A Navigation Model to Support Persons with Stroke Transitioning to the Community

Transitions from hospital to the community can be a challenging time for both the stroke survivor and family. The Canadian Best Practice Recommendations state that “patients and families should be provided with information, support, and access to services throughout transitions to the community following a stroke to optimize the return to life roles and activities” (Cameron et al., 2016, p. 815)

In the Fall of 2013, A Navigation Model to Support Persons with Stroke Transitioning to the Community was identified as a provincial priority. To help move this work forward a Provincial Integrated Working Group was formed. The main objective of this group was to develop a set of resources for health service organizations and/or teams to support and improve the processes for the transitioning the stroke survivor from inpatient care to the community.

Work plan

Navigation Model Work Plan January 2013

Final Report

A Navigation Model to Support Persons with Stroke Transitioning to the Community- Final Report (2015)

Deliverables

Additional Documents/Tools

currently there are no additional documents/tools. If you would like more information on the resources used to support the development of this work please contact oh-corh_service@ontariohealth.ca

Regional Use of PIWP Deliverables

Region	Description of Use	Contact Name	Contact Email	Additional Information
Central East	Develop new program Improve current program Other	Alda Tee	cesn@rvh.on.ca oh-corh_service@ontariohealth.ca	Provincial documents and resources shared with navigation roles throughout the region. Information used to inform development of the navigation function as part of a system re-design initiative.
Central South	Implement best practices Develop new program Improve patient outcomes	Stefan Pagliuso	pagliuso@hhsc.ca oh-corh_service@ontariohealth.ca	Central South Regional Stroke Network is currently in the developmental stages of a model for community stroke navigation within the region. The Navigation Model PIWP has provided excellent information and resource for this model development.
Northeastern Ontario	Improve current program Improve patient outcomes Provide new hire orientation	Sue Verrilli Rebecca Bowes	sverrilli@hsnsudbury.ca rbowes@ican-cerd.com oh-corh_service@ontariohealth.ca	The North East area is a pioneer when it comes to community navigation. We have Community Stroke Nagivators in Parry Sound, North Bay, Sault Ste Marie, Timmins, Temiskaming Shores and Sudbury. We partnered with Laurentian University School of Nursing and conducted a three year Community Reintegration Research Project which showed the value of navigation. This was published and was presented at International Stroke Conference. We aim to continue to promote the value, need and impact of COMMUNITY navigation (as opposed to system navigation) across the province. We were well into development of this program when Sue took on co-lead of PIWP. Our program helped inform the deliverables of PIWP group and also, subsequently, the final report and model from the PIWP, in turn, supported our regional program.
Northwestern Ontario	Develop new program Improve current program Evaluate current program	Keli Cristofaro	cristofk@tbh.net nwostroke@tbh.net oh-corh_service@ontariohealth.ca	Navigation model documents used to inform community organization regarding this model of care. Deliverables supported initial discussions however have not moved beyond exploratory phase as yet. Keen interest from community organizations at this time with further discussions to commence.
Southeastern Ontario	Develop new program	Stroke Network of Southeastern Ontario	StrokeNetworkSEO@KGH.KARI.NET	We are curretly exploring navigation models and approaches and the potential application here in the SE. The PIWP provides collated information on some existing programs as well as research supporting the benefits of structured navigation support.
Southwestern Ontario	Implement best practices Develop new program Improve current program Develop business case Improve patient outcomes Perform needs assessment Provide new hire orientation Evaluate current programs Improve access	Margo Collver	margo.collver@lhsc.on.ca oh-corh_service@ontariohealth.ca	Used to support the creation of a joint LHSC/Parkwood Institute pilot stroke navigator position to support transitions from LHSC. Information used to create the job description and support the hiring of a community navigator in Windsor Essex. Trigger Tool from resource repository used in Community Re-Engagement workshops.
West GTA	Implement best practices Develop business case Improve patient outcomes Improve access	Nicole Pageau	nicole.pageau@thp.ca oh-corh_service@ontariohealth.ca	We have had a community Stroke Navigator model for 5 years and are in the process of builidng a business case to expand throughout the WGTASN Region.

Cameron JI, O’Connell CM, on behalf of the Managing Stroke Transitions of Care Writing Group. Managing Stroke Transitions of Care Module 2015. In Lindsay MP, Gubitz G, Bayley M, and Smith EE (Editors) on behalf of the Canadian Stroke Best Practices and Advisory Committee. Canadian Stroke Best Practice Recommendations, 2015; Ottawa, Ontario Canada: Heart and Stroke Foundation