Supporting post-stroke access to services and resources for individuals with low income: understanding usual care practices in acute care and rehabilitation settings

Abstract Purpose Following stroke, individuals who live in a low-income or are at risk of living in a low-income situation face challenges with timely access to social services and community resources. Understanding the usual care practices of stroke teams, specifically, how they support this access to services and resources, is an important first step in promoting the implementation of practice change. Method A qualitative multiple-case study of acute care, inpatient, and outpatient rehabilitation stroke teams in an urban area of Canada. Semi-structured interviews and questionnaires about the workplace context were conducted with 19 professionals (social workers, occupational therapists, physiotherapists, speech-language pathologists) at four sites. Results In their usual practice, stroke teams prioritized immediate care needs. The stroke team professionals did not address income or resources unless it directly affected discharge. Usual care was influenced by factors such as time constraints, lack of knowledge about services and resources, and social service system limitations. Conclusion To better support post-stroke access to social services and resource for low-income individuals, a multidisciplinary approach, with actions beginning earlier on and extending throughout the continuum of care, is recommended, in addition to system-level advocacy. IMPLICATIONS FOR REHABILITATION Access to social services and community resources for people with stroke and living in a low-income situation is not consistently addressed in acute care or rehabilitation settings. Supporting access to social services and community resources is influenced by the professionals’ availability of time and resources, as well as knowledge about services and resources and the limitations of the social service system. Using a multidisciplinary approach, extending over the continuum of care from acute care to rehabilitation program may be a way forward to better support people with stroke and low income to access services and resources.


Introduction
Once discharged from inpatient care, finding and accessing social services and community resources is often a challenge for people who have experienced a stroke and their care partners [1,2], even in the Canadian context [3].Social services and community resources include income support, prescription drug subsidies, social housing, and benefit programs, as well as homemaking and disability transportation services.Studies have shown that people with stroke and their care partners would prefer to receive tailored information and support to access social services and resources early in their admission to the hospital [4][5][6][7] and that this discussion could be started in acute care and continue until discharge from rehabilitation [8].
Providing timely information and support to access social services and community resources is particularly important for stroke survivors living in low-income situation.Low income can have significant consequences on post-stroke health and wellbeing, such as creating difficulties accessing healthy foods, affording medication [9] and obtaining needed safety equipment [10].It can cause difficulties with maintaining housing and can negatively influence return to participation in meaningful occupations [11].Living in a low-income situation can be pre-existing or can occur following the stroke because of an inability to return to paid employment [12].It is therefore important to consider the needs of individuals who are currently living in a low-income situation or who are at risk of falling into financial hardship because of an inability to return to work.
The Canadian Stroke Best Practice Recommendations state that stroke survivors are provided with access to social supports and community resources during transitions from institutions, such as hospitals, back to the community [13].However, there is evidence that acute care and rehabilitation settings do not consistently provide information, or assistance with applying to services and resources, for example, income replacement programs for those unable to return to work [3,11].There is a clear need to evaluate and improve practice in the healthcare system context.
Improvements to practice are best planned and initiated once there is an accurate understanding of usual care practices across the continuum of care.This knowledge can then be used to inform future targets and sustainable interventions that fit the local contexts [14,15].This study, therefore, aimed to describe how acute care and rehabilitation stroke team members perceived: 1. Usual care practices for providing information and support to people with stroke (living, or at risk of living, in a low-income situation) to access needed social services and community resources; 2. Roles and responsibilities for supporting access to services and resources for low-income stroke survivors transitioning back to the community; and 3. Setting and workplace indicators linked to the successful implementation of future change.These indicators were (a) the team climate, which is linked to openness to initiating change [16] (b) change fatigue, which is related to exhaustion and withdrawal in the context of introducing organizational change [17], and (c) the general level of readiness for change, or degree to which a team is motivated and capable of executing a change [18].

Methodology
A multiple-case study design was used, drawing on Yin's replication logic approach [19].The initial cases were defined as the stroke teams in acute care, in-patient, and out-patient rehabilitation programs in one urban area of Ontario, Canada.

Participants
Social workers (SW), occupational therapists (OT), physiotherapists (PT), and speech-language pathologists (SLP) were recruited from these stroke teams.These professionals provide direct care to patients with stroke and can discuss and provide interventions for accessing social services and community resources.Professionals who rotate through various medicine units with stroke beds every six months were also eligible to be recruited; however, only those providing services to stroke beds at the time of recruitment were invited to participate.The aim was to have a representative of each of these professions from each of the stroke teams; all interested potential participants were accepted in the study.All participants provided informed consent.

Data collection
The data sources were semi-structured interviews, questionnaires and documents related to national and provincial stroke best practice recommendations.All participants took part in a 45-60-min semi-structured interview conducted in French or English.The audio-recorded interviews were conducted in person or by telephone.Questions focused on usual care practices linked to identifying and working with patients in a low-income situation.Questions such as "Do you have any specific roles and responsibilities when it comes to either low-income or at risk of being low-income patients?"were used to explore the topic.For more information, the interview guide is available in the Supplemental Online Materials.
Three questionnaires were completed by each participant using an online platform.They explored the workplace context and potential barriers and facilitators for the future implementation of practice change.The Change Fatigue questionnaire gauges the perceived level of fatigue related to change within an organization with six seven-point Likert scale questions [17].Content validity is adequate and internal consistency is good [17,20].The 19-item short version of the Team Climate Inventory explores the team members' perceptions of how they work together, including support for innovation, with Likert scale questions such as, "This unit is open and responsive to change" [21].This shortened tool has good internal consistency for each subscale, and for all subscales combined [21].The Texas Christian University Organizational Readiness for Change questionnaire (TCU ORC) measures factors related to an organization's readiness to translate research into practice [22].Selected subsections of a staff version of the tool were used [23]; questions related to a specific innovation were removed from the questionnaire as well as questions about physical and technological resources (for example, the internet).The 37 retained Likert scale questions cover topics such as stress levels and the availability of human resources.This measure has adequate internal consistency, high general psychometric ratings [24] and high instrument validity [25] compared to other commonly used readiness for change measures.
Information on practice guidelines and organization of services was obtained from the Canadian Stroke Best Practice Recommendations document from the Heart and Stroke Foundation [13] and the provincial Quality-Based Procedures: Clinical Handbook for Stroke (Acute and post-acute), which outlines pathways of care and specifics about practice in Ontario [26].

Data analysis
Data were managed using Nvivo 12 software (QSR International, Doncaster, Australia).The first interview verbatims were coded independently by authors KSS and PD, using both a deductive (based on the research questions) and inductive (based on emerging patterns and themes) approach and an initial code reference was agreed upon.Codes and interpretations were reviewed by the two coders with each subsequent interview (for example, to modify code definitions, to add or eliminate codes, to aggregate codes) [27].
The two coders re-combined codes into larger categories from which they identified themes for all interviews within each stroke team case.A cognitive map was then created, showing the links between the themes identified for the case [27].The cognitive map represented the described stroke team's usual care practices and the flow of actions related to addressing the social service/ community resource needs of low-income and at-risk of becoming low-income stroke survivors.
Themes and a cognitive map were generated for each case separately before conducting cross-case analyses, during which these were reviewed for similarities and differences.
The questionnaire responses were analysed descriptively to examine if they corroborated the themes and cognitive maps identified in each of the cases.The Stroke documentation was used as references to better understand the practice context and guidelines for stroke care in Canada and Ontario.
A theoretical replication logic [19] was initially planned, as contrasting results were predicted between the acute care and rehabilitation stroke team cases.However, because of similar experiences and usual care practices across the different cases, a literal replication logic was used.
A second stage of analysis was also completed to determine if experiences and actions would be similar across professions rather than across the initial team cases.Study participants were reorganized so that cases were defined by professional discipline, for example, all physiotherapy participants were defined as a case.Code categories and themes and questionnaire data were reviewed and aggregated by professional groupings as the cases.This led to a set of assertions about the professionals' perceived roles, responsibilities, and actions related to low-income.
All initial analyses and findings were reviewed with a third author (JS).These interpretations were then reviewed and discussed with all authors (KSS, PD, SBS, LS, MT, JS) during a group meeting.The original data were re-examined before accepting modifications to the interpretations.

Findings
Participants were five stroke teams from three acute care hospitals and one rehabilitation centre.Each site is described in Table 1.
From these 4 sites, a total of 19 stroke professionals participated in this study.Research results are presented by Cases as (i) Stroke teams at each site and cases (ii) by Professional discipline (SW, OT, PT SLP).The participants had varied years of experience working within their stroke teams (from less than one year to more than 10 years) at the time of the interviews.The case and participant details are presented in Table 2.
The cross-case analysis revealed few differences between the acute care and the rehabilitation stroke team cases with regards to usual care practices.Thus, themes related to practice, and common to all stroke team cases, are presented first, followed by themes stemming from the professional group case analysis.Finally, we present challenges common to all cases and insights for possible improvements.Quotes in French were translated into English.
The five themes identified and described below are: Stroke teams prioritize immediate care needs and discharge planning; Social workers are most "involved" with income-related discharge challenges; OT, PT, SLP have different levels of involvement with the immediate impact of low income; Providing more support is a challenge; Professionals are willing to change their practice.

Stroke teams prioritize immediate care needs and discharge planning
Multidisciplinary stroke teams focused on immediate care needs and discharge planning.While income was considered in the teams' usual care practices or routines, the professionals on the acute care and rehabilitation stroke teams stated that they did not have an overarching strategy or formal process for identifying stroke survivors in a low-income situation and for supporting their specific information and resource needs."…we're not doing anything kind of systematically [about income].Like it's just kind of haphazard."(PT_1001) The professionals agreed that income was discussed during rounds if it compromised safety and discharge planning."…only if, for whatever reason, their financial situation is stopping discharge or not allowing them to go back home, then is it brought up as an issue."(OT_3004) The teams identified the social worker as the lead for all issues related to finances, with other team members sharing any information they may have gathered on that situation.
We don't talk about income during rounds.That's not something unless there is a specific [reason].I mean, it may come up in terms of discharge planning because the rounds, that's what they're for.(…) Unless [income is] a barrier to discharge, that's … the only time that that would come up.(OT_4002) Team members could identify many situations when a stroke survivor could become a low-income individual following a Rehabilitation centre with inpatient stroke unit (>30 beds) and outpatient programs, both with distinct dedicated multidisciplinary teams for stroke patients, with some professionals devoting their time between both programs.at the time of the project, only the inpatient clinic had a social worker.2 acute care hospital with multidisciplinary team dedicated to stroke services, but not an official stroke unit with dedicated beds.3 acute care regional stroke hospital, with >20 stroke care beds on a dedicated inpatient unit with a multidisciplinary team.4 acute care hospital with multidisciplinary team dedicated to stroke services, but not an official stroke unit with dedicated beds.
Table 2. Cases defined as stroke teams and cases defined by professional discipline.stroke.For example, the professionals recognized the link between an inability to return to work and the loss of a source of income.
When we're talking about people who can't go back to work for a prolonged time or can't go back to the same job because of a communication disorder or other aspects of their stroke, (…) I've had some patients say they're thinking about having to potentially sell their house.(SLP_1005) The teams stated that they rarely addressed possible future needs related to decreased income, for example, applications to income replacement programs."We identify patients who are already in a low-income situation…but at risk of becoming?We probably don't think of that all the time."(SW_2001) They stated that the team's focus was on immediate care needs."Not saying that the people in low-income situations don't have future needs when they discharge, absolutely not, [but] when they're coming on the unit, we're looking at those immediate care needs."(OT_1006) Furthermore, none of the participating professionals in this region were involved with return-to-work interventions nor did they identify a role or responsibility towards stroke survivors at risk of low income because of future work issues.The acute care professionals responded that while they may discuss and offer general guidance about return to work, they believed it was likely the responsibility of the rehabilitation professionals to address return to work issues.However, the rehabilitation professionals reported that return to work was not a consistent priority either."… [return to work] 's not really all that coordinated, I find, and they're here for such a brief period of time sometimes that return to work isn't always addressed."(PT_1001)

Social workers are most "involved" with income-related discharge challenges
The participating social workers identified themselves, and were also identified by their team members, as the primary professionals responsible for addressing issues related to income following stroke.The social workers reported that they ask about the general financial situation, for example, if the individual is employed or retired at the time of stroke, and about general sources of income, always with a focus on discharge planning.
The social work role is really, really focused on discharge planning because we have a limited length of stay (…) I end up doing a lot of support and counselling throughout the discharge planning process with patients and families and also referrals to resources.(SW_1003) The social workers reported that they may ask directly about monthly income if eligibility to a service or resource is income based.I don't always ask them directly at our first meeting, but when we are doing discharge planning, it may become important and appropriate to ask [about monthly income] to see if they qualify for certain services.(SW_2001) The social worker from the rehabilitation program reported being involved in helping with applications for income support and benefits.They often assisted with applications for employment insurance, occasionally assisted with applications to social assistance programs and rarely were involved with applications to the provincial disability income support program.
One of the first things is also making sure that they have applied for employment insurance if it hasn't already been done in acute care with the social worker, because they may have not had time… It's something social work keeps an eye out for.(SW_1003) Social workers in acute care were less likely to be involved with applications to social assistance and income replacement programs than those in the rehabilitation setting.The social workers indicated that they were responsible for finding suitable and affordable discharge locations, but applications to social housing were not usual practice.
That's very rare because the [social housing] wait list is two years and there's just really no point in us doing it in terms of clinical priorities… And it's a lengthy application.And so, we tell people, "You know what?I'm really sorry.That's not going to be a priority for us while you're here".(SW_1003) However, the professionals stated that they will advocate or write support letters for individuals who are already on the waiting list for social housing."So yes, I've sent like letters of support, but no, I haven't actually completed a full registry application."(SW_3002) While income and financial concerns were clearly identified as being within the scope of practice of the social workers, they still reported feeling limited in their actions due to the stroke team's focus on survival and biomedical outcomes."I would say, typically [finances] aren't like their main priority.It's really about like the medical.The survival […] and the medical and stabilizing and focusing on getting to rehab and recovering."(SW_3002) This was echoed by other professionals: "Our scope is becoming less -how do I say this, holistic at home?And more of like a medical focus on getting good results back and more of control in your arm and more cognition and perception."(OT_1004)

OT, PT, SLP have different levels of involvement with the immediate impact of low income
The participating occupational therapists and physiotherapists had similar perceptions about their roles and responsibilities related to income.They felt that as stroke team members, actions related to income were not within their professional scope of practice.Furthermore, the participating occupational therapists and physiotherapists perceived that there was insufficient time or resources allocated to goals related to income and return to work.They explained that they were already having difficulty addressing all the established and prioritized goals within the targeted length of stay, both on acute care and rehabilitation.
Neither the occupational therapists nor physiotherapists stated having a formal process for identifying stroke survivors with immediate or future financial difficulties.While they did not ask directly about income, some patients volunteered their sources of income."We don't really ask questions about their income, like level of income and all that, but often, they will tell us if they are on [disability income support programs] or things like that." (OT_2004) Therapists would also obtain information indirectly about the patient's financial situation during conversations about renting or purchasing equipment in preparation for discharge."We don't look at their finances, but we see if they can purchase certain equipment."(PT_2003) Importantly, the participating occupational therapists and physiotherapists felt they had a responsibility to inform the social worker if any financial concerns arose during these conversations with patients.
Neither the occupational therapists nor physiotherapists reported being involved with completing income support program forms or applications for benefits programs but stated being involved with helping patients find low-cost medical equipment if needed.They consistently provided patients with lists of medical equipment vendors and often gave a list of vendors who sell used equipment.I do tell people like "go check [local thrift store or hardware store] has really good deals on walkers normally…" just for like lower-cost options if they have like a family that's kind of able to do that kind of stuff so they don't have to spend like hundreds of dollars on equipment.(PT_4001) The occupational therapists and physiotherapists mentioned it was also within their role to connect patients with community services, such as grocery or medication delivery services, or to make referrals to provincially funded physiotherapy for eligible patients.
People who already are tight for cash don't have the flexibility of hiring help when they aren't able to do something themselves.[…] I sit down with the social worker and the patient, and we try to find community programs that they can access that don't cost money or are cheaper options for them.(OT_3004) The participating speech-language pathologists perceived that they did not have a significant role in identifying or providing specific services for individuals in low-income situations, other than informing the social worker if they were privy to the patients' financial concerns."Honestly, in terms of socio-economic status, it is not information that I would collect or that I would be aware of."(SLP_2002).However, they recognized that income was an important consideration."You're mindful of [low income] because it is part of their social history, and it's kind of always within your mind, but I wouldn't say I have any designated roles or responsibilities."(SLP_1005) The speech-language pathologists were aware that income also had a significant impact on patients' rehabilitation.They stated that resources were limited in the community, specifically for post-stroke follow-up for communication or swallowing issues, and that private services were expensive.
We often maybe recommend supplemental therapy via tablet, like a tablet-based home therapy program… people who have more financial freedom often already have one, or it's not an issue to get one.And then there's also private therapy.You know, I'm less likely to bring up private therapy, (…) If you look at most insurance companies, they cover maybe up to, you know, $300 or something like that… for somebody who is a low-income earner, that's usually not something that's on the table.(SLP 1005)

Providing more support is a challenge
The participating social workers, occupational therapists, physiotherapists, and speech-language pathologists identified several challenges that limited their ability to address the social services and community resources needs of their patients.The first challenge was a lack of time."We are so pressed for time all the time, it never stops.The pace of our work never slows.And as soon as one patient is out, a new patient is in."(SW_1003) Importantly, two occupational therapists working in the rehabilitation program questioned whether certain interventions, such as filling out applications and discussing community services and resources, could be included as rehabilitation intensity minutes or goals as defined in the Quality-Based Procedures: Clinical Handbook for Stroke (Acute and post-acute), which outlines pathways of care and specifics about the practice from the province [26].They also questioned what interventions should be prioritized.
Filling out a [disability transport service] application absolutely could be done in a therapy session.It again comes back to, is it going to be taking the entire 45 min [of my session] when there's a lot of other goals that we need to be working on?Or if this is a patient [who] needs to be working on their upper extremity?In my mind, we really need to focus on that, and I'll try and do the [adapted transportation] application later.Rehab intensity, which is that face-to-face patient time, I think you can involve some of those applications or discussing services.I certainly do.But it just can't be taking the entire session.(OT_1006) We have rehab intensity goals that we need to meet, so every patient needs to be seen for a certain number of minutes every day, which gives us less flexibility to spend two hours with someone in the kitchen in the morning and really talk about some of those more traditional OT [community services] that might come up.(OT_1004) Even the social workers who are generally responsible for income reported insufficient time to address it."I would love to have the time to sit down with someone and just do the application right online and make sure it's in and it's done properly, but I don't have that luxury…" (SW_3002) The lack of time and competing workplace demands was also an issue reiterated in the workplace questionnaires completed by the participants.According to the questionnaire responses, almost all social workers, occupational therapists, physiotherapists, and most of the speech-language pathologists agreed that there was insufficient time to complete duties and that there were too many pressures for them to work effectively.In addition, these professionals felt that there was a shortage of staff to meet organizational needs at their site.
A second challenge was the belief that income would be addressed in the next phase of the continuum of care.The acute care professionals believed that the rehabilitation team would address income concerns, while the rehabilitation team believed that the community services would take care of these concerns.An occupational therapist in acute care stated, "I find that people prefer outpatient services to address [income] because in acute care, it is too big, it is too complex, it is not medical enough."(OT_3005) A speech-language pathologist on the inpatient rehabilitation team felt that income should be addressed in outpatient services: I think it would be very challenging to do on the in-patient stroke unit, just because the demands on us are already really high and you have such a short period of time to work with people…On the out-patient side, I think there is room for it.(SLP_1005) A third challenge was the possible overlap between professional responsibilities for certain social services or social needs (for example, food insecurity).There was concern that if responsibilities were not well defined, no one might address them.
Does it fall under OT?Does it fall under social work?You know, something like the food bank, for example, yeah, it's kind of… could be either.Could be either, [which] leads to, well, it could be nobody also.

Nobody might bring it up…So there's no clear line of [who is] doing what when it comes to things like that. (OT_1004)
A fourth challenge was the unpredictability of stroke recovery.Professionals mentioned that it could be difficult to commit to certain discharge decisions early in the continuum of care.
So, the problem is that in acute care, it is difficult to predict what the person will need, what services they will need when they return home or the equipment they will need.And for low-income people there is a high risk that all that will be a problem.(SW_2001) Professionals in the in-patient rehabilitation program also felt that it was too early for them to commit to certain discharge decisions.
Sometimes it's too early for us to say because the patient is on an upward trajectory, and we think that with out-patient stroke [therapy] they're going to make even more improvements.And so, we'll, in the referral to out-patient, we'll flag that as "continue looking at this"…But generally we don't really have, I would say, enough information at the time to really do much about it when they're here because we don't yet exactly know what the end will look like.(SW_1003) All participants reported that limitations in the health and social system restricted their ability to support patient access to services and resources.They felt that services were not adequately meeting needs and that complex rules and regulations made it more difficult for providers to navigate the system.…but the social assistance system is also flawed, and so they qualify for one thing, but then the other financial support is clawed back, or "oh, you applied too late, too bad.You don't qualify anymore.Oh, you're this age.You don't qualify".It's such a flawed system, and if you don't know the ins and outs like the back of your hand, you're not going to even access that tiny little bit of financial support from the government that you can get.(SW_1003) Several participants mentioned the particularly complex rules of accessing equipment support, in particular for those identified as having a low income.
We've had people that, yeah, have spent their [own] money because they need a walker now.And although maybe the [disability income support program] application has been submitted; it has not been approved yet.So, they've had to pay out of pocket.[The disability income support program] or any of these programs will not fund retroactively.(PT_1001) Health system rules about eligibility to participate in a rehabilitation program after admission in acute care was also stated as an issue that could more adversely impact low-income stroke survivors.Being discharged back to the community straight from acute care, without being admitted to a rehabilitation program, meant that there may have been insufficient time to provide information about needed services and resources."They are not [all] eligible to go [to rehabilitation].Those are the people that I would say are more likely to fall through the cracks."(PT_2005) While several challenges were identified, the professionals indicated that good communication within teams and the ease of sharing of information about income and other patient needs were factors that facilitated their ability to support access to services and resources."We're all pretty open with each other too… Like we all work really well as a team and we're all very comfortable with approaching each other about issues and stuff."(PT_4001) According to the workplace questionnaires, almost all social workers, occupational therapists, physiotherapists, and speech-language pathologists agreed that they keep each other informed about work-related issues and readily share information within their unit team.

Professionals are willing to change their practices
Almost all participants identified actions that could be implemented to improve how they address the service and resource needs of individuals with low income and stroke.They suggested that income could be considered by the entire multidisciplinary team."We probably all need to be a little more aware of what's available, not just leaving it up to the social worker."(PT_4001) This was echoed by an acute care occupational therapist.
I think we could do a better job at having it be a multidisciplinary discussion, for sure, and I think probably there would be a role for us helping fill out some of those applications.We don't really talk about it too much and we don't get asked for assistance in filling them out, but I [wouldn't] be surprised if there are some areas that would pertain to OT and PT and the SLP as well too.(OT_3003) Understanding that the social system is complex and slow-moving, an OT in rehabilitation recommended that income challenges should be addressed earlier on in the continuum of care."I think there is definitely room for the in-patient [acute care] OT to be involved in determining what services are out there and what could be really useful?" (OT_1006).An acute care physiotherapist shared a similar perception.
I feel like we should probably be more aware of [addressing low-income and at-risk] from the start to be able to plan better, even though we're kind of the first or probably the second kind of the point of contact after the person comes into the hospital with a stroke, so it's pretty early days, but it probably should be considered more at that point to help with the discharge planning down the road.(PT_4001) They suggested simple ways to start to improve their practices, such as using reminders and checklists.
Having like a checklist and a specific process…would be definitely helpful to at least, at least if we can get them on lists earlier or seeing if there's anything else that we could explore in a timely manner since things do take so long.(OT_3003) The participants felt that being more informed about options, resources, and services for patients, and having more knowledge about the application processes would be beneficial.
I think there's room for more education and also maybe, you know, whether it is formal processes that we need (…) trying to discuss as a team what solutions or what could be put in place to help these individuals.(OT_1006) I'd say that we could educate ourselves a bit more on how to help people with low income because there is really a… but there is also really a lack of resources that we can [offer].(SW_2001) One participant suggested that having a better understanding of the general limitations of the social system may help them as a team to support patients to navigate the system.
The more we're educated about the flaws of the system, the more it becomes a higher priority item (…).The more we know, then the more we'll be able to help out.(OT_3003) Another participant suggested that advocacy at the system level was necessary, while also working on feasible changes at the level of the frontline worker.
I think there also needs to be advocacy higher up (…) about the importance of people in low-income situations and indicating that they're suffering.Yet you also have to have a conversation with your frontline workers about what is feasible, what's not, and see okay, can we change a few things or change the demands that are being placed on healthcare workers.(OT_1006)

Discussion
This study described the usual care practices of stroke team members in acute care and rehabilitation, specifically, how they support access to services and resources for individuals living in or at risk of living in a low-income situation.We found that the stroke teams focused on the immediate care needs of people with stroke, which were generally medical or related to basic functional recovery.Within stroke teams, the social worker usually took the lead in guiding discussions and acting on recommendations for services and resources.While the other professionals (occupational therapists, physiotherapists, and speech-language pathologists) had variable levels of involvement, they all contributed by responding to the social service and community resource needs identified.They also shared information on income-related discharge challenges with the team.
The professionals (social workers, occupational therapists, physiotherapists, and speech-language pathologists) collected information on sources of income.However, they did not consistently and explicitly explore financial struggles.They usually waited for the individual with a stroke to initiate a discussion about financial concerns, which could be problematic as people with stroke and their care partners may be hesitant to disclose this personal information [10].Overall, the professionals could only offer limited help with accessing services and resources related to income.Further, they often did not take action to address the possible future consequences of a stroke on income (for example, loss of employment and challenges with return to work).These findings corroborate the experiences of people with stroke and their caregivers reported in other studies conducted in Canada [3,10,11].

Challenges addressing income and service needs in routine practices
The Canadian Stroke Best Practice Recommendations state that teams should address income and social service needs after a stroke.Specifically, teams should "review financial concerns, sustainability, and benefit options during admission and/or prior to discharge, and later in follow-up assessments and transitions." [13], to support social, life, and vocational roles.
However, most professionals who participated in this study were not reviewing financial concerns and benefit options, nor addressing income and social service needs in their usual care practices.Several factors were identified to explain this discrepancy between best practice recommendations and the current usual care practices.
Firstly, professionals experienced a high workload, competing priorities, and time constraints.While they may have been aware of the patient financial concerns, the professionals felt that they should prioritize other team goals.These goals were often focused on biomedical outcomes, which left them little time to explore concerns such as food insecurity, housing precarity, and loss of employment.
Secondly, as of 2015, facilities across Ontario must collect inpatient rehabilitation intensity data.Rehabilitation intensity is a record of the time that the "patient spends in individual, goal-directed rehabilitation therapy, focused on physical, functional, cognitive, perceptual, communicative and social goals to maximize the patient's recovery, over a seven day/week period" [28].This data is used for evaluating system efficiency, and guidelines stipulate that a minimum rehabilitation intensity should be provided [28].However, income and social service needs are not explicitly listed as part of rehabilitation intensity minutes.Professionals may therefore be less likely to spend therapy time to address those needs with patients.This concern was raised by some occupational therapists in this study.They were hesitant about devoting time to help fill out forms and discuss social services since it may not count as rehabilitation intensity minutes.
Thirdly, the best practice recommendations do not specify which team members are responsible for addressing income and social service needs.In practice, it is often assumed that the social workers are solely responsible, which may result in inaction by other team members.Further, most of these best practice recommendations are based on writing group consensus [13] and provide insufficient information on integration into usual practice.Importantly, there is limited high-level evidence on the effectiveness and timing of interventions along the continuum of care [8].
Lastly, a significant challenge to addressing income and service needs is the larger social system.The professionals in this study highlighted that there are inadequate community services to meet the needs of people with stroke in low-income situations.They felt that there is a gap between what they wanted to provide, versus what they could feasibly provide given the available resources.It has been well documented in the Canadian context that there are ongoing challenges for people post-stroke who are attempting to access services from the social system (e.g., financial assistance for equipment, social housing, and income support programs).These challenges are often linked to strict eligibility criteria, complicated application processes, and long waitlists [10,11].

Recommendations for expanding usual care practices and future research
This study found that many of the professionals were willing to adapt their usual care practices to better respond to social service and community resources needs.They suggested focusing on teamwork and on shared responsibility.They also identified actions that could be incorporated into their current roles and were considered feasible given time and resource limits: 1. Using a multidisciplinary approach to identify and to respond to current and future income challenges, as well as service and resource needs.Teams should not assume that it is only the social workers' responsibility.2. Identifying income challenges earlier on after a stroke admission and sharing related responsibilities along the entire continuum of care.Teams could implement system-level or cross-organization checklists and reminders to help prompt questions and explore solutions related to income and social service needs.Applications and referrals could also be completed earlier on in the continuum of care and be shared with the next professionals/service providers for follow-up.Beginning to address social service and community resource needs earlier on in the continuum of care has been recommended by several researchers as well as people with stroke and their care partners [4][5][6][7].3. Gathering and sharing information among team members about various options and application processes for local social services and community resources.A more comprehensive understanding of the social system and its limitations would allow teams to more effectively use available services and resources and to better prioritize their efforts.
There are several recommendations at the healthcare system level: 1. Stroke best practice recommendations should provide more specific guidance on what actions to take and when they should be carried out.Delegating which professionals on the team should take the lead and be responsible for these actions would save time and minimize duplication of efforts.2. The provincial rehabilitation intensity guidelines should be clarified to include time spent on discussing social services and community resources as rehabilitation intensity minutes.3. Local organizations should create documents listing resources and services for people with income needs.These documents should be specific to the geographical region and include information such as how to access services for return to work, income support and benefits, and subsidized equipment and social housing.
While these recommendations could improve the immediate needs of individuals with stroke and their care partners, there remains a need for change in the current healthcare and social system.The current system priorities leave little room for professionals to explore concerns such as food insecurity, housing precarity, and loss of employment, as well as the consequences of low income on life after stroke.Advocacy is required to ensure sustainable change at both healthcare and social system levels.
Future research should investigate the stroke teams' understanding and application of the stroke best practice recommendations across more regions of the province and country.Research should also focus on collaboratively creating, implementing, and testing interventions to meet the social service and community resource needs of people with stroke at the acute care and rehabilitation team level.

Limitations
There are limitations to consider in this study.Firstly, participants belonging to the same team may share common views; this is an inherent bias to acknowledge.Secondly, data was collected from only one region.Other regions of the country may have different usual care practices, social service availability, and policies.Thirdly, the interviews were conducted before and during the first weeks of the COVID-19 pandemic.The current reality of practice, in the years following the onset of the pandemic, is likely different than at the time of the initial interviews (for example, significant staff shortages and resource challenges in the health and social system).

Conclusion
Improving access to social services and community resources has been identified as a priority for people with stroke living in, or at risk of living, in a low-income situation.This study found that acute care and rehabilitation stroke team professionals were limited in their ability to meet the service and resource needs of these people with stroke within their usual care practices.The teams were limited by several challenges, including competing demands, limited time and knowledge, and difficulties navigating a complex social service system.
Stroke teams can contribute to better access to services and resources by expanding professional roles, improving collaboration, learning how to navigate the system despite the flaws, and advocating for higher-level changes in the healthcare and social systems.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The author(s) reported there is no funding associated with the work featured in this article.
Work; ot: occupational therapy; Pt: Physiotherapy; slP: speech language Pathology.a Pt_1001 and slP_1005 work in both the outpatient and inpatient programs.b Participating professional has more or equal number of years of experience compared to the professional group median.c Participating professional has fewer number of years of experience compared to the professional group median.

Table 1 .
Description of participating sites.
"I've done all kinds of [provincial disability income support program] applications [in my career], but for the stroke program?No.But I have reached out to [social assistance programs]."(SW_3002) Social workers in acute care and rehabilitation settings consistently discussed financial assistance to pay for medical equipment (purchase or rental of bathroom safety equipment, and rental of mobility aids) or for medication."I'll certainly try and explore in terms of 'Do you have any type of medication coverage, extended health benefits, insurance?'Things like that.And [I] ask just about the employment situation.You know, 'Do you work?Are you retired?'" (SW_3002)