The Integration of Stroke Best Practice into LTC Resident Care
Planning
Frequently Asked Questions
Q. What are the benefits of using the new Stroke Care Plans?
A. Twenty-two percent of residents in LTC age 65 or older have had a stroke and
stroke is the third most common diagnosis in long-term care. 1,2 These Stroke Care
Plans will facilitate best practice stroke care for those residents while supporting
compliance with:
 Accreditation Canada and other certification standards
 The LTC Act (July 2012)
 MOHLTC Quality Inspector expectations
The Stroke Care Plans were drafted by working groups comprised of representatives
from LTC Homes and the Ontario Stroke System (OSS) to ensure practical application
while optimizing the data available in the RAI-MDS.
Q. What is the Ontario Stroke System?
A. The Ontario Stroke System (OSS) is a collaborative system of provider
organizations and partners who deliver stroke prevention programs and stroke care
across the continuum of care. The OSS is guided by four principles:
 Comprehensive: Improve stroke services across the continuum of care from
prevention to care in a long-term care or community setting.
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Integrated: Create an integrated or coordinated system of care where different
services and sectors function as a unified whole across the continuum of care
and across Ontario
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Evidence-based: Promote the use of practices and care that have been
supported by scientific evidence or are considered the gold standard according to
prevailing knowledge.
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Province-wide: Benefit all Ontarians regardless of their geographic location.
The OSS includes 11 Regional Stroke Centres, 18 District Stroke Centres/Enhanced
District Stroke Centres, 24 Secondary Prevention Clinics, community hospitals, and
many regional partners.
The Integration of Stroke Best Practice into LTC Resident Care Planning
Frequently Asked Questions
April 2013
The Ontario Stroke Network provides provincial leadership and planning for the Ontario
Stroke System by measuring performance, partnering to achieve best practices, and
creating innovations for stroke prevention, care, recovery and reintegration.
In each regional stroke network the Regional Community & LTC Coordinator/Specialist
is responsible for supporting the implementation and sustainability of best practice
stroke care in LTC Homes.
Q. How can I access the Stroke Care Plans?
A. The Stroke Care Plans are included in the attached implementation toolkit. They
may also be found on the Ontario Stroke Network (OSN) website
http://www.ontariostrokenetwork.ca.
Q. Who can I contact for assistance in implementing the Stroke Care Plans?
A. Your regional Community and Long Term Care (C&LTC) Stroke Coordinator would
welcome the opportunity to discuss how s/he might be able to support you in the
implementation process. Support may include: recommending resources, facilitating
education sessions and linking your Home with professionals who have an expertise in
stroke care. You can access contact information for your regional Community and Long
Term Care (C&LTC) Stroke Coordinator through your regional stroke network website.
A listing of the Regional Stroke Networks is available at www.ontariostrokenetwork.ca.
Four Ontario LTC Homes participated in the 2012 pilot and your regional Community
and Long Term Care (C&LTC) Stroke Coordinator can also facilitate a connection with
these facilities.
Q. How many Stroke Care Plans are there and what are they?
A. There are 12 stroke best practice Stroke Care Plans addressing the areas of:
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Cognition
Depression/Mood
Mobility/Transfers
Hydration, Activities of Daily Living (ADL)
Leisure
Skin Care/Hygiene
Bowel and Bladder
Behaviour
Meal Assistance
Nutrition
Communication
Pain
The Integration of Stroke Best Practice into LTC Resident Care Planning
Frequently Asked Questions
April 2013
The Stroke Care Plans were selected based on the modules within the Tips and
Tools for Everyday Living (Heart and Stroke Foundation, 2010). These care plans
reflect the need areas most experienced by residents who have had a stroke event.
Q. How will the Stroke Care Plans work with our existing library?
A. The Stroke Care Plans have been formatted to support adaptation to the specific
protocols and processes within LTC Homes. They are also formatted to reflect the
importance of reflecting resident-specific needs. The Stroke Care Plans may be
implemented as stand-alone plans or integrated into existing care plans either in part or
in their entirety. For example, generic care plans currently housed in LTC Home
libraries on bowel and bladder care may include the interventions contained in the
Stroke Care Plans. Conversely, the Transfers/Mobility Stroke Care Plan will provide
more comprehensive, stroke-specific interventions than would be contained in a generic
plan.
Connecting with your software provider and capitalizing on the expertise of your inhouse RAI Coordinator will facilitate the integration of the Stroke Care Plans into your
current library.
Q. How much will it cost to implement the Stroke Care Plans?
A. There is no cost to obtain the Stroke Care Plans. The cost of implementation will
vary and will be reflective of each LTC Home’s education needs, capacity of staff to
manage the integration of the Stroke Care Plans into existing libraries and other Homespecific needs and requirements. Note that the LTC Homes participating in the pilot
Working Groups and Steering Committee represented diverse profiles in Ontario (e.g.
rural and urban, independent and corporate, large and small). The software programs
used by the participant Homes also represent various companies.
Q. What resources are available to support staff in achieving and sustaining best
practice stroke care?
A. The attached Stroke Care Plan Implementation Toolkit provides information on
available resources.
Q. Have any Ontario LTC Homes implemented the Stroke Care Plans?
A. Four Ontario LTC Homes were involved in the pilot phase of this project. The results
from that pilot have been used to move the project forward. Your regional Community &
LTC Coordinator will be able to facilitate a connection to one of those Homes and/or
another Home in your area who has recently implemented the Stroke Care Plans.
The Integration of Stroke Best Practice into LTC Resident Care Planning
Frequently Asked Questions
April 2013
Q. What did the LTC facilities who participated in the pilot say about the care
plans?
A. The pilot Homes recommended wide dissemination of the Stroke Care Plans as a
best practice initiative. Comments from the pilot Homes included:
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“The opportunity to ensure that our care planning contained best practices and an
evidence base was the foundation for us to move forward in this project.”
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“Staff demonstrated enthusiasm for the project resulting from their own personal
experiences and those of the residents for whom they provide care.”
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“This resource (Tips and Tools for Everyday Living) has been an extremely
beneficial tool which assisted staff to understand brain physiology, risk factors,
stroke impact on life and how the care team can affect resident outcomes.”
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“Tips and Tools for Everyday Living provided an evidence based approach for team
members to assist the stroke survivor to achieve the optimal wellness level and their
full potential. Our staff repeatedly expressed the value of this resource.”
1 Heart
2
and Stroke Foundation of Ontario, 2000
PriceWaterhouseCooper, 2001
The Integration of Stroke Best Practice into LTC Resident Care Planning
Frequently Asked Questions
April 2013