Rebuilding Independence: Personalized Stroke Rehabilitation with Early Support Discharge Service
Overview
Our Stroke – Early Support Discharge (ESD) Service provides specialised stroke rehabilitation to individuals who have recently received a stroke diagnosis. This rehabilitation begins shortly after their discharge from the hospital and continues for a duration of up to six weeks.
Who Is This Service For? Eligibility Criteria
This service is available for adults (over 18) who have been newly diagnosed with a stroke or spontaneous Sub Arachnoid Haemorrhage (SAH) and are registered with a Mid Essex GP. To be eligible, individuals must meet the following criteria:
- The person has received multidisciplinary therapy assessment and treatment during their hospital stay.
- Their medical and rehabilitation needs can be effectively addressed within the home environment.
- It is safe for them to return home, and their household can raise an alarm in case of an emergency.
- They have ongoing Occupational Therapy (OT), Physiotherapy (PT), or Speech and Language Therapy (SLT) needs, and they provide consent for intervention by the ESD team (or a best interests decision has been made).
- For patients discharged alone to a private address, they must be capable of independently ensuring their safety between carer visits.
- There is a means identified for staff to access the property.
- Patients cannot be discharged with ESD until necessary care, medication, equipment, and transportation arrangements are in place, which should be organized by the discharging stroke unit.
Service Details
Our ESD Service offers comprehensive stroke rehabilitation that is tailored to each individual’s specific needs. Rehabilitation begins shortly after discharge from the hospital and can continue for up to six weeks. The assessment and treatment provided by our specialist team are personalized to help patients achieve their goals and desired outcomes. We also offer guidance, education, and training to empower the individual, their partner, family, or carers to confidently continue therapy between sessions and after discharge. Additionally, we provide advice and information on lifestyle changes aimed at reducing the risk of future strokes.
We also offer a review of needs between four to eight months post-stroke by our Stroke Nurse.
Service Delivery
Our service operates from Monday to Friday, between 8:30 am and 5:00 pm, and is delivered in the individual’s home. This includes care home settings and transitional beds.
Referral Process
To initiate a referral, please call our service at 0300 303 2651 to discuss a new referral. You will be required to complete our referral form and email it along with the discharge letter from the referring unit to Provide.esdforstroke@nhs.net.
If you are registered with SystmOnline you will be able to view your own Electronic Medical Record (EMR), manage your appointments, request repeat medication, update contact details and message your healthcare service. There is also a SystmOnline app available for Apple and Android devices.
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