Scenario 4 Albert, a 56 year old stroke survivor with right sided deficits and a mild expressive aphasia, has just completed rehab in a tertiary rehab centre. He has recovered to the point where he can transfer with a 1 person assist. He is cognitively intact and has expressed the desire to return home to live with his 46 year old wife and 9 year old son. In the interim, he will have to return to the Healthcare Centre in his home community. What communication options are available to support Albert’s transition back to his community Healthcare Centre? a. Use of Telehealth to link rehab team from Tertiary Centre and local HCC Healthcare Providers b. Transfer sheets with completed discharge functional assessments c. Telephone/ Teleconference discussions d. All of the above How can the local HC Team support Albert’s transition to home? a. Meet with wife to determine her ability/ desire to meet his care needs b. Assess potential for other care providers c. Do a home assessment to determine wheelchair accessibility d. Provide training to caregivers e. This could be a “what’s missing” question??? Albert has been home for 3 weeks now. His wife had taken vacation time off from work to care for him, but now must go back. Albert can spend some time alone, but does need some assistance for meal preparation and toileting. He is also becoming quite bored and restless spending most of his time in the house. What could be done to support Albert and his wife at this stage? (consider respite care, alternate caregivers, support from Alberta brain injury network, DATS transportation, access to community sports arenas) Albert has been more active the past couple of weeks as he got back out into the community. A previous smoker, he’s experienced increased cravings as he’s joined his friends again for coffee, and at one point, he smoked a cigarette. He has also been having increasing weakness in his right leg in the evenings and was also expecting to have more function in his right arm by this point. Albert is feeling discouraged and blames stress for his higher than normal blood pressure readings. What options are appropriate for Albert at this stage? a. See his PCN physician and team b. Participate in a self-management group c. Review education material regarding stroke recovery d. Contact rehab department Albert has made an appointment to see his PCN physician for follow up. What support can the PCN team provide for Albert? a. Complete Stroke Checklist to determine how well Albert and his family are coping b. Advise Albert about post-stroke fatigue as it relates to his evening symptoms c. Compete depression screen and refer as necessary d. Provide education regarding realistic expectations at this stage of recovery e. Provide education regarding risk factor management to prevent another stroke f. Support Albert in setting some patient centred goals for moving forward g. Make referrals to chronic disease management education programs h. Review Albert’s medications and compliance i. Refer to a smoking cessation program/ support group