Several times each week, Occupational Therapist Aurélie Hawes leaves Richardson Hospital and heads out to long-term care centres across the Santé Québec West-Central Montreal Health and Social Services University Network. Her unique mission: to help stroke survivors on the path to recovery.
It’s often assumed that when a stroke patient moves into long-term care, rehabilitation is over. In June, Stroke Awareness Month, our network is shining a light on the Mobile Stroke Rehab Team—a small but mighty group that is challenging that reality.
Ms. Hawes, accompanied by a physiotherapist and a speech-language pathologist, helps residents in long-term care with such basic tasks as sitting in a wheelchair for longer periods of time, practicing dressing and hygiene, or helping with swallowing. The team is part of a pilot project that’s now expanding across the Island of Montreal.
The Mobile Stroke Rehab Team (Équipe mobile AVC) was born out of a gap in the stroke care continuum. Patients with more significant physical or cognitive impairments often move directly from acute care to a long-term care centre, with little or no access to stroke-specific rehabilitation.
“Part of the Canadian stroke best-practice guidelines is that every person who’s had a stroke merits stroke-specific rehabilitation,” says Ms. Hawes, Team Liaison at the Richardson Hospital. “The long-term care teams do incredible work, but their mandate is really to maintain functioning.”
“We come in with a different lens, to see how much we can help someone improve.”
Occupational Therapist Aurélie Hawes
The results can be life-changing.
“We see small improvements that make a big difference,” she says. “Getting someone to tolerate sitting a little longer means they can participate more in conversations and spend more meaningful time with family.”
A central component of the team’s work is knowledge transfer. Through coaching, modeling, and collaboration, members help long-term care staff integrate stroke-specific approaches into daily care practices. This ensures that improvements are sustained over time, even after the team’s involvement ends.
“If someone has significant communication deficits and the staff doesn’t have the tools to support them effectively, we can help implement strategies,” says Kate McClurg, Program Manager of the Mobile Stroke Rehab Team at Richardson Hospital.
“It allows the person to express their needs and participate more fully in their care and environment.”
Kate McClurg, Program Manager
Sharing stroke-specific approaches—with staff and families alike—also ensures that residents benefit long after the team moves on.
“There’s a window of opportunity after a stroke to gain as much function as possible,” says Fiona Chan, Program Manager of Rehabilitation Services in long-term care for the Directorate of Rehabilitation and Multidisciplinary Services.
“Our teams in long-term care are dedicated, but they don’t have the capacity for the intensity of therapy needed in those critical weeks,” Ms. Chan says. “The Mobile Stroke Rehab Team fills that gap and what’s truly special is that the goals are always worked on together, collaboratively.”
The mobile team’s initiative aligns with our network’s approach of Care Everywhere, in which staff seeks to achieve the right outcomes by providing the right care at the right time by the right person in the location that is the safest, most appropriate and most convenient for users.
After three years of strong results, the program has expanded to provide services in long-term care sites in Santé Québec Ouest-de-l’Île-de-Montréal – Universitaire.
Nancy Cox, Coordinator of Rehabilitation Programs for Adults with a Motor Disability in our West-Central Montreal network, helped expand the model, bringing together rehabilitation managers and coordinators in a shared goal: ensuring that every stroke survivor has access to the same quality of care.
“We shared the results of our pilot project, and other territories came on board to launch their own pilot initiatives, so that stroke survivors across the island can be served through a similar model,” Ms. Cox says. “You could say we’re pioneers: We’re innovating, sharing our results, and leading the way to better meet the needs of stroke survivors across the continuum of care.”
