For the Healthcare Provider

Coordinate care and connect the person with stroke to health care providers, community resources and services to ensure a comprehensive and cohesive approach to care.

This may include providing:

• personalized, up-to-date information on community resources
• the Guide for Stroke Recovery book or website link to access information and resources on an array of topics
• help with applications
• information on funding sources, and/or
• warm handovers to other care providers to ease transitions

Help the person with stroke and their family/caregiver achieve their goals, promote mental and emotional health and manage their holistic needs.

For example, providing:

• active listening
• open, empathetic and non-judgmental communication
• validation to help relieve feelings of loneliness, isolation, and anxiety
• coping strategies
• resilience-building techniques
• opportunities for questions and discussions about concerns and preferences
• access to translation/interpretation services in order to support full engagement in conversation
• links to peer support or other forms of psychosocial support services

Provide personalized education to meet learning needs and goals.  Education should be offered in a variety of languages and formats, address varying levels of health literacy (e.g. clear, jargon-free language), and cultural preferences. Education should be accessible for people with aphasia, those with visual, hearing and cognitive impairments (e.g. written materials, videos, journey maps, and apps). 

For example, promoting:

• adherence to lifestyle modifications
• access to group education sessions 
• the use of problem-solving technique
• ways to continue therapy at home 
• meaningful goal setting

Help build self-management and self-advocacy skills using a person-centred approach.  

For example, empower the person with stroke by encouraging:

• problem-solving, goal setting, decision making and action planning to promote self-efficacy
• use of the Guide for Stroke Recovery and the Community Re-engagement Cue to Action Trigger Tool to:
  • build knowledge
  • guide self-reflection regarding their needs
  • identify questions to ask about their progress and journey, and
  • locate resources in the community
• engagement in all aspects related to their care and recovery 
• use of tools to overcome obstacles like transportation, fear, anxiety, self-image, etc.

• Collaborative Goal Setting: Work with persons with stroke to set goals to regain control over their health and well-being by making changes that are meaningful to them. For example, use a problem-solving approach such as the Cognitive Orientation to Daily Occupational Performance (CO-OP).
• Action Plans: Develop personalized action plans that outline steps to take to reach their goals, including medication management, dietary changes, and physical activity.
• Cognitive Strategies: Use global cognitive strategies, such as Goal-Plan-Do-Check.

• Self-Monitoring Tools: Provide tools such as blood pressure monitors, glucose meters, and fitness trackers to use at home to monitor their health.
• Check-ins: Schedule regular follow-up appointments or virtual check-ins to review progress, provide feedback, discuss challenges, and adjust the action plan as needed.

• Motivational Interviewing: Use motivational interviewing techniques to help patients explore and resolve ambivalence about behavior change.  Learn techniques through the Choices and Changes: Motivating Healthy Behaviours program.
• Cognitive Behavioral Therapy (CBT): Refer patients to CBT or other counseling services if they struggle with mental health issues that impact their self-management.
• Stress Management: Teach stress management techniques such as mindfulness, meditation, and relaxation exercises.