Fraser Health Authority: Community Engagement Project
Final Report SUMMARY April 2011
Read Full Report: Bridging the Gap Final Report April 2011
UPDATE:
START Program
STroke Assessment, Rehabilitation, and Transitions
A stroke program focused on facilitating independence and community reintegration for people who have have recently had a stroke and are living in the Abbotsford and Mission area. This is a partnership project between Fraser Health Authority, SRABC provincial office and SRABC Abbotsford Branch and the Abbotsford Parks, Recreation & Culture Commission. It represents a great opportunity to demonstrate how stroke recovery programs make a difference in the lives of stroke survivors.
Executive Summary
The transition from specialized medically-based stroke services to the community where the survivor lives, works, and socializes marks the true beginning of life after stroke. Community re-integration represents the longest period of stroke survivorship when viewed from the perspective of the whole continuum of stroke. The transition process for stroke survivors and caregivers back into BC’s communities is informal with no established and proven pathways.
Fraser Health Authority’s Integrated Health Network Community Wellness Initiative provided the Stroke Recovery Association of BC (SRABC) with a grant to establish a system for connecting with stroke survivors within Fraser Health Authority while in hospital, in order to help link them to stroke recovery resources in their community post-discharge.
We began with a theory that offering “reachback”[1] activities, including a modified hospital stroke recovery program and a peer visitation program could strengthen community linkages for stroke survivors between hospital and home. After reviewing relevant documents and literature on community reintegration as well as findings from this project (Section 6), it became very clear that a more systemic approach is required to bridge the gap from hospital to home.
Although this project was very exploratory in nature, a key theme emerging from the findings was the acknowledgement that community reintegration and comprehensive discharge planning are equally important as acute and rehabilitation stroke care.
British Columbia is home to talented and skilled medical and rehabilitation experts who save people who have had a stroke every day. However, what point is there in saving lives if when upon returning home stroke survivors and their families have a poor quality of life or limited independence because they weren’t supported physically, mentally and emotionally in their recovery?
Using qualitative information from 14 in-depth interviews with key informants in the FHA health and community sectors, the project explored the current Stroke Care Pathway at Surrey Memorial Hospital. It also examined the determinants of an effective community linkage and discharge planning process during a stroke survivor and caregiver’s transition from hospital to home.
Findings from the project support that a care pathway for stroke survivors and their families from hospital to home is very complex and highly individualized. Although many respondents felt the current care pathway was working well, several barriers were highlighted including:
- Challenges in completing assessments in a timely manner.
- Limited Human Resources.
- Information through transfers can get lost.
- Disconnect between hospital discharge and community-based services.
- Difficulty in accessing the right type of help at the right time.
- Need for formalized patient and family stroke education.
- An expressed desire from health providers to connect stroke survivors to the community while still in hospital.
Health and service providers need to recognize that there is no “discharge” from stroke recovery. A proposed Community Reintegration Care Pathway is provided as a very tentative approach to define the process from hospital to home (see Appendix B. Community Reintegration Pathway Model). Key aspects to a successful transition include a community-based approach to hospital discharge involving follow up with stroke survivors once back home, on-going support to assist with system navigation and access to support and services in the community.
Future recommendations include:
- Increasing the capacity and resources of SRABC’s Stroke Recovery Branches.
- Improving liaison between community organizations serving stroke survivors.
- Creating a focus on the Community Integration aspect of the BC Stroke Action Plan.
- Closing the gap between discharging patients and ensuring that their needs are met in the community.
- Adequate provision of translation and interpretation services and cultural sensitivity resources.
- Implementing the second phase of this study – a Community Stroke Linkage Program, using the Care Pathway.
