Stroke Systems of Care

Stroke is on the rise in Canada due to an aging population, as well as an increasing incidence of younger individuals having strokes. Every year, over 108,000 strokes occur in Canada. ² Stroke is a leading cause of adult disability, with 969,000 individuals estimated to be living with the effects of stroke in Canada in 2022-2023.³ The total cost of stroke to the Canadian economy is over $3.6 billion per year. Organized stroke systems of care have been found to reduce rates of mortality and lead to an increased availability of resources including stroke units, specialized healthcare professionals, stroke prevention clinics, and virtual stroke care services. ⁴ This module applies to care provided to all stroke styles, including ischemic, TIA, hemorrhagic and cerebral venous thrombosis, as systems of care follow a similar path.

Ultimately, most individuals who experience a stroke will return to their community, to live independently or with some degree of support. The complexity and needs of individuals living in the community following stroke and their families has been increasing with shorter lengths of hospital stay and longer waits for community services. Individuals with stroke and their families have reported that coordination and integration of services are often major challenges as they try to navigate complex health care and social services, according to the Community Consultation and Review Panel, conducted in 2024. They reported “falling through the cracks” and not being able to meet their short and long-term recovery goals as a result. In addition, social determinant factors such as socio-economic status, education, and geographic location can also pose additional barriers to accessing care. Stroke systems of care need to be designed in partnership with individuals who have experienced stroke, themselves or as caregivers, and incorporate solutions to the barriers and challenges they identify.

This module synthesizes the current evidence for the development and implementation of integrated stroke systems of care and will serve as the foundation for other CSBPR modules by focusing on common, cross functional and higher-level principles and processes of stroke care planning and delivery across the continuum of care (Figure 2). It is critical that integrated and coordinated stroke systems are established locally, regionally and provincially/territorially to optimize timely access to care, optimize outcomes and meet the needs of individuals with stroke, families and caregivers. Healthcare providers and system leaders must work collaboratively with effective communication to ensure continuity of care for individuals with stroke and their families as they transition from one phase and setting of care to the next.

Topics addressed in this module are considered cross-functional and cross continuum. They include the application of core elements of a stroke system, general principles for integrated care, transitions of care, virtual stroke care, education and support for the individual experiencing a stroke, their family and caregivers, stroke care in long-term care settings, advance care planning, and palliative and end-of-life care across the continuum. While primary prevention is an important part of the continuum of care, recommendations related to primary prevention, beyond the importance of strong communication mechanisms, are out of scope for these guidelines.

Stroke best practice recommendations and clinical considerations related to Stroke Systems of Care were, in previous editions, included in other Canadian Stroke Best Practice modules, and for the Seventh edition have been brought together in this module to emphasize the importance of considering these from a more integrated perspective, across phases of care and across all possible settings where stroke care is provided, and where individuals with stroke continue their recovery and resume life roles and community participation. Specific recommendations related to each of these topics may be addressed in individual modules, ^5-11 while the foundational recommendations and supporting materials will be focused on this module.

There is an urgent imperative for health systems of care to address the recovery needs of individuals with stroke, and ensure services and resources are in place and accessible to reduce complications and provide equitable opportunities for all individuals recovering from stroke to achieve optimal health outcomes. The physical, emotional, psychological, social and environmental needs of individuals with stroke are considered throughout this set of CSBP recommendations. Considerations for equity in accessing and receiving needed services and facilitating linkages to resources must be addressed at all stages of recovery.

Notable Updates for CSBPR Stroke Systems of Care, Update 2026 +-

Redevelopment of this module, bringing together topics that cross the continuum of care and provides the general principles and structural elements (Section 1) from a wholistic systems perspective, that other modules can then build on and specify for their topic area.
Stronger emphasis on people-centred care and working with individuals and their family across the full continuum of care and across all transition points.
Development of a comprehensive framework for education of individuals with stroke, their family and caregivers, that considers the individual’s abilities, health literacy, comprehension levels, values and preferences, and offered in a variety of languages. Further these recommendations highlight that all healthcare providers share a responsibility for providing education throughout the stroke journey.
Recognition of the important role of virtual care across the continuum and integration into routine care, where appropriate.
Focus on the importance of advance care planning, palliative and end-of-life care for individuals with stroke along the continuum of care, including consideration of MAiD when appropriate.

Guideline Development Methodology +-

The detailed methodology and explanations for each of these steps in the development and dissemination of the CSBPR is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual.

Conflict of Interest
All potential participants in the recommendation development and review process were required to complete confidentiality agreements and declare all actual and potential conflicts of interest prior to participation. Declared conflicts of interest were reviewed by the co-chairs of the CSBPR Advisory Committee and Heart & Stroke staff to assess the potential impact. Those with significant conflicts with respect to the module topic were not selected for writing group or reviewer roles.

Participants who have conflicts for a particular topic area were identified at the beginning of discussions for that topic and were recused from voting. If a co-chair is in conflict, they were recused from their responsibilities for that discussion, and another non-conflicted participant assumes the role for that discussion and vote. Heart & Stroke senior staff members participated in all writing group discussions and intervene if they perceived an untoward bias by a writing group member.

Conflict of interest declarations for the Stroke Systems of Care module writing group members can be found in Appendix One.

Acknowledgements +-

Heart & Stroke gratefully acknowledges the Stroke Systems of Care writing group leaders and members, all of whom have volunteered their time and expertise to develop these new recommendations. We acknowledge Dr. M. Patrice Lindsay for her efforts as Team Lead and Senior Writer and Editor of this module. Members of the Canadian Stroke Consortium, Can Stroke Recovery Trials Platform, Canadian Neurological Sciences Federation and the Evidence-based Review of Stroke Rehabilitation team were involved in the development of these recommendations. These recommendations (in whole or specific parts) underwent external review by Andrew Dawson, Andrea King, Renee D. Cashin, Luciana Catanese, Michael Kelly, Lisa Korec, Anne Martineau, Kelly Sharp, Shelley A Sharp, Sandy Steinwender, Kristel Smith, Donelda Sooley, and Mary Trainor. The performance measures were reviewed and updated by M. Patrice Lindsay, Amy Yu, Michael D Hill, Aravind Ganesh, Jessalyn K Holodynsky, Raed Joundi, Noreen Kamal, Shannon MacDonald, and Kathryn Yearwood.

We thank the Canadian Stroke Best Practices and Quality Advisory Committee members: Eric E. Smith (Past Chair), Anita Mountain (Co-Chair), Dylan Blacquiere (Co-Chair), Gord Gubitz, Dar Dowlatshahi, Shannon Bayluk, Janice Daitchman, Margie Burns, Emma Ferguson, Thalia S. Field, Mary Lou Halabi, Manraj Heran, Trish Helm-Neima, Michael D Hill, Adam Kirton, Pascale Lavoie, Farrell Leibovitch, Katie Lin, Erin McHattie, Katharine McKeen, Colleen O’Connell, Christine Papoushek, Kara Patterson, Richard H Swartz, Jennifer Yao, and Ruth Whelan.

We acknowledge and thank Norine Foley and the evidence analysis team at workHORSE; Laurie Charest of Heart & Stroke for her coordination of the CSBPR teams and processes; and Francine Forget Marin and the Heart & Stroke internal teams who contributed to the development and publication of these recommendations (Translation, Communications, Knowledge Translation, Lived Experience Engagement Support, Health Policy, and Digital Solutions).

Community Consultation and Review Panel

Heart & Stroke is especially grateful to the members of the Stroke Systems of Care Community Consultation and Review Panel (CCRP) who worked in tandem with the scientific writing group for this module and shared their personal experiences and insights on living with stroke and optimizing recovery and health outcomes. CCRP members include Cyndi Barron, Barry Bowser, Patricia Bukowsky, Heather Quale Goranson, Sarah Lansdown, Cheryl Kimberly Ann MacKenzie, Akira Neeson, Matthew Ranta, and Sydney Reid Smith.

Citing the Stroke Systems of Care, 7^th Edition, 2026 +-

Gary Hunter (Co-Chair), Sacha Arsenault (Co-Chair), Norine Foley, Rebecca A. Bowes, Jacqueline Cochrane, Lisa Collins, Nancy Cox, Sherry Xueying Hu, Mahesh Kate, Lisa McQueen, Jason Moller, Tony Nguyen, Stefan Pagliuso, Trudy Robertson, Annette Samson, Ravinder- Jeet Singh, Lily Zhou, Katie White, Gord Gubitz (Senior Advisor), Trish Helm-Neima (Senior Advisor), Anita Mountain (Advisory Co-Chair), Dylan Blacquiere (Advisory Co-Chair), Rebecca Lund, and M. Patrice Lindsay (Senior Editor, Senior Author), on behalf of the Canadian Stroke Best Practice Recommendations Advisory Committee, in collaboration with the Canadian Stroke Consortium, Can Stroke Recovery Trials Platform, and the Canadian Neurological Sciences Federation. Canadian Stroke Best Practice Recommendations: Stroke Systems of Care, 7th Edition, 2026; Toronto, Ontario, Canada: Heart and Stroke Foundation.

Stroke Systems of Care Module Contents +-