Working Together with Stroke Survivors and their Caregivers

 to Achieve Optimal Outcomes

Components

Goals

Examples

Questions?

Scenario

Patient / Family Education

Provide the right education at the right time

Education needs are to be addressed throughout the continuum of care, at each transition point

What information/education is appropriate for the patient/ caregiver at this transition point?

How do you determine readiness for information?

What format for education is appropriate at this transition?

What tools/ resources are available to use?

How would you monitor uptake of information

Andy’s ( He has concerns wasn’t regaining ability in right arm)  , Sylvia,  Albert

Patient/Caregiver Assessment and recognition that stroke affects the whole family unit

Health, employment, social responsibilities,

 capabilities,

financial resources,

experience and resources are assessed to determine capability  of caring for stroke patient:  

= small children, dependent parents, community responsibilities

Health  + ability to understand, and carry out care and support, and commitment to care giving

Income, Work flexibility, Shift work

What referrals would be appropriate if issues were identified?

Andy ?, Albert ( being addressed by wife)

Patient/ Caregiver Support

Equip patients/ caregivers with the tools and information required to manage their recovery

Training provided as required

Evaluate home environment. Equipment needs, consults with dieticians, services: linkage to homecare, outpatient rehabilitation OT, community resources: handy bus, meals on wheels

What would be an example of tools and information needed to manage a stroke patient requiring assisted transfers?

New scenario: community integration and patient self management, physical management following stroke

Collaborative Care Planning and Goal Setting

Patient/family/caregivers are part of the stroke team and are involved in decision making goal setting and care planning

Gauge patient’s willingness to change, stage of change, what their goals are. Ability to comprehend. Patient and caregiver selected goals.

Important (possibly all scenarios)

Early Discharge Planning

Discharge planning should be initiated as soon as possible after the patient is admitted to each stage and setting of care

Ability to return to pre-stroke life.

What is the vision for discharge disposition for this patient?

(Where are they going next?)

Waiting lists? Lining up Inpatient rehab referrals. Lining up homecare, OT( forms) Educating them about the above, how to use equipment, walkers, wheelchairs.

What tools support discharge planning?

Discharge planning activities may include which of the following?

Do we add this in early checking 4 understanding

Health Professional Communication

Timely and appropriate communication between HC Professionals, patient and family/caregivers

Timely and appropriate referrals

Quality and clarity of information between healthcare professionals/units, patient,  families

Already in scenarios?

Community Reintegration

Pt is able to participate in desired and meaningful activities of daily living

Patient/ family have links to and information about local community supports and survivor groups

Not letting new deficits overtake quality of life (finding a new active normal) support groups, engagements, finding new meaningful activities. Assess for potential to return to work, school or volunteering (previous interests activities).

Cognitive assessments: counselling

example: ability to do banking

Targeted therapeutic leisure / recreation.

Disability supports within the community.

Andy (partial?) others?

Patient Self-Management

Through Self- Management, patient is empowered to have a better quality of life

Patient is an active participant in a plan developed collaboratively with Healthcare Professionals

Self- management: Goal setting, referring them to CDM  programs in community, support goal setting. Learning to manage symptoms better quality of life.

Sylvia? Andy? family involvement - what action showed they were committed to self management?

Physical Health Management Following Stroke, Reaccess

Patients have access to regular and on-going medical follow-up

Patients have access to rehabilitation and restorative care

Secondary prevention of stroke is aggressively managed

Managing their risk factors: ie control diabetes, ( CDM education for hypertension + cholesterol ),    regular follow up to reassess, to avoid deterioration  

New scenario PCN reassessment tool, Using checklist

Stroke Navigators/ Case Managers

Patients/families receive support to successfully transition across the continuum of stroke care

Someone ( or more than one)  who can support navigation through transitions, referrals, calls, forms, what to do next contact number

Just make reference to ---

Successful Transition  to Long Term Care

Patients have continued access to specialized stroke services including rehab services

Good care plan, reassessment, Staff in long term care should be trained and knowledgeable in stroke care. Should be living within active and stimulating environment.

Su? (  LTC often lacking stroke knowledge) How would stroke education for staff  improve Su’s outcome for recovery?