Aging, Community and Health Research Group (ACHRU)

McMaster University

Studies & Research

Funded by

Study 7

A Community Navigation and Rehabilitation Intervention for Stroke Survivors with Multiple Chronic Conditions


Stroke survivors with multiple chronic conditions (MCC) move between multiple care settings, and so they are at high risk of receiving fragmented care leading to increased risk for avoidable illness, death, and health care costs. Recent Canadian studies and reports identify significant gaps in the delivery of effective stroke care to stroke survivors with MCC in community-based settings. Most stroke rehabilitation programs and guidelines are entirely focused on stroke only and do not address the challenges to patients and providers of managing comorbid conditions.

This pragmatic mixed methods randomized controlled trial evaluated the effectiveness of a  community navigation and rehabilitation intervention on HRQOL, depression, anxiety, community reintegration, number of strokes, physical functioning, and the costs of use of health services for stroke survivors with MCC receiving home care and their family caregivers. The results inform: (1) the development of national standards for community-based stroke rehabilitation and (2) the development of a new and innovative community-based model for stroke rehabilitation that can be adapted and implemented for stroke survivors with MCC across Canada.


Research Summary

A Community Navigation and Rehabilitation Intervention for Stroke Survivors with MCC Video

Publication in Journal of Comorbidity

  • Maureen Markle-Reid
    Professor and Canada Research Chair in Person Centred Interventions for Older Adults with Multimorbidity and their Caregivers
    McMaster University School of Nursing
    Scientific Co-Lead, MIRA Collaborative for Health and Aging (OSSU SPOR Research Centre)
  • Jenny Ploeg
    Professor Emeritus
    McMaster University School of Nursing
    Department of Health, Aging and Society
  • Lorraine Venturato
    Associate Professor
    University of Calgary
    Faculty of Nursing
  • Sean Dukelow
    Assistant Professor
    University of Calgary
    Physical Medicine & Rehabilitation
  • Amiram Gafni
  • Noori Akhtar-Danesh
  • Duane Bender
  • Cheryl A. Sadowski
  • Nancy Matthew-Maich
  • Lehana Thabane
  • Christopher Patterson
  • Christy Taberner
  • Sid Feldman
  • Holly Reimer
  • Sarah I
  • Alexandra Vickers
  • Sue Bookey-Bassett
  • David Kanters
  • Leslie Brugger

Publications and Activities relating to this study:

New Report: My Stroke Team (MyST) Knowledge Exchange Event

Learn how our MyST intervention helps stroke patients like David, find the best road to recovery when they come home from hospital.

Read More

Congratulations to Dr. Sue Bookey-Bassett

She recently successfully defended her thesis to earn a Doctor of Philosophy (PhD) in Nursing.

Read More

Stroke Outpatients Embrace MyST’s Team Approach and In-Home Visits

If Candace Coe was a quarterback for stroke patients, she’d be coordinating a touchdown for stroke recovery with a new offensive team for outpatients.

Read More