Engagement Opportunities
The Ministry of Health has made integrated care a priority. As a result, the Toronto Stroke Networks are driven to prioritize this approach in our work. There are many engagement opportunities for our care partners through the Toronto Stroke Networks to support integrated, specialized stroke care. For more information on Toronto Stroke Networks’ initiatives, please contact the Regional Stroke Network coordinator associated with each of the initiatives listed below.
Hyperacute Care
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.
Setting: Cross-continuum
Contact: Lishan.Taneza@unityhealth.to
EStroke - Access to Rehab
Description: To enable timely access and transition to rehab for all patients to the most appropriate post-acute rehab destination
- Monitoring access and transitions for high and low intensity, and outpatient rehab including:
- Automatic acceptance for high intensity rehab patients with AlphaFIM® 40-80 (referred ≤ 7 days post stroke)
- Updating transition resources and delivering staff education
- Data from eStroke will be used to inform system evaluation and identify quality improvement opportunities
Setting: Acute Care, Rehabilitation
Contact: Donna.Cheung@uhn.ca
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.
Setting: Cross-continuum
Contact: Jocelyne.McKellar@uhn.ca
Community Stroke Rehab (CSR)
Description: Using a population-based approach to support care closest to home, this initiative will focus on aligning delivery of and access to CSR in Toronto with the provincial CSR Model of Care. A working group has been convened consisting on members of existing Toronto-based CSR programs and other partners with the goal of implementing a more fulsome model of CSR in Toronto. This group will confirm implementation considerations and determine a work plan to progress towards increased alignment with the provincial CSR Model of Care.
Setting: Outpatient Rehabilitation, Specialized Community Stroke Rehabilitation Services
Contact: Jocelyne.McKellar@uhn.ca
Cognitive Orientation to daily Occupational Performance (CO-OP)
Description: The CO-OP Approach is a functional, patient-centered, problem-solving approach that is associated with improved function, activity performance, participation and self-efficacy in persons with stroke. It enables patients to acquire skills through a process of strategy use and guided discovery. Care providers in the TSN have been offered courses to support the use of CO-OP, including: The 'CO-OP Introductory Workshop Series' and 'Maximizing CO-OP Effectiveness with Family, Caregivers and Healthcare Provider Support'.
Setting: Acute Care, Rehabilitation
Contact: Jaclyn.Gilpin@uhn.ca
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. 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.
Setting: Cross-continuum
Contact: Sandy.Lyeo@sunnybrook.ca
Choices and Changes
Description: The ‘Clinical Utilization and Application of the Guide for Stroke Recovery’ workshop has been integrated into the provincially recognized education framework and workshop: ‘Choices and Changes: Motivating Healthy Behaviours’. This workshop equips clinicians with knowledge and skills to empower and motivate change in patients/clients for better health outcomes.
Setting: Cross-continuum
Contact: jaclyn.gilpin@uhn.ca
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.
Setting: Cross-continuum
Contact: Yasmin.Visram@sunnybrook.ca
Guide for Stroke Recovery (GSR) Resource and Workshop
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.
Setting: Cross-continuum
Contact: Jocelyne.McKellar@uhn.ca
Long-Term Care (LTC) Engagement
Description: Partner with LTC organizations across our region to provide education asn support the implementation of stroke best practices
Setting: Long-Term Care
Contact: Michelle.Mohan@unityhealth.to
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.
Setting: Cross-continuum
Contact: Yasmin.Visram@sunnybrook.ca
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.
Aphasia-Friendly PFEQ (printable version)
Setting: Outpatient Rehabilitation, Secondary Stroke Prevention, and Community Services
Contact: Yasmin.Visram@sunnybrook.ca
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.
Setting: Cross-continuum
Contact: Lishan.Taneza@unityhealth.to
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".
Setting: Cross-continuum
Contact: Sandy.Lyeo@sunnybrook.ca
Stroke Best Practice Education
Description: The Stroke Best Practice Education initiative aims to respond to the learning needs of our clinicians and enhance stroke care by providing a series of interprofessional workshops. These workshops are designed to support best practices and are accessible to stroke care providers across the entire continuum of care within the TSN. The goal is to improve stroke outcomes and ensure consistent, evidence-based care for patients.
Setting: Cross-continuum
Contact: Lishan.Taneza@unityhealth.to
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.
Setting: Cross-continuum
Contact: Sandy.Lyeo@sunnybrook.ca
Stroke Prevention and Awareness
Description: This initiative will develop an educational campaign to inform the public about the risk factors, signs, and symptoms of stroke, along with strategies for lifestyle changes to reduce risk. Essential components will include messaging on the importance of calling 9-1-1 and the concept of "Time is Brain." From an EDI perspective, the campaign will focus on a targeted immigrant population, incorporating community outreach programs, workshops, and partnerships with healthcare providers to offer resources for stroke prevention and management.
Setting: Cross-continuum
Contact: Michelle.Mohan@unityhealth.to
Stroke System Performance
Description: Stroke System Performance was developed to integrate the cross-continuum 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.
- Stroke: standards reports for rehab referral pathways
- 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.
Setting: Cross-continuum
Contact: Tina.Sahota@sunnybrook.ca
Supported Conversations for Adults with Aphasia (SCATM)
Description: The goal of SCA™ is to facilitate understanding and expression of spoken and written messages, and to demonstrate respect for the competence of the person with aphasia. Healthcare providers who participate, will increase their understanding of: (a) aphasia, (b) strategies to enhance communication and participation of individuals with aphasia, and (c) strategies to integrate SCA™ into their daily practice.
Setting: Cross-continuum
Contact: Jaclyn.Gilpin@uhn.ca
TSNs Annual Collaborative
Description: The Annual Collaborative is an annual event held by the TSNs, which brings together Healthcare Partners across the continuum to celebrate system successes, learn about each other’s local work and engage attendees in small group discussions that inform the year’s strategic priorities.
Setting: Cross-continuum
Contact: Tina.Sahota@sunnybrook.ca