The aim of this study is to determine the feasibility, potential effectiveness, and implementation of a new web-based mobile application, My Stroke Team (MyST), to support hospital-based community outreach management and prevention for older adults with multiple chronic conditions (MCC).

Hamilton Health Sciences (HHS) has partnered with the Aging Community and Health Research Unit (ACHRU) on the six month intervention with staggered enrolment. The study continues for approximately 12 months to obtain a sample of 30 patients who are older than 55, who have two other chronic conditions and are recovering from a stroke. A dedicated inter-professional team (occupational therapy, physiotherapy, speech language pathology, social work, and registered nurse) provides stroke rehabilitation services, vascular disease prevention and management through regular in-home visits to participants for six months.

The overall goal of the mobile technology (MyST) is to support:

• Patient and family-centred care
• Collaborative practice through real-time communication and decision-making among hospital, clients, and family caregivers to enhance community reintegration
• A proactive comprehensive approach to care that focuses on health promotion and disease prevention
• The use of best practices for hospital and community-based management of vascular disease and MCC
• Linkage and referral to home and community-based services
• Empowerment of clients to take a lead role in the self-management of their health, stroke recovery prevention and management as well as other chronic conditions through the use of strength-based practice.

Study Partner: Hamilton Health Sciences

Funders: Max Bell Foundation, Canadian Institutes of Health Research (CIHR) Catalyst Fund

MyST was developed with support from the MOHLTC Health System Research Fund, click here to link to ACHRU Study 4 

Research Summary

Video: Community-based Stroke Care: Evaluating a Mobile App (MyST)

Video: Post-stroke intervention helps older adults transition home from hospital

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

Knowledge Exchange Event Report: Advancing transitional care for community-based older adults with stroke and multiple chronic conditions