The Winnipeg Regional Health Authority (WRHA) Community Stroke Care Service (CSCS) is a specialized home care program for people who have suffered a stroke and would benefit from community re-engagement. The program focuses on home-based rehabilitation in the community, modeled on evidence from the United Kingdom and New Zealand. The CSCS team provides case coordination, home care support and rehabilitation services to clients with rehabilitation potential referred from the Riverview Hospital inpatient stroke program. The team members include nursing and rehabilitation professionals and rehabilitation assistants who work with clients in their homes and neighborhoods. Clients and families set individual goals that are established, measured, and re-evaluated until discharge. Other outcomes include improvements in activities of daily living (ADL) and instrumental activities of daily living (IADL), functioning and reduction of depression, with the help of data generated from the RAI/MDS HC tool. A positive impact on the health system is measured by the decrease in the use of community-based personal and home support services from intake to discharge.

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