Home Care Program - Community Stroke Care Service An Early Supported Discharge Model of Service Coordination and Rehabilitation

From U of M Internal Medicine Wiki

The Community Stroke Care Service (CSCS) is a centralized Home Care service and has been in operation since 2005. This service applies an Early Supported Discharge (ESD) model, in keeping with evidence-based practice (http://www.strokebestpractices.ca) as described in the Canadian Best Practice Recommendations for stroke care. CSCS provides case coordination, home care support and home-based rehabilitation services, to people with stroke who have been discharged home from either from the emergency department, acute care or rehab, would benefit from support and rehabilitation but do not require inpatient care.

CSCS is funded to provide service for persons with stroke discharged from the Riverview Health Centre Stroke Rehab Unit, HSC and SBGH.

ESD: A service in which patients are discharged from hospital at an earlier point in recovery than would normally occur, and receive intensive home based rehab by a team of stroke rehab specialists. In-home therapy and /or contact with the client at home will begin as early as 48 hours after patient discharge from acute care and within 72 hours of discharge from a stroke rehab unit. Services are provided by a core team including: Case Coordinators, Resource Coordinators, Occupational Therapists, Physiotherapists, Speech-Language Pathologists, Rehabilitation Assistants and a Social Worker and, where appropriate rehabilitation is as intensive as an inpatient rehab setting.

ESD delivered by a comprehensive, well-resourced, coordinated interprofessional team in an acceptable alternative to inpatient rehab for some persons with mild and some moderate stroke and can decrease LOS by 8-13 days, with the same client outcome as inpatient rehab (Level A).

Rationale: Clients who are medically stable, do not require 24 hour nursing care, and can tolerate daily therapy are best served at home. Providing ESD for persons with mild or moderate stroke can eliminate the need for admission to inpatient rehab or more prolonged stays in acute care. This form of community-based rehab demonstrates a 30% reduction in bad outcomes, including death, dependency and institutionalization; patients are discharged earlier and have similar outcomes to inpatient rehab. By providing ESD services for mild and moderate stroke patients and bypassing the need for inpatient rehab, there should be an increased capacity for the some moderately severe and severe stroke patients, many who are currently unable to access rehab services, and thereby reducing premature institutionalization and high ALC utilization for some.

Contact: For additional information, contact Louise Nichol Interro-01.gif phone number?