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Health System Level Tools and Guidelines: Community Re-engagement

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

Final Report

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The intention of this committee was to create resources for health service provider organizations and/or teams to support improved processes for the transition of persons with stroke from inpatient care to the community. Each project deliverable may be used as a stand alone resource or in conjunction with the other deliverables to support the development of a transition model. It should also be noted that persons with stroke and their families may also find some resources compiled for this project very useful e.g., Discharge Linkage Checklist. The unique needs of each person with stroke and their caregivers should be taken into consideration in the application of this model.

Implementation Toolkit

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The following toolkit was created by the Ontario Stroke Network’s Provincial Integrated Work Group tasked with developing a Navigation Model to Support Persons with Stroke Transitioning to the Community and is intended to support organizations as they develop new or existing transition models. For further explanation and understanding of this toolkit please refer to the Final Report which expands upon each of the deliverables completed by the work group. Each project deliverable within the toolkit may be used as a stand alone resource or in conjunction with other deliverables.

Provides health system planners with a repository of resources including stroke best practice guidelines and standards of care.