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Your rehabilitation will continue at home and the type of support that you receive will depend on your particular needs.

This will be arranged before you leave hospital and your progress will be regularly reviewed to ensure that the level of care meets your needs as they change.

Some patients will leave hospital to be cared for at home by the early supported discharge team. This team provides a comprehensive range of intensive stroke care in the community seven days a week.

Some people will be able to undertake their rehabilitation at home by themselves with occasional contact from a health professional. Other people will need more intensive care and support. They will have regular visits to their home from members of their community home nursing team. These teams have different names in different parts of the country but provide nursing care and access to rehabilitation specialists as required.

When you are discharged home from hospital, responsibility for your medical care transfers from the hospital stroke specialist to your GP. If you are discharged under the care of the early supported discharge team, then your GP will be responsible for your care when the support from the specialist ESD team ends, even though the patient will have been at home.

Your GP will work with nurses, therapists, support workers and social workers as necessary to ensure that your rehabilitation continues and that you and your carers are managing successfully at home.

It is best practice that the hospital contacts you 72 hours after you have been discharged. They will offer you an initial follow-up appointment and make sure that your GP arranges a six month follow-up appointment, with further regular follow-up appointments.

 

What you can expect

These are the standards that you should expect:

 

National Institute for Health and Clinical Excellence (NICE) Quality Standard for Stroke

 

Patients with stroke are offered a minimum of 45 minutes of each active therapy that is required for a minimum of 5 days a week at a level that enables the patient to meet their rehabilitation goals for as long as they are continuing to benefit from the therapy and are able to tolerate it.

What this means for you:

  • Your care plan will set out the therapy support that you need and the goals for your recovery and rehabilitation. For each of the various therapies (occupational therapy, physiotherapy, speech and language therapy) you should receive at least 45 minutes of active therapy for at least 5 days a week.
  • In Surrey, the stroke teams have worked together to produce guidelines setting out that the therapy can be delivered through several different routes using qualified and suitably trained rehabilitation support workers and agreed forms of tele-therapy (assisted therapies using modern electronic and telecommunications). This therapy is in addition to every day activities undertaken by the patient with help.

 

All patients with stroke are screened within 6 weeks of diagnosis using a validated tool to identify mood disturbance and cognitive impairment.

What this means for you:

  • Having a stroke is a major event and some patients find that as they are going through physical therapies they also need to be assessed for psychological needs.
  • In Surrey, the stroke teams have worked together to produce guidelines that all patients with stroke are screened to identify mood disturbance and cognitive impairment soon after admission to hospital and that they are referred into the relevant psychological support programmes.