Early Supported Discharge

Early Supported Discharge (ESD) is defined as “a form of rehabilitation designed to accelerate the transition from hospital to home through the provision of rehabilitation therapies delivered by an interprofessional team, in the community. It is intended as an alternative to a complete course of inpatient rehabilitation and is most suitable for patients recovering from mild to moderate stroke” (Dawson et al., 2013, p. 36)

In the Fall of 2013, ESD was identified as a provincial priority by the 11 regional stroke networks of Ontario. To better address this priority, a Provincial Integrated Working Group was formed. The main purpose of this working group was to support the implementation of ESD programs in Ontario.

Work plan

Early Supported Discharge- Work Plan November-2013-March-2015

Final Report

Early Supported Discharge- Final Report (2015)

Deliverables

1. Early Supported Discharge-Core Elements (2015)

2. Early Supported Discharge- Sample Business Case Elements (2015)

3. OSN Backgrounder: ESD for People with Stroke: An amenable and cost-effective alternative to in-hospital rehabilitation (2014)

4. Early Supported Discharge Literature Review (2014)

5. Early Supported Discharge Inventory (2015)

Additional Documents/Tools

currently there are no additional documents/tools. If you would like more information on the resources used to support the development of this work please contact oh-corh_service@ontariohealth.ca

Regional Use of PIWP Deliverables

Region	Description of Use	Contact Name	Contact Email	Additional Information
Central East	Develop new program Other	Donelda Sooley	cesn@rvh.on.ca oh-corh_service@ontariohealth.ca	Provincial ESD documents, including the final report and deliverables, were used to inform regional health system planners regarding the ESD model of care. The information was used to develop a small pilot of ESD services. The pilot was completed and next steps are being considered by the organization and LHIN.
Northwestern Ontario	Develop new program Develop business case Perform needs assessment Other	Esmé French	frenche@tbh.net nwostroke@tbh.net oh-corh_service@ontariohealth.ca	Provincial ESD documents used to inform regional health system planners regarding this model of care. Deliverables supported initial discussions however have not moved beyond exploratory phase as yet.
Southeastern Ontario	Evaluate current programs	Stroke Network of Southeastern Ontario	StrokeNetworkSEO@KGH.KARI.NET	Use of core elements for education and to assist regional team and Home/Community Care team in jointly identifying gaps in SE home-based community rehab program and planning changes.
Southwestern Ontario	Improve current program Develop business case	Margo Collver	margo.collver@lhsc.on.ca oh-corh_service@ontariohealth.ca	Used information to help create a business case to submit to the Erie St. Clair LHIN. Referenced in South West Stroke Project Phase 2 when developing directional recommendations for Community Rehabilitation and Recovery.
Toronto Stroke Networks	Develop new program Develop business case	Beth Linkewich	beth.linkewich@sunnybrook.ca oh-corh_service@ontariohealth.ca	Literature review was used as background information to inform stroke Integrated Funding Model in-home and outpatient ESD pilot plannning and business case development. This in turn helped to inform the development of a common model for community based rehab as described by Quality-Based Procedures. This model includes ESD, outpatient and home based rehab service provision that will support multi-LHIN planning to create a standard of community based rehab services across the LHINs.

Dawson AS, Knox J, McClure A, Foley N, and Teasell R, on behalf of the Stroke Rehabilitation Writing Group. Chapter 5: Stroke Rehabilitation. In Lindsay MP, Gubitz G, Bayley M, and Phillips S (editors) on behalf of the Canadian Stroke Best Practices and Standards Advisory Committee. Canadian Best Practice Recommendations for Stroke Care: 2013; Ottawa, Ontario Canada: Heart and Stroke Foundation and the Canadian Stroke Network.