In Ontario, Canada the hospital and the community sectors are funded separately and opportunities for collaboration are not always explored to their full potential.  In 2017, Central West Local Health Integration Network (CWLHIN) Home and Community Care partnered with William Osler Health System (WOHS) to co-design an integrated approach to meet best practice targets for mild stroke patients (Alpha FIM ® > 80).  Shared funding between the hospital and community sectors was obtained to explore innovative ways of providing community stroke rehabilitation services. A review of stroke best practices and environmental scan of existing community rehabilitation programs was the starting point for this work.  Creating a culture of innovation and patient centeredness within the project team and identifying and leveraging the strengths of the involved stakeholders were also critical to this work.  A robust evaluation framework was developed to monitor the program.  

An interdisciplinary cross-sector clinical rehabilitation team was formed.  This team had access to hospital records and the opportunity to treat the client in either the home or congregate settings based on patient goals and needs.  Service levels provided by the rehabilitation team were aligned with the Canadian Stroke Best Practices.  The team received joint orientation and training opportunities to improve stroke knowledge. Problems that arose during the program implementation were addressed during weekly project team meetings.  A dedicated rehab coordinator served as a navigator and assisted patients to develop patient centered goals.

This approach to planning services facilitated cross sector collaboration and innovation in community stroke rehabilitation.

CROSS SECTOR COLLABORATION TO ACHIEVE INNOVATION IN MULTIDISCIPLINARY CLINICAL REHABILITATION