In 2009, a community-based rehabilitation services initiative in the South East LHIN called the “Discharge Link” aimed to enhance the intensity and timeliness of community-based rehabilitation therapy for stroke survivors living in this largely rural region. The initiative also sought to improve health system utilization, maximize patient outcomes and increase interprofessional collaboration and stroke expertise.

Through the Discharge Link, eligible patients receive timely rehabilitation therapy with enhanced intensity for the first two months following their hospital discharge, with the highest intensity provided in the first month. The mean number of CCAC visits in the South East LHIN was 10.9 in 2010/11–2011/12, compared to the provincial benchmark of 7.9 (data from the 2010/11 and 2011/12 Ontario Stroke Report Cards). For patients in the South East LHIN referred to the Discharge Link program from an inpatient rehabilitation setting, CCAC rehabilitation intensity increased from 16.4 rehabilitation visits to 25.6 visits in the first three months.

To increase the timeliness of rehabilitation services, therapists initiate rehabilitation for stroke patients within 5 days of hospital discharge. The wait time for rehabilitation services has decreased from 44.0 to 4.4 days. The mean active length of acute care and rehabilitation hospital stay has decreased by 15.7 days without any negative impact on functional outcomes at hospital discharge; a positive impact has been observed in FIM efficiency.

Readmission rates have been lower for patients discharged from acute care who received enhanced CCAC rehabilitation service. These positive results have led to sustained LHIN funding in the South East CCAC base budget for ongoing delivery of the enhanced rehabilitation services.

Results are from the South East LHIN’s evaluation of the Discharge Link initiative (2009 to the present). For more information about the Discharge Link, contact Caryn Langstaff, Regional Stroke Rehabilitation Coordinator for the Stroke Network of Southeastern Ontario at 613-549-6666 ext. 6841, or at langstac@kgh.kari.net.