The sixth update of the Canadian Stroke Best Practice Recommendations for Transitions and Community Participation following Stroke is a comprehensive set of evidence-based guidelines addressing issues faced by people following an acute stroke event. Establishing a coordinated and seamless system of care that supports progress achieved during the initial recovery stages throughout the transition to the community is more essential than ever as the medical complexity of people with stroke is also on the rise. All members of the health-care team engaged with people with stroke, their families, and caregivers are responsible for partnerships and collaborations to ensure successful transitions and return to the community following stroke. These guidelines reinforce the growing and changing body of research evidence available to guide ongoing screening, assessment, and management of individuals following stroke as they move from one phase and stage of care to the next without "falling through the cracks." It also recognizes the growing role of family and informal caregivers in providing significant hours of support that disrupt their own lives and responsibilities and addresses their support and educational needs. According to Statistics Canada, in 2012, eight million Canadians provided care to family members or friends with a long-term health condition, disability, or problems associated with aging. These recommendations incorporate aspects that were previously in the rehabilitation module for the purposes of streamlining, and both modules should be reviewed in order to provide comprehensive care addressing recovery and community reintegration and participation. These recommendations cover topics related to support and education of people with stroke, families, and caregivers during transitions and community reintegration. They include interprofessional planning and communication, return to driving, vocational roles, leisure activities and relationships and sexuality, and transition to long-term care.

中文翻译：

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加拿大中风最佳实践建议：中风后的康复、恢复和社区参与。第二部分：中风后的过渡和社区参与。

关于中风后过渡和社区参与的加拿大中风最佳实践建议的第六次更新是一套全面的循证指南，用于解决急性中风事件后人们面临的问题。由于中风患者的医疗复杂性也在增加，因此建立一个协调和无缝的护理系统以支持在整个过渡到社区的初始恢复阶段取得的进展比以往任何时候都更加重要。与中风患者、他们的家人和护理人员打交道的医疗保健团队的所有成员都有责任建立伙伴关系和合作，以确保中风后成功过渡并返回社区。这些指南加强了可用于指导正在进行的筛查的不断增长和不断变化的研究证据，评估和管理中风后的个体，因为他们从一个阶段和阶段的护理阶段转移到下一个阶段，而不会“陷入困境”。它还承认家庭和非正式照顾者在提供大量支持方面的作用越来越大，这些支持扰乱了他们自己的生活和责任，并满足了他们的支持和教育需求。根据加拿大统计局的数据，2012 年，有 800 万加拿大人为患有长期健康状况、残疾或与衰老相关的问题的家人或朋友提供护理。这些建议结合了以前在康复模块中为简化目的而存在的方面，并且应该对这两个模块进行审查，以提供解决康复和社区重新融入和参与的综合护理。这些建议涵盖了与中风患者、家庭和护理人员在过渡和重新融入社区期间的支持和教育相关的主题。它们包括跨专业规划和沟通、重新驾驶、职业角色、休闲活动和人际关系以及性行为，以及向长期护理的过渡。