Ontario’s Stroke System

Acute Care

Within the stroke services framework of Ontario, hospitals are classified based on the type of specialized acute stroke services they provide and the role they play within the system in leading, developing, implementing, coordinating, and integrating of stroke care or administration (Ontario Health, 2025b).

The stroke care system in Ontario is organized into eleven regional networks that provide cross-continuum stroke care within the province (Ontario Health, 2025a). This continuum includes primary prevention, secondary stroke prevention, the pre-hospital phase, the hyperacute phase, the acute phase, rehabilitation, and community re-engagement (Ontario Health, 2025a). The regional stroke systems comprise a network of care providers that identify, prioritize and implement initiatives to promote timely access to specialized stroke care (Ontario Health, 2025a). These networks include:

• Regional Stroke Centres or Enhanced District Stroke Centres (Ontario Health, 2025a),
• District stroke centres, depending on geographical requirements (Ontario Health, 2025a),
• Community hospitals (Ontario Health, 2025a),
• Stroke Prevention Clinics (Ontario Health, 2025a),
• Rehabilitation providers (Ontario Health, 2025a),
• Community-based providers (Ontario Health, 2025a),
• A governance structure (Ontario Health, 2025a).

Regional Stroke Centres provide the largest range of specialized clinical services, including neurosurgery, endovascular thrombectomy, thrombolysis, a community stroke prevention clinic and a stroke unit (Ontario Health, 2025b). They also support a stroke network team and lead the development, implementation, coordination and integration of the stroke system within a defined region (Ontario Health, 2025b).

When a regional stroke system covers a large geographical area, it may be further divided into smaller stroke districts to support the collaborative identification, prioritization, and implementation of opportunities aimed at promoting timely access to specialized stroke care in support of the broader regional stroke system (Ontario Health, 2025a). The leadership for these districts is provided through District Stroke Centres (Ontario Health, 2025a). District Stroke Centres provide thrombolysis and have a stroke unit and a community stroke prevention clinic (Ontario Health, 2025b). They also provide leadership, development, implementation and integration for the stroke care continuum within a defined district (Ontario Health, 2025b). There are Enhanced District Stroke Centres that also provide all the services that District centres provide but to a defined region rather than a district (Ontario Health, 2025b).

Non-Stroke Service Hospitals do not offer specialized clinical stroke services on-site, but they have established protocols that help facilitate access to specialized stroke services for individuals identified as needing these services (Ontario Health, 2025b).

For a list of regional and district stroke centres in Ontario, please visit: Cardiac, Stroke & Vascular Centres – CorHealth Ontario

Community Stroke Rehabilitation

Community Stroke rehabilitation (CSR) is person-centred, coordinated care provided by an interprofessional team with stroke-specific expertise, delivered in a setting and frequency that best meets the needs of the person with stroke (Ontario Health, 2022). It allows the opportunity for re-entry to services, follow-up care, and connecting to community supports to maintain functional recovery and community re-integration (Ontario Health, 2022). Ontario Health (2022) notes that variability exists in the CSR programming offered in the province.

The key components in this model are:

• Population (Ontario Health, 2022),
• Team members (Ontario Health, 2022),
• Referral Process (Ontario Health, 2022),
• Care settings (Ontario Health, 2022),
• Duration of care (Ontario Health, 2022),
• Clinical delivery (Ontario Health, 2022).

Key underpinnings include:

• The importance of stroke-specialized teams;
• The importance of a person-centred, individualized approach to care planning and implementation, including timing, duration and frequency of therapies provided;
• Designing care programs with the aim of helping individuals reach their goals of returning to meaningful life activities and roles;
• The importance of setting up programs within the integrated stroke pathway to ensure seamless transitions between care settings, which is supported by high levels of communication and coordination between team members working in different settings along the pathway.

Population

Persons with stroke with ongoing achievable and meaningful rehabilitation goals should have access to specialized stroke services after their hospital stay, and eligible persons should be identified early to facilitate improved transitions (Ontario Health, 2022). Persons may require varying intensity and frequency, and varying rehabilitation disciplines (Ontario Health, 2022).

Team members

The community stroke rehabilitation team is a specialized, interdisciplinary team of clinicians who are specialized in stroke and stroke rehabilitation (Ontario Health, 2022). Teams include, at minimum, occupational therapy, physiotherapy, speech-language pathology, social work, and a dedicated stroke care coordinator/navigator (Ontario Health, 2022). The team may also include a nurse with stroke expertise, rehabilitation assistants, administrative supports, pathways for accessing additional team members or specialists, a neurological rehabilitation program (in areas where dedicated stroke teams are not available), and a primary care physician (Ontario Health, 2022).

Referral Process

Referrals to community stroke rehabilitation can occur from inpatient settings, primary care, stroke prevention clinics, and home and community care teams (Ontario Health, 2022). Referrals and transition planning should be planned with the person’s goal in mind and in partnership with persons with stroke, family members, informal caregivers, and both the referring and receiving teams before the transition (Ontario Health, 2022). Each region or sub-region is responsible for ensuring that community stroke rehabilitation services are provided as part of a coordinated and integrated stroke care pathway, for example, through centralized referral access (Ontario Health, 2022).

Care Settings

Settings for rehabilitation can be a mix of outpatient clinics, home and virtual (Ontario Health, 2022).

Duration of Care

Ontario Health (2022) notes that the CSR program is provided, on average, over eight to twelve weeks, at a frequency dictated by the needs and goals of the person with stroke, and guided by best practice, which is noted as 45 minutes per day per required discipline and two to five days per week. Visits should be flexible and occur at a time that works best for the person with stroke (Ontario Health, 2022). Re-entry to the program can occur for persons with stroke who meet eligibility criteria up to one year after discharge from the program (Ontario Health, 2022). If the person consents, follow-ups can be provided at regular intervals, usually 6 months and one year after discharge from the program, with clear objectives for follow-ups (Ontario Health, 2022). After one year, monitoring and support should occur with the person’s primary care provider (Ontario Health, 2022).

Clinical Delivery

Clinical Assessment

Assessment of a person with stroke includes assessment of impairment, functional limitations, role participation restrictions, and environmental factors using validated tools (Ontario Health, 2022). Tools should be adapted to accommodate communication limitations of a person with stroke (Ontario Health, 2022). The person, their family, and informal caregivers should be assessed for readiness for education, ability to integrate knowledge, training, and psychosocial support (Ontario Health, 2022).

Treatment

Clinicians should use evidence-based treatments and involve persons with stroke, their families, and informal caregivers in planning care and transitions (Ontario Health, 2022). Persons with stroke and their caregivers should be provided with general emotional and psychosocial supports, links to community programs, agencies that provide these services, vocational rehabilitation, community re-integration planning, exploration of return to driving, an emphasis on self-learning and practice, education about the impact of stroke on relationships, and opportunities for check-ins (Ontario Health, 2022).

Education

The educational needs of people with stroke and their families/informal caregivers should be reassessed and updated regularly, and education should be individualized and implemented based on their learning needs and goals (Ontario Health, 2022). The opportunity to interact with the team and review progress or adjust care plans should be provided (Ontario Health, 2022). Education should be provided on how to support and care for persons with stroke at home, on risk factors and their management, and on goals-of-care discussions (Ontario Health, 2022).

Care Delivery Formats

Formats can include one-to-one therapy, virtual consultations/care, telemedicine, and in-person or virtual group sessions (Ontario Health, 2022).

Transition Out of the Program

It should be clearly communicated when the transition from the formal CSR program to community rehabilitation will occur (Ontario Health, 2022). Contact information for persons or services for continued support, peer support groups, and information for person-initiated CSR follow-up pathways should be provided (Ontario Health, 2022).

Team Processes

Communication is key for high-functioning teams, including with the person with stroke and their family members/informal caregivers (Ontario Health, 2022). A case coordination approach is recommended (Ontario Health, 2022). Some important components outlined for the maintenance of high-functioning teams include:

• Team meetings held at regular intervals (one to two weeks) to review new referrals, plan care and schedule therapy visits (Ontario Health, 2022);
• Continuous quality improvement (Ontario Health, 2022);
• Working closely with community agencies that provide social services, health promotion and wellness programming, and keeping up to date with available community resources (Ontario Health, 2022);
• Simple and secure tools for communication amongst team members (Ontario Health, 2022);
• Access to the right technology and equipment for care delivery based on best practice and care delivery setting (Ontario Health, 2022);
• Providing training in supportive conversation with adults with aphasia to all team members (Ontario Health, 2022);
• Continuing education on stroke best practices (Ontario Health, 2022).

Caregiver resources

The HSFC compiles a list of resources for caregiver support across the provinces and territories, which can be accessed through: Caregiver support | Heart and Stroke Foundation