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.



Community Reintegration refers to a return to participation in desired and meaningful activities of daily living, community interests and life roles following a stroke event. The term encompasses the return to mainstream family and active community living and continuing to contribute to one’s social groups and family life. Community reintegration is a component in the continuum of care post-stroke; rehabilitation helps clients identify meaningful goals for community reintegration and through structured interventions facilitates resumption of these activities to the best of their abilities. The stroke survivor, family, friends, stroke recovery associations, rehabilitation programs and the community at large are all integral to successful community reintegration.

Successful community reintegration may require health services and community-support services that aim to optimize patient and family functioning and maximize quality of life after return to the community. To achieve these goals, the following are examples of services that may be required for stroke patients, their families and informal caregivers: social support, monitoring of caregiver burden and depression and family interactions, family education interventions, adaptation of social and leisure activities post stroke, leisure therapy, and encouragement to actively participate in all aspects of society (Central East Stroke Network, 2018).

The Toronto West and The South East Toronto Stroke Networks developed the Trigger Tool to help clinicians assist their clients with community reintegration. This tool outlines the 8 components of community reintegration: 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.    

The Central East Stroke Network and the Stroke Network of Northwestern Ontario developed Stroke Survivor Journey Maps which also highlight community reintegration.

Central East Network-The Journey to Recovery After Stroke

Northwestern Ontario Stroke Network-Stroke Journey in Northwestern Ontario

The Stroke Network of Southwestern Ontario conducted focus groups with providers, patients and family members to identify components that facilitate community reintegration.  The findings of this engagement is available in a report titled Pathways for People with Stroke to Live Fully in the Community.

The Stroke Recovery Association of British Columbia Developed the 7 Steps to Stroke Recovery which outlines steps that can be taken to overcome challenges as a result of a stroke.

The Stroke Network of Southeastern Ontario conducted a community consultation in 2015.  The intent of the consultation was to hear stroke survivor, caregiver and health care provider voices and to actionably respond to those stories by charting a course toward improved community reintegration.  This report identifies priority areas for change as identified by the consultation participants as well as the resulting recommendations for charting that course.  





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:

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  CorHealth Ontario 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:


The Stroke Network of Southwestern Ontario developed A Guide for Persons with Stroke about Long Term Care Homes.  This guide includes information that will help stroke survivors and their loved ones make decisions about choosing, moving into, and living in a Long Term Care (LTC) Home.
Knowing what questions to ask, and getting the answers you need, will help you find the Long Term Care Home and the services that best meet your needs.


This report focuses on stroke survivors admitted to complex continuing care and long-term care facilities in Ontario between 2010 and 2015. The report describes stroke survivors’ health status and trajectories of care, and evaluates the nature and extent of rehabilitation therapy and other stroke best practices available in the two types of facilities.  The full report is available  Institute for Clinical Evaluative Sciences website

Hot Topics in the Community


Stroke rehabilitation in the community and outpatient setting was identified as a provincial priority by the eleven regional stroke networks in Fall 2016. To address this priority, a working group from the stroke networks was formed and the resulting components of this work include:
1.       A resource tool outlining methodology to do an estimate demands analysis for stroke outpatient/community rehabilitative services based on a region's own geography.
2.       Summary of common emerging facilitators and change ideas that outpatient (OP) programs have implemented to meet stroke best practices.
3.       A decision making algorithm to assist clinical teams to determine what factors to consider when referring patients to existing programs.

These deliverables are now available on the CorHealth Ontario website.

The Laura Allen report on Community Stroke Rehabilitation Models in Ontario was released by the Ontario Stroke Network on July 4, 2016.  The purpose of this work was to amalgamate the knowledge and lessons learned from the development, implementation, and successes of existing and emerging programs in an attempt to inform and guide the development of future models.



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 GuidelinesThis document will help you provide a safe and effective exercise program. 

Another resource available to clinicians to guide implementation of aerobic exercise programs post stroke is the Aerobics Guidelines This resource is an easy reference summary for clinicians of the Aerobic Exercise Recommendations which were released recently.  An online module to support the implementation of the Aerobics Guidelines can be found here.  A patient's guide titled How Aerobic Activity Can Help You After A Stroke is also available.

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).

FAME is a community-based exercise program developed for people with stroke who have some standing and walking ability.  This program has shown to improve mobility, cardiovascular fitness, arm and hand function post stroke.  A physical therapist or occupational therapist instructed the patient in the program, but the patient did the program independently. 

The Nortwestern Ontario Stroke Network developed the Fitness Instructor Training Programme: Community-Based Exercise for People Living with Stroke.  This resource is an instructor training package in DVD format with the goal to provide a standardized, competency-based approach to training. Completion of the training programme enables non-health care professionals to deliver an exercise programme based on best practice to people living with stroke. This strategy is one way to utilize the expertise of physiotherapists, while more fully integrating community programmes into the continuum of stroke care.

Several Stroke Specific Exercise/Recreation Programs are available in Our Region!

TIME - Together in Movement and Exercise, River Oaks Community Center, Oakville

Central West LHIN Stroke Exercise Classes

Oakville Strokers

‘Sauga Stroke Breakers

TIME-Together in Movement and Exercise: Halton Hills


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.


Ministry of Transportation: Driver Assessment Centres

Additional information about Driving After Stroke in Ontario can be found in a resource developed by the Stroke Network of Southwestern Ontario and Stroke Engine.

Please also see the BrainXchange Driving and Dementia e-learning module.


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:

Resources in the Community

  • Check out the West GTA Stroke Network’s Community Stroke Resource book (updated Fall 2018).  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
    • Regional Health Care Centers

Community Resource Book Button

Referral Forms





IMG_1090Maggie 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.


Copyright ©WestGTAStrokeNetwork - VIEW OUR PRIVACY POLICY