community AND Long-TERM CARE

Community and Long-term care

Community and Long-Term Care

The stroke survivor’s journey continues long after they have been discharged from the hospital.  It is in the community that much of the stroke survivor’s physical, psychological, and cognitive improvement occurs.  Therefore, as healthcare providers it is important to ensure that survivors and their families have access to the resources, services and tools needed to ensure successful reintegration into the home and community.

Referral Forms


Resources in the Community

  • Check out the West GTA Stroke Network’s Community Stroke Resource book (updated spring 2016 version).  The Community Stroke Resource Book provides stroke survivors, caregivers and healthcare professionals with information on:

    • home support services
    • Specific regional stroke programs and other community services
    • Books, links to other stroke websites
    • Alternative Therapies
    • Regional Health Care Centres

Community Resource Book Button



Following a stroke, it can be difficult for survivors and their families to resume active roles within the community.  Helping the stroke survivor to successfully re-engage in the community is a complex process that involves ongoing collaboration between the clinician, stroke survivor, family, and community supports.

The Toronto West and The South East Toronto Stroke Networks developed the Trigger Tool to help clinicians assist their clients with community re-engagement. This tool outlines the 8 components of community re-engagement: health management, social network, communication, caregiver support, life roles, environment, mobility and financial management (1).

Recognizing that transitioning from hospital to home can often be an overwhelming and emotional time for patients and their families the Toronto Stroke Networks also developed the Community Re-Engagement Cue to Action Trigger Tool (CR CATT)This tool, designed for stroke survivors and their families, acts as a guide to help stroke survivors ask the right questions to ensure that all of their post-stroke needs are addressed.    



21.3% of residents living in LTC Homes are stroke survivors (2).  With over 50 LTC homes in the West GTA, our team is dedicated to promoting the use of stroke best practices within these facilities.  As outlined in the Canadian Stroke Best Practice Recommendations:

(Canadian Best Practice Recommendations, 2013, Section 6.6)

Patients who have experienced a stroke and are transitioned to long-term care should continue to have their physical, functional, emotional, cognitive and social needs addressed to optimize quality of life and meet their ongoing goals of care.”

The updated Best Practice Stroke Care Plans for Long Term Care Homes are now available on the Ontario Stroke Network  website .  These care plans have been updated to reflect the new Heart and Stroke Foundation’s Taking Action for Optimal Community and Long-Term Stroke Care (2015) - a resource for healthcare providers caring for stroke survivors.

The Community & LTC Coordinator of the West GTA Stroke Network can help support your organization with the implementation of the Stroke Care Plans as well as other quality initiatives designed to provide LTC residents with care that reflects best practices. 

For a list of LTC Homes in our region please click on the Central West and Mississauga-Halton healthline icons below:


Hot Topics in the Community


The Laura Allen report on Community Stroke Rehabilitation Modes in Ontario was released by the Ontario Stroke Network on July 4, 2016.

 In the West GTA: Mississauga Halton’s  CCAC Stroke Pathway was mentioned as a program of interest in this report!


Physical exercise post stroke can help to lower a person’s risk of subsequent stroke.  Participating in exercise classes within the community allows the stroke survivor to build a social network, reducing social isolation and improving community reintegration (3).  

“Patients should be provided with a list of community-based resources for engaging in aerobic and leisure activities in the community prior to discharge; they should be referred to relevant agencies as appropriate to provide support in re-engaging in leisure activities” (Canadian Stroke Best Practice Recommendations, 2013, Section 6.5.3)

Are you interested in starting a stroke specific exercise program at your facility?  The Ontario Stroke Network recently released the revised Post Stroke Community Based Exercise Guidelines (2015)This document will help you provide a safe and effective exercise program. 

Need help designing a program for stroke survivors? 

                The (Together in Movement and Exercise) TIMEprogram, developed by Toronto Rehab, is a community based exercise program for persons with balance and mobility issues. This program involves the joint cooperation of both the community organization and a licensed healthcare provider.  A toolkit and license can be purchased online to assist you in starting up a TIME™ program in your community.  The West GTA Stroke Network can help connect you with local healthcare providers who can assist with the training and running of the program (4).

Stroke Specific Exercise/Recreation Programs in Our Region:

Stroke Circuit Training, River Oaks Community Centre, Oakville

Central West CCAC Stroke Exercise Program

Oakville Strokers

‘Sauga Stroke Breakers

Halton Hills T I M E program


Many Stroke Survivors have questions about driving post-stroke.  The resumption of driving is addressed in the Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines (2015).

When ready (at least 1 month post stroke) survivors who are interested in returning to driving must have their sensory, motor and cognitive abilities assessed and, in some cases, their driving tested (5). Below is a list of service providers in the West GTA and surrounding areas that can help get clients back on the road.


CBI Physiotherapy and Rehabilitation

Driver Rehab Therapy

Drive Lab Inc.

Drive Again-Driver Assessment and Training Centre

Ministry of Transportation: Driver Assessment Centres

Frequently Asked Questions about driving post-stroke are answered in the Heart and Stroke Foundation’s Driving After Stroke: Family/Patient Information resources.


Many Stroke Survivors have questions returning to work post-stroke.  Returning to Work post stroke is addressed in the Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines (2015).

“Patients, especially those < 65 years of age, should be asked about vocational interests (i.e., work, school, volunteering) and be assessed for their potential to return to their vocations.(Canadian Best Practice Recommendations, 2013, Section 11)

 The Southwestern Ontario Stroke Network has developed a website to help stroke survivors, family members and health care providers better understand the return to work process:




Maggie Traetto

Regional Community and LTC Coordinator- 905-848-7580 Ext. 5477



Reference List for Community and LTC Page
  1. Toronto Stroke Networks. (2014). Supporting Stroke Survivors in Community Re-engagement
  2. Continuing Care Reporting System, 2014–2015, Canadian Institute for Health Information.
  3. Ontario Stroke Network (OSN) Post Stroke Community Based Exercise Guidelines Working Group (December 2015). Post Stroke Community Based Exercise Guidelines
  4. UHN: Toronto Rehabilitation Institute. (2016). Together in Movement and Exercise. Retrieved from:
  5. Hebert D, Teasell R, on behalf of the Stroke Rehabilitation Writing Group. Stroke Rehabilitation 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.


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