A vision for stroke rehabilitation transformation in ontario.

state that the Ministry of Health and Long-Term Care is unable to adequately assess rehabilitation efficiency and that program administrators have little incentive to improve access to stroke rehabilitation programs. Although these observations may be perceived as hurtful to some program administrators, they are accurate and merit further discussion. The authors propose a vision for transformation to a patientfocused system that encompasses principles such as addressing the needs of all stroke survivors, including those who are not able to access the care they need, and a “patient-first” approach to treatment provision. This would be achieved in part by developing and collecting a composite indicator reflecting both patient outcomes and population-level efficiency. The first step would be to compile information regarding the proportion and characteristics of patients recovering from stroke in all regions who are not admitted to rehabilitation programs. This is certainly required. Only then will we be able to create specific models to ensure better accessibility for all stroke survivors. The authors’ recommendation for appropriate peer-group comparisons is valid, and the current system is inadequate to carry out such comparisons. Particularly controversial is the proposal that, once benchmarks have been established, the dose and duration of rehabilitation therapy can be “treated in the same way that they are in pharmaceutical administration.” The concept of “seven day a week” stroke rehabilitation is one that most definitely must be discussed. The efficacy of such a model and whether it fits within Canadian work standards and capabilities need to be examined. Questions such as “Can we afford not to utilize weekend hours for stroke rehabilitation therapies?” versus “Can the (often aged) person recovering from a stroke tolerate the extra weekend rehabilitation demands?” need to be laid on the table. The authors’ vision for stroke rehabilitation transformation makes much sense. The core value of the paper lies in the concept that we need to change aspects of the stroke rehabilitation care provided in Canada. Many of the principles apply to acute care as well. This change will not happen within individual institutions but, rather, will need a government or multiorganizational approach to create the necessary structures and incentives to make it happen. The authors note that the CMA recommends shifting public reporting from “shame and blame” to quality improvement, with rewards provided for efficient, patient-focused care. This is a very hopeful message. We need more visionary articles like this one so that patients can truly benefit from a continuum of care that starts with stroke prevention, moves to acute care, then rehabilitation, and ends up back in the community, where rehabilitation continues for as long as needed.