers across the continuum to obtain insight and provide information and current state in relation to the year’s strategic priorities.
Click here to learn more about TSNs Annual Collaborative initiative.
Setting: Cross continuum
TSNs Health Equity Framework
Description: The purpose of this initiative is to give all persons with stroke the best chance to receive the care they need. By doing research to understand the health equity experience of persons with stroke in Toronto, we are creating a stroke-specific Health Equity Framework which will be used to inform all TSNs initiatives, in turn improving patient experience, access to best practice stroke care as well as patient outcomes. We are also working collaboratively with Ontario Health and GTA Rehab Network/Rehab Care Alliance (RCA) to support the development and implementation of health equity indicators that can be centrally collected, and applied to stroke across the continuum. This will assist with stroke system-planning and decision-making.
Click here to learn more about TSNs Health Equity Framework initiative.
Setting: Cross continuum
TSNs Virtual Community of Practice (VCoP)
Description: The Toronto Stroke Networks Virtual Community of Practice (VCoP) is an interactive social media platform for any person working, providing care, researching, and learning in the area of stroke care. The VCoP has been utilized as a knowledge translation resource to support interprofessional collaborative learning and system-wide integration of stroke best practices.
Click here to learn more about the VCoP initiative
Setting: Cross continuum
Virtual Care
Description: This initiative is meant to evaluate the implementation of virtual care in the Outpatient Rehabilitation setting across Toronto and the GTA. This will lead to the identification of successes and opportunities for improvement. In doing this, the goal is to uncover what current resources and best practices exist, and understand the needs of our stakeholders in regards to the use of virtual care in their practice.
Click here to learn more about the Virtual Care initiative.
Setting: Outpatient Rehabilitation, Secondary Prevention Clinics