Definitions and Descriptions

Definitions and Descriptions

Advance Care Plan is defined as written communication by a competent individual imparting their preferences regarding potential future healthcare decisions. These plans are to be referred to in the event of future incapacity of the individual. 

Advance Care Planning is a process of reflection and communication. It is a time for individuals to reflect on their values and wishes, and to communicate their preferences about future healthcare decisions if they were unable to speak for themselves. (Adapted from: https://www.advancecareplanning.ca/acp-basics/glossary/)

Caregiver refers to a family member or friend who is unpaid and involved in the care of an individual who has had a stroke across their illness and recovery trajectory. They assist with many aspects of care including activities and basic and instrumental activities of daily living, attending to healthcare needs, supporting emotional needs, advocacy, rehabilitation, and community re-integration and resuming life roles. As an integral member of the care team, they need to be recognized and supported in their caregiving role and their capacity to provide the many facets of care.  

Community is defined as the physical and social care environment where individuals may live after having a stroke.  It includes any non-healthcare setting, where one would reside and resume life roles and activities following a stroke, such as a family home, assisted living facility, long-term care, or other habitational settings.  

Community Participation involves return to meaningful engagement in desired basic and instrumental activities of daily living, community interests and life roles, including vocational and educational, following a stroke. The term encompasses the return to active community living and contributing to one’s social groups and family life. Community reintegration includes identifying meaningful goals and, through structured interventions, facilitates resumption of these activities to the best of the individual’s abilities. 

Continuity of Care is the delivery of healthcare services by different providers in a coherent, logical, and timely fashion across the continuum of stroke care. ¹⁴

Goals of Care are the clinical and personal goals for individuals with stroke that are determined through a shared decision-making process. They reflect a shared understanding between individuals, family, caregivers, other support people and the clinical team. (Adapted from the Australian Commission on Safety and Quality in Health Care. ¹⁵)

Integrated Care is a coordinated approach that involves multiple providers from various specialties working together to support an individual’s health and well-being over time. It's a person-centered approach that focuses on what matters to the individual, ensuring that care is continuous and seamless across different settings and providers, as defined by the International Foundation for Integrated Care.¹⁶

Self-management refers to the ability of individuals to manage their health following a stroke to optimize rehabilitation and recovery and prevent recurrent stroke. It includes knowledge, skills, attitudes and behaviours to enhance self-efficacy for managing physical, cognitive and lifestyle changes. It involves active participation of the individual and may include a plan developed collaboratively with healthcare providers, families, and caregivers. 

Stroke System Navigation is a comprehensive and collaborative process that facilitates achieving optimal person-centred outcomes by overseeing, coordinating, and integrating care. This process involves continuous assessment of individual needs and providing wholistic support to individuals, families, and caregivers throughout the stroke recovery journey. By supporting timely access to healthcare services and resources, and mitigating barriers and challenges, stroke system navigation aims to enhance quality of life and promote the highest level of functioning and independence. This process is often overseen by roles such as case managers or stroke navigators, where such resourcing and capacity is available.

Stroke Rehabilitation is a progressive, dynamic, goal orientated process that addresses stroke-related impairments, activity limitations and participation restrictions to optimize individuals’ physical, cognitive, emotional, communicative, and social functional levels. In the complex stage of stroke, rehabilitation may also focus on maintaining current functional abilities and preventing or slowing future functional decline and secondary health conditions (such as depression).

Support refers to providing direct care, access to required services, and facilitating linkages to resources to ensure individual, family and caregiver needs, and recovery goals are met throughout the continuum of stroke care. The goal is to manage recovery and optimize health outcomes, participation and fulfillment of life roles. Support needs can change across the illness and recovery trajectory and are most beneficial when closely matched to the individual, family, and caregiver’s current needs.

Types of individual, family and caregiver needs may include:

• Emotional (e.g., providing comfort, listening to problems, coping skills)
• Instrumental (e.g., providing training, organizing services, direct care, connection to required services, helping with household chores, financial support) 
• Informational (e.g., providing information about illness and services)
• Appraisal (e.g., providing feedback about their caregiving activities) 

Transition refers to the movement of individuals across various healthcare locations, services, settings, providers and stages of care and recovery (physical, psychological, emotional, social, environmental).

Transition Management includes working with individuals with stroke, their families, and caregivers to establish and implement a transition plan that includes goal setting which has the flexibility to respond to evolving needs. Successful transition management requires intersectoral collaboration and communication among healthcare providers, individuals with stroke, their families, and caregivers. It encompasses the organization, coordination, education, and communication required as individuals move through the stages and settings for stroke treatment, recovery, reintegration in the community, adaptation, and end-of-life care. Note that a transition plan includes discharge planning.

The goal of transition management is to facilitate and support seamless movement and continuity across the continuum of care, and to achieve and maintain optimal treatment, outcomes, adaptation, and quality of life for individuals with stroke, their families and caregivers. This incorporates physical, cognitive, communication, emotional, environmental, financial and social factors.  

Virtual Health is a broad ‘umbrella term’ that encompasses all the ways healthcare providers remotely interact with and on behalf of their individuals with stroke that does not involve in-person contact.

Virtual Healthcare has been defined as any interaction between individuals and one or more members of their health circle of care, occurring remotely, using any forms of communication or information technologies with the aim of providing and for maximizing the quality and effectiveness of individual with stroke care.

• Virtual care encompasses all means by which healthcare providers interact with individuals separated by space (in different locations) and/or time (synchronicity) - often called virtual visits. 
• A virtual visit is an electronic exchange via teleconferencing, videoconferencing, secure messaging, or audio digital tools, where one or more healthcare providers deliver healthcare services to an individual with stroke.
• Includes: Provider to an individual with stroke/Family, and Provider to Provider.