Community & LTC
Introduction:
For some time after a stroke, the lives of the stroke survivor and the caregiver are dominated by the stroke and its aftermath. Eventually, the impact of the stroke gets smaller and life beyond the stroke expands. The anticipated end result of rehabilitation, and the goal for stroke survivors, is community re-engagement.
Stats:
- 20 000 people have a stroke each year in Ontario
- Approximately 115 000 Ontarians are living with the affects of stroke
- 65% of people with stroke will be left with some level of disability
- Stroke is the leading cause of long term adult neurological disability
- Stroke is the 4th leading cause of death in Canada
- 22% (1 in 5) residents in long term care (LTC) homes have had a stroke
Community re-engagement focuses on processes and supports that maximize the likelihood of stroke survivors feeling empowered and achieving their personal goals.
The components of community re-engagement include:
- Health Management – Stroke survivors are able to manage their health issues to achieve and maintain the highest possible health status. Stroke survivors or caregivers have appropriate access to healthcare resources and a family physician. Ensure that they know and can access primary health care, secondary prevention clinics, community supports (i.e. Community Care Access Centres (CCAC), day programs, outpatient clinics), or hospital services. Stroke survivors also must understand the risk or post-stroke depression.
- Life roles – Stroke survivors are satisfied with life roles and participate in these life roles optimally
- Social network – Stroke survivors are assisted to self-manage goals, outcomes, decisions through identifying a range of contacts, agencies and individuals to form a coordinated resource that recognizes and supports the stroke survivor for abilities, not limitations
- Environment – Stroke survivors achieve maximum independence with abilities by modifying the home or community environment to support life roles or routines.
- Communications – Stroke survivors are able to communicate at an optimal level to express needs, goals, and desires and can participate in desired social interactions.
- Mobility – Stroke survivors can move and access desired leisure and self-care activities, places and roles.
- Caregiver Support – Caregiver copes with care needs of the stroke survivor, while maintaining physical health and emotional and psychological social well being. This may be accomplished by ensuring the caregiver can access community-based resources, respite care and educational opportunities.
Best Practice in Community Re-engagement
- Canadian Stroke Strategy Best Practice Recommendations for Stroke Care 2010
- Case Management Best Practices for Community Stroke Care
- Community Stroke Best Practice Guidelines February 2005
Resources
- Guidelines for Community Based Exercise Programs for People with Stroke
- Exercise Provider Flyer to promote the Guidelines for Community Based Exercise Programs for People with Stroke
- Canadian Physical Activity Guidelines
- Trigger Tool – Supporting Stroke Survivors in Community Re-engagement
- Return to Work
- Return to Work after Stroke Fact Sheets: List of agencies who provide return to work services in Windsor/Essex, Chatham/Kent, Sarnia/Lambton, Thames Valley, Huron/Perth and Grey/Bruce
- Living with Stroke Brochure
- Living with Stroke (LWS) and Moving on after Stroke (MOST) Program Comparison document
- Fitness and Mobility Exercise (FAME) Program
- Raising Children
- Young Carers – A resource for parents document
- Young Carers – A resource for professionals document
- Driving after Stroke for Survivors document
- Driving Fact Sheet for Health Professionals document
- Tips and Tools for Everyday Living resource
- Tips and Tools for Everyday Living Power Point Presentations
- Tips and Tools for Everyday Living Facilitators Manual
- External Resources for Long Term Care – Kent County
- External Resources for Long Term Care – Lambton County
- External Resources for Long Term Care – Middlesex County
- BP (Best Practice) Bloggers for LTC:
- OLTCA Magazine Article: Perceptual Impairments and Stroke
- Equal Access to Community Support or Stroke Survivors and Caregivers: An Advocacy Toolkit for Ontario Stroke Survivors and Caregivers – January 2011
- Ontario Stroke Survivors’ Advocacy Sample MPP Letter
- Guidelines for Community Based Exercise Programs for People with Stroke Poster
- Collaborative Interprofessional Stroke Care in Community Re-engagement Final Report
- Evaluation of the Transition Information Plan (TIP) Tool – November 16, 2009
- Pathways June2009 Update: Putting Words into Action
- Pathways for People with Stroke to Live Fully in the Community – Executive Summary
- Pathways for People with Stroke to Live Fully in the Community – Full Report
- Pathways Poster
- Community and LTC Evaluation Indicators Report
- Health System Pressures Impacting Access to Stroke Services in Long Term Care and the Community document
- Living with Stroke Pilot Report Presentation
Websites
- Personal Support Network of Ontario
- March of Dimes – Stroke Recovery Canada
- Ontario Association of Community Care Access Centres
- Ontario Long Term Care Association
- Ontario Community Support Association
- Canadian Best Practice Recommendations for Stroke Care 2010
- Heart and Stroke Foundation of Ontario
- Evidence Based Review of Stroke Rehabilitation
- StrokEngine
- Prevent Stroke
- Self Management Toolkit
- 310 CCAC
- Stroke Survivor Blog
- Stroke Survivor Association of Ottawa
For more information about community re-engagement initiatives in Southwestern Ontario, please contact:
Paula Gilmore (paula.gilmore@lhsc.on.ca)
Community and Long Term Care Coordinator
Southwestern Ontario Stroke Strategy

