Community Stroke Discharge and Rehab Team
Aims and objectives of service
The Community Stroke Discharge and Rehabilitation (CSDR) Service delivers high quality, therapy-led, community-based specialist rehabilitation for people who have suffered a stroke. The objectives include allowing early supported discharge from acute care and the provision of longer term rehabilitation to maximise the opportunities for care at home.
A stroke skilled multi-disciplinary team manages patients where they live - whether that is a private home or a residential or care home - and provides rehabilitation of similar intensity to that of a stroke unit. The service is also delivered in appropriate community venues e.g. community/leisure centres.
There are two key elements to the service:
- ‘Supported Discharge’ service, providing intense rehabilitation to support discharge for an average of 28 days after the patient leaves acute care and a longer term rehabilitation service, providing ongoing rehabilitation support.
- Stroke specialist, multi-disciplinary assessment, active therapy and treatment to support recovery after stroke. Patients will be supported to work towards a structured, individually tailored treatment plan which will include combinations of the following elements: Occupational Therapy, Physiotherapy, Speech and Language Therapy, Psychological Support and other rehabilitation (swallowing, nutrition, cognitive difficulties, vision and perceptual difficulties, continence, relationships and sex. Information and signposting).
Following ‘Supported Discharge’ the service will visit the patient at home within 24 hours of planned discharge. The service is an integral part of the Nottingham City Stroke Pathway.
To qualify for intensive ‘Supported Discharge’, in addition to the overall service criteria the patient must currently be an inpatient on the Nottingham University Hospital (NUH) Stroke Unit or have been through the stroke pathway (i.e. be under the care of a stroke consultant) or have written agreement from a stroke consultant that the patient is sufficiently medically fit to be managed at home.
There is a direct pathway of referral for patients eligible for ‘Supported Discharge’ from the Stroke Unit of NUH, with proactive identification by members of the CSDR team.
For referrals for ongoing rehabilitation, a health or social care professional must complete a referral form and submit to the service via Health and Care Point. An open referral system back to the team within two years post stroke will operate for patients or carers known to the service.
Referrals for ‘StrokeAbility’ are made via Health and Care Point.
Days/hours of operation
This service is available seven days a week between 8am and 6pm.
Referrals to ‘StrokeAbility’ will operate on an open referral basis. This programme runs for 12 weeks made up of two one-hour sessions per week.
All other services will be provided Monday to Friday between 8.30am and 4.30pm.
Those who have had a stroke and are registered with a GP in Nottingham City.
- www.stroke.org.uk - The Stroke Association. This web site is good source of information for people who have had a stoke or know someone who has.
- www.ukconnect.org - Connect is a UK charity for people with aphasia (speech problems) that offer information and support.
- http://www.differentstrokes.co.uk - a charity run to support younger stroke survivors.