Nicola Tahair, Shelley Sharp, Mark Bayley, Elizabeth Linkewich
SUPPORTING ACCESS TO INPATIENT REHABILITATION FOR STROKE PATIENTS WITH COMPLEX NEEDS 
BACKGROUND
A regional Stroke/Musculoskeletal Initiative (2012-14) identified a number of system focused improvements  that resulted in gains in timely access to rehab, standardization of services and alignment of resources. Challenges persisted with accessing inpatient stroke rehabilitation for patients with “complex needs.” Providers interpret “complex needs” differently across the healthcare continuum. 
METHODS
Tools currently used in the system to define complexity were compiled and integrated to form a framework. Cross sector stakeholder engagement sessions were held to validate the framework using clinical profiles.  Stakeholders were also asked to identify changes to cross-sector processes, principles and existing policies to support successful transition of patients with complex needs to rehabilitation and the community.  
RESULTS
The compiled framework reflected the main domains of complexity (psychosocial, functional, medical). Stakeholder input augmented several factors within these domains, including:
-	Psychosocial – role of the patient as a caregiver, family relationships and dynamics, legal/criminal social history.
-	Medical - incontinence, CPAP, cancer treatment, polypharmacy. 
In addition, several previously highlighted complexity factors were removed from the framework. Psychosocial factors were the dominant theme influencing the concept of complexity associated with managing patient discharge from hospital. Prioritized transition enablers were identified: common admission criteria, enhanced capacity for complexity, cross-continuum partnerships to support varied patient needs, and shared accountability. 

CONCLUSIONS
A validated framework is being used to define complexity across the stroke system in Toronto, Canada. Identified enablers provide a foundation for system improvement priorities and tests of change to optimize care for stroke patients with complex needs.