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New In-Home Intensive Stroke Rehabilitation Program Improves Health Outcomes for Stroke Patients

November 10, 2015, Waterloo – Today, the Waterloo Wellington Community Care Access Centre (WWCCAC) released preliminary results of its new, leading practice, community stroke program – one full year after implementation. The assessment showed that on average, stroke patients experienced a statistically significant, 10‑point increase in their ability to perform basic activities of daily living including: eating, dressing, toilet use, navigating stairs and general mobility, after a 12 week period. Results were measured using the Barthel Index – an index that measures performance and likelihood of being able to live at home with a degree of independence.

Stroke strikes one Canadian every 10 minutes and with our population growing and aging, it's expected that the number of people needing stroke rehabilitation and other forms of post-stroke support will increase.

The WWCCAC's Community Stroke program is unique to the Waterloo Wellington Region and is run in partnership with 5 hospitals across the region, including Grand River Hospital. The program which ensures a seamless transition for patients returning home from hospital provides up to 12 weeks of best practice, intensive, stroke rehabilitation in the home.

"To ensure the best possible outcomes from stroke patients in our community, rehabilitation must extend beyond the walls of a hospital," says Dale Clement, Chief Executive Officer - WWCCAC. "The WWCCAC continues to work with our system partners to look at new and innovative ways to expand capacity across the health care system, while allowing patients to achieve best possible health outcomes in the comfort of their home, which is where they've told us they want to be."

The program works as follows:

  • At each hospital, a designated WWCCAC stroke care coordinator and community occupational therapist is integrated into the discharge planning process. This collaboration between inpatient and community-based teams enables the development of a transition plan that ensures the in-home supports are in place, and there is no disruption in therapy while the patient transitions back to home.
  • Once home, a specialized Care Coordinator oversees the coordination of care from a community-based, interdisciplinary team that provides up to three months of in-home intensive rehabilitation, based on best practice guidelines. The stroke team which includes occupational therapists, physiotherapists, rehab assistants, dieticians, social workers, and/or speech and language pathologists work closely with each patient to reach individual goals and begin the integration back into the community and everyday life.

"The WWCCAC's Community Stroke program incorporates a fully integrated team approach," says Martina Rozsa, Senior Director, Patient Services, WWCCAC. "With the support of a specialized stroke team, patients can return home from hospital and continue to access leading practice stroke rehabilitation as they work toward their personal goals and optimal health"

After a major stroke left a Kitchener man, Cedric Thorne, 71, unable to walk, communicate and eat on his own, his wife, Esmie began to think that she would have no choice but to move Cedric into a long-term care facility. Through the Waterloo Wellington CCAC's Community Stroke Program and the support of an interdisciplinary team of care providers, Cedric was able to avoid long-term placement and return home to continue his intensive rehabilitation. At the end of the 12-week program, Esmie is thrilled that Cedric is now able to talk and eat on his own. Once house-bound, Cedric is now able to leave the house to join Esmie for daily walks and to run errands

"I would never have been able to manage in those early days without the help of the Waterloo Wellington CCAC, I would have had to put Cedric in a home which is not what either of us wanted." says Elsie Thorne.

Based on the successes achieved thus far, plans are underway to expand the interdisciplinary care team to include personal support workers and nurses into the community best practice pathway.

The WWCCAC's Community Stroke Program was named as a leading practice by Accreditation Canada, a third party organization that evaluates the quality and safety of health care organizations, and was nominated for the Minister's Medal an award honouring exceptional work across the health system.


About the Waterloo Wellington CCAC

The Waterloo Wellington Community Care Access Centre (CCAC) connects people with services, helps them get home from hospital and stay home safely, helps them find a place in a long-term care home, and much more. The CCAC works in partnership with hospitals, family doctors, community agencies and others to help patients get the right care at the right time and place. Every day the CCAC helps some 17,000 people in our community.

About the CCAC

Community Care Access Centres (CCACs) connect people across Ontario with quality in‐home and community‐based health care. CCACs provide information, access to qualified care providers and community‐based services to help people come home from hospital or live independently at home.