Background: Waterloo Wellington has a comprehensive system of integrated stroke rehabilitative care. All stroke patients access specialized stroke rehabilitation teams on an inpatient service, regardless of the severity of their stroke. This has enabled this LHIN to be a top performer in Ontario, Canada with respect to FIM efficiency, Rehabilitation Intensity, and proportion of severe strokes accessing rehab.
Methods: Dedicated stroke teams exist in all rehabilitation sites. All stroke patients requiring inpatient rehabilitation access intensive stroke rehab teams regardless of stroke severity. No persons with stroke are admitted to other levels of rehabilitative care, from acute care. To ensure all clinicians were capturing data accurately to show clinical progression, a full refresh of FIM documentation and assessment practices was conducted. Dedicated stroke teams were developed, with a focus on maximizing rehabilitation intensity.
Results: Pre and post implementation data will be presented to demonstrate the success of the model. Data will focus on FIM efficiency,, Rehabilitation Intensity, , and the proportion of severe stroke patients accessing rehabilitation. Results will also demonstrate functional outcomes for severe stroke patients and the proportion that have a discharge disposition other than Long Term Care. Qualitative narratives will outline the cross-system challenges that organizations have encountered using this approach as well as strategies for success. 

Conclusion: Developing a system of care for stroke patients that allows everyone access to intensive rehabilitation results in superior functional improvements, efficiencies in care, and provides patients with severe strokes the opportunity to maximize functional improvements.

AN INTEGRATED STROKE REHABILITATION SYSTEM ACHIEVES IMPROVED PATIENT OUTCOMES FOR ALL SEVERITIES OF STROKE