TORONTO, ON – May 1, 2015The Stroke Best Practice Care Plans Implementation Toolkit is helping to change the way residents with a diagnosis of stroke receive care in Long-Term Care (LTC).

This Toolkit includes 12 Stroke Care Plans, tips for implementation, an adaptable PowerPoint presentation and a frequently asked questions document. The Toolkit can be accessed through the Ontario Stroke Network (OSN) website (, the Stroke Network of Southeastern Ontario website ( or the Central South Regional Stroke Network (

The objective of creating the Toolkit was to link stroke best practice information with RAI-MDS data elements and Resident Assessment Protocols (RAPs) through the integration of best practice Stroke Care Plans into existing LTC care plan libraries. The Resident Assessment Instrument – Minimum Data Set (RAI-MDS) is one of the instruments implemented to improve the care of frail, elderly and disabled adults in chronic care and institutional long-term care homes by standardizing the assessment and care planning process.

“The mandatory implementation of the RAI-MDS into all Ontario LTC Homes provided an ideal opportunity to align the measures embedded in that assessment with care plan goal statements,” said Gwen Brown, Regional Stroke Community & LTC Coordinator, Stroke Network of Southeastern Ontario.

In June 2011, a collaborative project between LTC Home representatives from across the province and the Ontario Stroke System Regional Community and LTC Coordinators developed stroke care plans based on the Heart and Stroke resource Tips and Tools for Everyday Living A Guide for Stroke Caregivers©.  The care plans are formatted so that they can be easily integrated into a facility’s existing care planning library .  A library of 12 Stroke Care Plans was developed to support the integration of stroke best practice into bedside care in LTC Homes.  Implementation of the Stroke Care Plans is supported by the Regional Community & LTC Coordinators/Specialists using local expertise, the contents of an Implementation Toolkit and the Tips and Tools for Everyday Living, A Guide for Stroke Caregivers©.

“The development and roll out of the Stroke Care Plans across our organization has been very beneficial to not only the recipients of this very individualized care but also for the interdisciplinary teams providing the care. They have provided us with key areas of focus for those individuals who have experienced a stroke as well as measureable goals and interventions that can be tailored to individual residents.”  Pam Brown, RAI-MDS Consultant, Extendicare Canada Inc.

The Stroke Care Plans were successfully piloted in four Ontario LTC Homes and have since been adopted by two LTC Corporations as well as individual LTC Homes across the province.  A post-pilot survey indicated that stroke care plans enhanced the provider’s ability to effectively care for stroke residents.

“The combination of the Tips and Tools resource and the library Stroke Care Plans provided us with a well-researched, evidence based plan of care,” said Leona Bryan, Nurse Manager, Seven Oaks, a long-term care facility in Toronto..

There are more than 50,000 strokes in Canada each year. Stroke is believed to be one of the leading causes of transfer of elderly individuals to long term care facilities (Statistics Canada, 2010). More than 10 per cent of patients who have experienced a stroke require long term care and 20 per cent of stroke survivors who are identified as having moderate or severe impairments following stroke are discharged to a LTC Home or to Complex Continuing Care. Twenty-two percent of residents in LTC age 65 or older have had a stroke. Stroke is the third most common diagnosis in long-term care


The Ontario Stroke Network (OSN,, created in 2008, is a non‐profit organization funded by the Ministry of Health and Long‐Term Care. The OSN provides provincial leadership and planning for the continuum of stroke care in Ontario—from health promotion and stroke prevention to acute care, recovery, rehabilitation and reintegration.  OSN is committed to creating innovations in stroke prevention and care and regularly evaluates the stroke system, partners to achieve best practices, and promotes excellent stroke care and vascular health while advocating for fewer strokes and better outcomes.



Patrick Moore
Communications Manager, Ontario Stroke Network
(c) 416-455-7394