Enhancing communication to improve the continuum of care

IPU Stroke Rehab team
The stroke rehabilitation team attending the 11th World Stroke Congress. From left, Physiotherapist Kenia Balestra, Nurse Evgenia Feigin, Speech Language Pathologist Yasmina Gribi, Occupational Therapists Ruba Sivananthan and Connie Reid, Occupational Therapist and Outpatient Clinical Coordinator Heather Stiglitz, Physiotherapist Thao Dang, Physiotherapist and Clinical Activities Specialist Kate McClurg, Occupational Therapist Joanne Li, Physiotherapist Cristina Marini, Ivy Gumboc, Occupational Therapist and Liaison for the Early Supported Discharge (CPA) program and Diana Chin, Occupational Therapist and Stroke Rehabilitation Program Manager.

This article is the second in a series following the launch of the Neuroscience IPU. Staff who specialize in stroke care from across the CIUSSS have come together to form a single inter-disciplinary team to provide stroke survivors with timely, customized care.

Stroke teams have been committed to providing seamless care long before the Neuroscience IPU was launched this past summer, contends Dr. Jeffrey Minuk, JGH Chief of Neurosciences.

Neuroscience IPU
Neuroscience IPU

“Even as a fledgling stroke team whose area of responsibility was in acute stroke management, we worked closely with rehab partners,” says Dr. Minuk. Although ties between the JGH and other rehabilitation facilities such as the Richardson Hospital pre-date the creation of the CIUSSS, the network has further opened channels between acute care and rehabilitation. Now, patients that are ready to participate in more advanced therapy are more likely to benefit from a smooth, timely and trouble-free transfer. And should the rehabilitation team have concerns about their client’s worsening condition, or in the event of a relapse, the transfer back to the JGH is carried out in the same efficient manner.

Streamlined communication between staff at the different sites can also prevent needless, disruptive transfers. For example, a family physician at the Richardson Hospital might spare their client a trip to the JGH Emergency Department for an evaluation simply by placing a phone call to a JGH Neurologist who is familiar with the patient’s case.

Felicia Guarna, the CIUSSS Director of Rehabilitation, points to another IPU initiative that has helped stroke patients transition with a minimum of hassle from one stage of care to the next. “The stroke team across the sites is now using a common set of evaluation tools to eliminate duplication,” she explains. Patients who are assessed before being transferred out of the JGH will not have to undergo an additional evaluation when they arrive at a CIUSSS rehabilitation centre.

As an example of a tool that has been harmonized across acute care and rehabilitation centres, Malgorzata Karna, the Interim Nursing Clinical Consultant in Neuroscience at the Jewish General Hospital, points to a screening for depression that had been used to evaluate clients of Constance-Lethbridge and the Richardson, which has now also been adopted at the JGH.

“This has been an especially big step forward for our patients,” says Diana Chin, the Richardson’s Stroke Rehabilitation Program Manager, who supervises rehabilitation for stroke patients in the Geriatric Rehabilitation Program. “Harmonizing the tools in all of our CIUSSS facilities may sound like a bureaucratic measure, but it improves the user experience by leaps and bounds, because patients aren’t getting fed up having to re-take tests,” Ms. Chin contends.

“They’re eager to get started as soon as possible. Once they’ve gone through our orientation along with their family members, and have shared their objectives with our team, they can begin their personalized, intensive therapy. Our staff can hit the ground running, because we don’t need to spend as long getting to know the patient. It is also very reassuring for patients, who feel that they are in the hands of professionals who are already familiar with their needs.”

Home is where the healing is  

IPU Kirkland CPA team
The CPA team from the Kirkland site, from left: Registered Nurse Evgenia Feigen; Physiotherapist Thao Dang; Heather Stiglitz, Occupational Therapist and Clinical Coordinator of Ambulatory Services; Speech-Language Pathologist Helen Lewis and Occupational Therapist Anat Lazar.

With recovering stroke patients who are motivated to begin their rehabilitation, the CIUSSS Neuroscience IPU has been pioneering new models of care to deliver therapy without the delays that can frustrate clients, and perhaps even compromise healing.

Chief among them, the Early Supported Discharge program (commonly known by the French Congé Précoce Assisté or CPA), a pilot project that launched in November 2017 offering therapy similar to that offered in in-patient rehabilitation centres such as the Richardson Hospital, carried out instead in the client’s home. This option is available for adults recovering from a mild-to-moderate stroke who are referred directly upon discharge from an acute-care or rehabilitation hospital within our network or the CIUSSS Centre-Sud.

The CPA trajectory minimizes the time spent in hospital altogether, points out Ms. Cox. The patient’s stay in acute care is decreased because they no longer wait for a vacant bed for the next phase in their recovery. They are also able to “skip” being admitted as a patient in a rehabilitation hospital. This helps minimize the risk of hospital-acquired infections. And as an added benefit, flow for all stroke patients is improved because beds are liberated both at the JGH and at the Richardson for people who have experienced a moderate or severe stroke and require intensive therapy, as well as support from the nursing and medical team.

The Notre-Dame-de-Grace CPA team, rear row from left: Diana Chin, Occupational Therapist and Stroke Rehabilitation Program Manager; Physiotherapists Renee Simand and Bessy Megoudis; Educator Andrew Mrozinski; Registered Nurse Evgenia Feigen; Social Worker Tina Recine. Front row, from left,: Heather Stiglitz, Occupational Therapist and Clinical Coordinator of Ambulatory Services; Speech-Language Pathologist Milana Schipper; Administrative Agent Lori Assayag; Ivy Gumboc, Occupational Therapist and CPA Liaison; Occupational Therapist Ruba Sivananthan and Speech Language-Pathologist Yasmina Gribi. Absent from the photo are CPA team members Elyse Berenbaum, Educator and Administrative Agent Bessy Fotinoupolos.

“Many of our clients tell us they prefer receiving therapy at home,” says Occupational Therapist Ivy Gumboc, Liaison for the CPA program for the Richardson Hospital. “It’s no wonder—it is a more meaningful experience for them to cook their meals in their own kitchen rather than a simulation kitchen. We also know that people generally sleep better in their own bed. It helps for our clients to be well rested because they can then be more energetic and focused in their therapy.”

“The greater availability of family to become involved in their loved one’s rehabilitation—when that care takes place in their home—can really help clients to progress in their therapy,” adds Ms. Gumboc. “Family members also appreciate having the recovering patient close, rather than travelling back and forth to a rehab hospital. Of course that arrangement is very motivating for everyone, including the team!”

Qualified clients receive a first visit within 48 hours of discharge from hospital of a specialized team of healthcare professionals dedicated to stroke clients. The CPA team is multidisciplinary, including, as needed, occupational therapists, physiotherapists, special educators, speech language pathologists, a social worker, nurse, neuro-psychologist and the CPA coordinator. A rehabilitation plan is developed based on the team’s evaluation, and always incorporates the input and objectives of the client. The team then leads the client in intensive rehabilitation sessions for up to three hours daily, four or five days a week, for a period of one month in their ‘milieu de vie’.

“This program is life-changing for all stroke patients, because it offers a continuum of services that most closely responds to the individual medical condition and needs of the client,” says Ms. Dupuis. “The CPA is centred on the person, providing care when—and where—it is most beneficial. It exemplifies the integration of hospital and community services, which in health care is the way of the future.”

CPA is the first rehabilitation program of its kind in Quebec. Over one hundred clients have participated until now, including referrals from six Montreal hospitals with dedicated stroke units, with 22 patients coming from the JGH. “There is a hope that the demonstrated benefits of the CPA program will lead to it being adopted province-wide,” says Ms. Cox.

Ambulatory rehab teams move forward together

As stroke patients move through their continuum of care in CIUSSS West-Central Montreal, the team members who work with them are gradually moving on a professional trajectory of their own. They are no longer employees belonging to a single small team, but rather part of a broader-based IPU that’s working collaboratively with patients at every stage of their recovery.

“2019 will be an important year in ambulatory rehab, as all of the teams come together to identify the best way to make the most of each client’s journey,” says Nancy Cox, Coordinator of Rehabilitation at Richardson Hospital and at the Lethbridge-Layton-Mackay Rehabilitation Centre.

“Historically, stroke patients had many stops and starts as they went from team to team,” notes Ms. Cox. “These transitions were not always smooth. Patients had to re-explain their history, and there were communication challenges for the transfer of information. The teams themselves did not fully understand what services existed at the next step, which made it hard for them to reassure and prepare a patient for the transition.”  

“Stroke clients deserve support and help to prepare for the various phases of their recovery,” she adds. “They need our guidance to identify and address their needs, which change over time.” The IPU is bringing together previously distinct teams, who will also improve links with community partners and home-care services.   

Thus, the multi-disciplinary ambulatory team (SARCA in French) that previously provided out-patient care to clients at Richardson Hospital will move to a newly renovated space at Lethbridge-Layton-Mackay. There, its members will work alongside the social-reintegration team (RAIS in French), which traditionally has provided rehabilitation services to clients at a later stage of their recovery. “Reintegration is not only working to resume previous roles and responsibilities,” remarks Ms. Cox. “It is also the process of adapting and discovering new roles for life after stroke.”   

The transfer to Lethbridge-Layton-Mackay comes on the heels of yet another move last year by some members of the Richardson SARCA team, who joined their RAIS colleagues at the Constance-Lethbridge satellite clinic in Kirkland. Working together at that location, they provide specialized stroke rehabilitation to West Island clients.

“The Kirkland clinic is the westernmost site in the CIUSSS. We offer services there in line with the IPU philosophy of flexibility—providing care in a setting that is most convenient to the client,” notes Ms. Cox.

“Minimizing travel is important for our clients recovering from stroke,” she continues, “because rehab can be an extremely demanding process. Routine daily practices, such as bathing, dressing or preparing meals, often require greater effort and take more time. By providing services closer to the environment of the client, we hope to minimize stress for caregivers, who are already coping with the upheaval a stroke causes in a family.”

Pooling rehab expertise across the network

All of these changes are good news for patients and clients, but what effect will they have on staff? What kind of support can employees receive, in order to complete a smooth transition of their own? The solution is to get everyone involved.

Representatives from the entire interdisciplinary team have been invited to join one of five work groups that were recently formed to closely examine key areas of stroke care:

Program development
• revise the service offer to best meet the needs of the stroke clientele

Communication and clinical tools
• evaluate and implement best practices
• identify communication strategies that spare clients from having to repeat already completed steps

Knowledge transfer and training
• familiarize the teams with one another, so that they learn about everyone’s sphere of expertise
• determine what therapists need to know in treating clients

• mobilize the teams through bonding activities in their new environment

Administrative committee
• plan logistics and provide guidelines and support to work groups to help create a smooth transition

“There is a great deal of added value in involving staff in the decision-making process as we redesign our programs,” says Josée Pelletier, Program Manager for Neurology and Traumatic Brain Injury.

This involved having some team members participate in a kaizen-type activity to pinpoint delays and limitations in services across the stroke trajectory. They also completed a survey to identify what, in their professional experience, are the five main difficulties faced by rehab clients.

“We are setting out to create an IPU that will deliver timely and high-quality interventions that are standardized, wherever our clients go,” says Ms. Pelletier. “We are listening closely to feedback from our therapists about what is needed.”

Whether employees have moved to a new site or are sharing a workspace with recently arrived colleagues, they already have shared interests by virtue of having chosen to participate in the same committee, points out Ms. Pelletier.

“The work groups will be a great way for members of staff from different teams and sites to get to know one another,” Ms. Pelletier contends. “This will make the adjustment to a new work environment, and possibly new roles, more agreeable. All along, we’ll be listening with an open mind to our teams’ concerns and questions. And, of course, we will provide the necessary support and training.”

“Our goal in assembling our staff on these committees is to consider how we can best move forward together,” explains Ms. Cox. “How do we achieve that perfect blend?

“For starters, we do so by better understanding everyone’s roles and developing very clear areas of responsibility. We’re asking our staff to reflect on what they do and how they work. It’s a challenging exercise, because we’ll have to let go of some of our established practices and reimagine our way of doing things.”

“What reassures me, through all this change, is one constant: Our rehabilitation professionals understand the deep impact of a stroke on our clients and their families. The members of all of our teams are committed to helping them regain the best possible quality of life.”