Definitions and Descriptions

Definitions and descriptions

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 chronic 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).

Rehabilitation is NOT a setting, rather, it is a process that includes a set of activities that begins soon after the initial event, once the individual with stroke is medically stable to participate and goals for rehabilitation, recovery and participation can be identified.  

Rehabilitation occurs across the continuum of stroke care in a variety of formal and informal settings such as acute care or sub-acute care; rehabilitation units, on general or mixed rehabilitation units; in ambulatory or community settings, such as outpatient or day clinics, home-based services (incudes early supported discharge and long-term care services), recreation centres, and outreach teams.  

Screening is a process for evaluating the possible presence of a particular problem. Screening is a purposeful action or query for early identification of individuals who may be at risk of developing a specific condition or disorder or problem. Screening may suggest that an issue may exist. Findings from screens can indicate the need for more comprehensive assessment. Screening is usually brief and used to identify possible concerns, not typically to diagnose. Healthcare providers may use preliminary screening measures to support clinical decision making.

Assessment is a process for defining and measuring the nature of a stroke-related health problem, informing a diagnosis, formulating a prognosis, and contributing to developing specific treatment recommendations for addressing the problem or diagnosis. Assessment may also include monitoring response to therapeutic intervention. The purpose of assessment is to gather more specific and detailed information to provide a comprehensive understanding of a potential issue. Assessments will include other information to help provide a broader context of results.

Note: Screening and assessment of individuals following stroke must take into consideration multiple factors. Ideally, both assessment and screening tools should be validated for their specific use and target population to provide the most accurate interpretation of results.

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 said 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/)

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.

Complex Continuing Care (CCC) is a specialized healthcare program for medically complex individuals requiring extended hospital stays and ongoing, intensive medical supervision. It focuses on individuals with multiple interacting chronic conditions who benefit from a coordinated, interdisciplinary approach to care to achieve optimal mental, physical, cognitive, and social well-being. CCC is characterized by specialized services that cannot be effectively managed in a community setting or under the scope of long-term care, emphasizing active care management and a progressive treatment plan tailored to the individual with stroke’s unique needs.

Early Supported Discharge (ESD) is a form of rehabilitation designed to accelerate the transition from hospital to home as soon as medically stable and safe through the provision of rehabilitation therapies delivered by an interprofessional team, in the community. ESD is provided by an interdisciplinary team of rehabilitation professionals and is intended as an alternative to a complete course of inpatient rehabilitation and is most suitable for individuals recovering from mild to moderate stroke.4, 5

Home Care is defined as providing medical, nursing, rehabilitation and personal care services to people in a home setting rather than in a medical facility, to enable people to remain safely in their home by continuing their rehabilitation therapy and increasing their independence.  Home Care can also include respite services to enable caregivers to maintain employment and attend to personal matters.

Integrated Stroke Systems consider all aspects of planning and delivering care, such as access, assessment, treatment, clinical evidence, data, outcomes, benchmarking, guidelines, planning, organization of services, funding, and education.

Long-Term Care is the provision of organized institutional care for people of all ages who need assistance with the activities of daily living (ADL). The goal of long-term care is to ensure that an individual who is not fully capable of self-care and independent living can maintain the best possible quality of life, with the greatest possible degree of independence, autonomy, participation, personal fulfilment and human dignity. The need for long-term care following a stroke is influenced by changing physical, psychological and/or cognitive functional capacities, an individual’s abilities and level of independence prior to the stroke, and the availability of family and caregivers.

Restorative Care is a wholistic approach aimed at enhancing the quality of life and promoting the well-being of individuals. It aims to enhance and maintain functional abilities and overall well-being, focusing on maximizing independence and improving functional abilities through supportive interventions that support maintaining and enhancing existing skills. Restorative care also helps individuals engage in daily activities and achieve their personal goals rather than solely targeting the improvement of specific deficits.

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 Systems of Care are defined as a comprehensive, diverse and longitudinal system that addresses all aspects of stroke care within an integrated, organized and coordinated approach. A stroke system spans the continuum of care from primary prevention to end of life.  A stroke system ensures access to evidence-based therapies which optimize their survival and recovery.

Stroke System Navigation is a comprehensive, collaborative process that facilitates optimal individual with stroke 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.

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) 
• Informational (e.g., providing information about illness and services)
• Appraisal (e.g., providing feedback about their caregiving activities) 

Supportive Living Environments may include a range of settings and support service levels, such as: a private home or residence where healthcare services are provided; group settings such as lodges, transitional care or respite centres where the individual with stroke resides with others with similar care and support needs; assisted living settings where the individual has a private room(s) within a community living setting and access to personal care support, group meals, organized social activities, and transportation.

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.

Virtual Stroke Rehabilitation (Telerehabilitation) refers to the use of information and communication technologies to deliver rehabilitation services from a distance.  This can include video or telephone conferencing.  Telerehabilitation includes a range of services including evaluation, assessment, monitoring, prevention, intervention, supervision, education, consultation, and coaching.

WHO International Classification of Functioning, Disability and Health 6

• Impairment: Problems in body function or structure such as a significant deviation or loss 
• Activity limitation: Difficulties an individual may have in executing activities 
• Participation restrictions: Problems an individual may experience in involvement in life situations