Community Stroke Rehabilitation Team - How To Access

Admission criteria

Eligibility Criteria:

Individuals are eligible to attend if ALL of the following apply:

  • 18 years or older
  • Have had a stroke in the past year and need care from a specialized rehab team
  • Live in the London-Middlesex, Oxford, Elgin and South West Norfolk regions
  • Are medically stable and care can be safely managed at home
  • Have a complete referral form and have agreed to join the program
  • Can make real progress toward rehab goals with short term, time limited treatment
  • Are motivated and able to take part in at least 60 minutes of therapy
  • Have the ability to carry-over learned activities  
  • Goals are clear, realistic, and achievable. They can be accomplished:
    • By working together with the rehabilitation team
    • With support and guidance from caregivers
    • By learning and using self-management skills
  • If they need help with personal care during therapy, a caregiver must be there 

Exclusion criteria

Individuals are not eligible to attend if any of the following apply:

  • They have had a transient ischemic attack (TIA) – sometimes called a mini-stroke – or another neurological condition was the reason for the referral
  • The same kind of care is available through motor vehicle accident insurance, the Workplace Safety and Insurance Board (WSIB), or another government-funded health program
  • Care is needed in a hospital bed
  • Ongoing maintenance rehab is needed, as defined by the Rehabilitative Care Alliance (RCA)
  • Outpatient rehab has already been completed for the same condition, with no new goals to work on
  • Recent inpatient rehab for the condition did not result in progress toward goals
  • Severe problems with thinking or memory make it hard to learn and take part in therapy
  • The person lives in a long-term care home or is in transitional care 

Determining service priorities

Referrals are triaged as they are received and priority for service is based on the following: 

  1. Recent discharge from hospital (vs. community/self-referrals)  
  2. Risk of admission to hospital
  3. Significant safety concerns:
  • Swallowing
  • High falls risk
  • Living alone, or having little-to-no support in the home
  • Significant emotional and mental health concerns related to stroke

Who can apply?

  • An individual who has suffered a stroke, their family members or caregivers, via self-referral
  • Family physicians, home and community care support services and other health care providers