Bridging the Gap for Stroke Survivors and their Families
By Bev Arsenault and Esther Krahn on behalf of the Penticton
Chronic Condition Steering Group.
A Penticton success story, based on the concept of Population
Health, which assesses community needs and utilizes the Chronic
Care Model. The emphasis is on the patients/clients/residents,
who need to be fully involved in decision making about all aspects
of their care. The following demonstrates that a Community Development
Model was deliberately followed to ensure that patients/ clients/residents
were fully involved throughout the process.
Through ongoing inquiries to the Healthy Heart Program, Community
Social Work, Rehab Social Work, and the South Okanagan Similkameen
Brain Injury Society, stroke survivors and their families identified
a gap in the Penticton area. The gap related to ongoing psycho-emotional
support for stroke survivors and their families.
In February 2003, key stakeholders from the above groups formed
a steering committee to address the “gap”. Members studied various
self-management models and examined the past. There had been a
previous self-help stroke support group meeting in Penticton,
under the auspicious of the Stroke Recovery Assn. of BC, which
was discontinued in 1999. The key stakeholders further investigated
the National Stroke Assn., via the Stroke Recovery Assn. of BC
for further information. The group agreed on a date and time to
teleconference with the Stroke Recovery Assn. of BC.
Then, in the interim, two BSN students contacted a steering committee
member looking for a project for their community development course.
(Truly serendipity!) The students were invited to the next steering
group meeting, the project proved to be a perfect fit for their
needs as well as the steering committee’s. The students embarked
on a mission to uncover the history of the Penticton Stroke Club.
They contacted the Stroke Recovery Assn. Of BC, requested a membership
list, phoned participants and received feedback. This feedback
was then brought back to the next steering committee meeting.
The steering committee, with the assistance of the nursing students,
decided on a central contact person, put ads in the paper and
facilitated focus groups to determine wants and needs of community
members whose lives had been affected by a stroke.
Stroke Recovery Assn. of BC had to offer fit the needs and wants
of the focus group participants. The Association was thus invited
to present to the focus groups. They presented the provincial
self-help support group model and requirements of the Stroke Recovery
Assn. membership. Following the focus group meeting the steering
committee again met and invited the Kelowna Stroke Support Group
Coordinator to speak about the Kelowna experience. An executive
committee composed of interested persons from the focus groups
was elected. The Penticton Stroke Support group became a reality!
Their first official duty was to advertise for a Coordinator.
This did not occur, due to a decrease in Provincial Stroke Recovery
Association’s funding.
The South Okanagen Similkameen Brain Injury Society has now agreed
to oversee the Coordinator role, with the hope of securing funding
in the future, as the funding support from the Provincial Stroke
Association would not be enough to cover the costs.
Patients/clients and families living in the Penticton can now
experience an integrated inter-professional wrap around model
of care if their lives have been affected by a stroke. They no
longer need to experience the burden of care, along with feeling
of isolation, frustration, sadness and aloneness. They have an
ongoing support group where they can give each other psycho-emotional
support. The future vision of the steering committee is to use
this model across the continuum of care for all chronic conditions.
Integrated, inter-professional program models of care utilize
all the professional resources effectively and efficiently across
the continuum of care to serve all clients with chronic conditions
in the Penticton health area.
The integrated wrap around care model allows patients/clients
and families to be referred to appropriate resources, without
having to fall through the cracks, be admitted to hospital because
of decrease in function, lack of managing the chronic condition,
etc. The following is a process example of the steps someone with
a newly diagnosed chronic condition would take:
Person has been diagnosed with a chronic condition.
- They would receive inter-professional education regarding
their specific condition.
- They would be referred to the chronic condition self-management
psycho-education group (model adopted by this health authority).
- They would receive referral to an ongoing support group
for their specific condition.
- They would have access to continued appointments to specific
clinics / programs or professionals as needed to assist in
optimal management of their chronic condition.
This leads to the whole issue of the self-management model which
is being looked at from a social development perspective by our
city council in Penticton.
Meetings are occurring
between the Penticton
Social Development
Committee and the
Chronic Condition
Steering Group, with
the hope of establishing
a community plan
that promotes optimal
health and wellness for
all it’s residents!
