BY SCOTT HADDOW
Health Sciences North in Sudbury and the Independence Centre and Network have formed a partnership to offer a new service for stroke patients to help them navigate the tough haul back to leading a full life.
Health care professionals from both the hospital and ICAN are working together at the Stroke Re-Check Clinic to assist stroke patients reintegrate into the community. The outpatient clinic is designed specifically for stroke patients who have been admitted to hospital and have completed their acute care treatment.
Stroke patients discharged from the hospital are referred to the clinic where they receive outpatient care for up to a year from a multidisciplinary clinical team. As part of this clinic, a stroke community navigator from ICAN works with patients and their families to help access a wide variety of community support services, including post-stroke exercise classes, support groups, transportation and education.
“The process can be overwhelming for patients and their caregivers and families,” said ICAN stroke community navigator Rebecca Bowes. “I have the experience and flexibility to help them. I can go to people’s homes and help connect them with programs. I show people there is help in our community for them. When they first get out, they don’t want to be a patient anymore, but they have to learn how to do things differently. I help motivate them to get out and change their lives for the better. It makes a huge difference.”
In the past, there was no long-term program to keep tabs on stroke patients who are discharged from the hospital. Staff members at both facilities knew there was a huge need for a long-term support program because the first year for a stroke patient is vital.
“It can take people months, even years, to recover from a stroke and some never fully recover,” said Darren Jermyn, regional director of the Northeastern Ontario Stroke Network. “Most people haven’t adjusted to a stroke once they’re released from the hospital. The goal of all this is to prevent a second stroke. We do a lot of medical management in the first year to prevent second strokes because a second stroke is always worse. In the first year, that is when the major improvements occur. The earlier we start with stroke patients, the more success we will have. It has never been co-ordinated and we’re trying to make it one big system for patients to flow through instead of weaving through it.”
The hospital and ICAN have had a strong partnership in the past, but this new initiative formalizes it. It took three years to develop, and was born out of consultations with the community and stroke patients.
“What we hear from patients is they feel lost and not aware of all the services available to them,” Bowes said.
The clinic serves people from Sudbury and Manitoulin Island, as well as communities as far away as Parry Sound and Elliot Lake. Staff from both sides work together to deliver services seamlessly. Some 450 stroke patients go through the Sudbury Emergency Department each year and 350 are admitted to hospital. The clinic will help any stroke patient, whether they recently had a stroke or suffered one years ago. Stroke is the third leading cause of death in Canada, accounting for six per cent of all deaths.
“Stroke recovery is different for everyone,” Jermyn said. “Fifty per cent of patients experience depression. The issues are wide ranging in recovery. There’s no certain menu to develop or follow. It takes a strong and dedicated family to make the recovery process better. If they try to do it alone, it can be worse. Needs change over time and we have to follow patients for a long time to help them.”
ICAN’s Post-Stroke Transitional Care Program also includes a new barrier-free, four-bedroom transitional apartment specially designed and equipped for stroke patients who need some assistance in a safe living environment before transitioning back to their homes.
It has already proved successful. A patient recently ended an eight-week stay in the unit and the results impressed staff.
“When she first came here, she rated her recovery at 50 out of 100. When she left, she rated her recovery at 85 out of 100,” Bowes said. “Her daughter told us she has her mom back. You can’t measure that in numbers. The patient learned how to take her blood pressure and got confidence back in her life thanks to having a support team behind her. She made goals and reached them and her mood changed for the better. She learned there is a life beyond a stroke. It was amazing to see.”
Funding for the program runs out in early 2012, but staff are hopeful that more funding can be secured to keep helping stroke patients transition back into the community.
“It is so obvious we need this,” Bowes said.
