Session 5 – Stroke Care in the Community

COMMUNITY REHABILITATON

Rehabilitation after a stroke commences in hospital and is provided by an inpatient based team including therapists, nurses and clinical psychologists. On discharge, the responsibility for ongoing neurorehabilitation is passed to a multi-disciplinary specialist community team who continue supporting the patient at home or in a nursing/care home.

Evidence shows patients do better when they:

• are discharged into community rehabilitation services
• receive up to 45 minutes of therapy per professional group every day 5 days/week
• receive support from a clinical psychologist if needed
• have their goals regularly reviewed
• are supported to return to work
• have a health and social care review at 6 months

COMMUNITY TEAMS

In our region, there are community stroke teams in each borough who support stroke survivors discharged from hospital or manage referrals from the community (e.g. via GP). You can find contact details for these local services here.

ROLE OF THE COMMUNITY TEAM

A community stroke team is multi-disciplinary and includes neurologically specialist nurses, therapists (physiotherapy, occupational therapy and speech and language therapy), clinical psychologists, and also assistant support workers.

The team offers a range of support to ensure patients can be discharged as early as possible from hospital, so that their rehabilitation can continue at home (or in a care home). They may also work closely with re-ablement services depending on the needs of the patient at home.

The team offer a range of support to aid physical recovery and ensure emotional wellbeing. They provide advice to the stroke survivor and their family/carers to help adapt to life e.g. returning to work or driving advice. You can find more information here.

Teams refer patients to other NHS services such as orthoptics and orthotics. They also refer into life after stroke support provided by the voluntary sector as well as local authority services.

When a patient is ready to be discharged from the team, they will provide the patient’s GP with a letter containing information about their unmet needs to support ongoing care planning.

In many areas, the community team will carry out a detailed review of the patient at 6 months, although in some boroughs this is conducted by the Stroke Association. 6 month review information is used to help address the patients unmet needs at this timepoint, including referral to other services. Teams accept self re-referrals back into their service if the patient requires further specialist support beyond 6 months.

LIFE AFTER STROKE SUPPORT

The voluntary sector, as well as local authorities, provide invaluable support for patients and their families/carers after a stroke. This support may start when in hospital and continue long after NHS rehabilitation finishes.

There is no time limit to someone’s recovery and stroke survivors may continue to improve for many years after their stroke.

Life after stroke services complement and augment NHS care and are a key aspect of recovery, especially in the longer term. They typically provide a key worker led approach and include support for: carers; communication; family, peer support and emotional wellbeing.

Many stroke survivors and their families continue to be engaged with these organisations as volunteers which can also support their longer term recovery.

We have an online directory of local voluntary sector services to refer people to. Local stroke voluntary sector organisations include:

BASIC – Local charity based in Salford providing brain injury support including rehabilitation using virtual reality

Speakeasy – Local charity supporting aphasia and communication

Stroke Association – local and also nation support for stroke. Commissioned to provide a Stroke Recovery Service in almost all Greater Manchester Boroughs with Stroke Association Connect also available

Think Ahead – Local charity providing stroke support in the Wigan area