Early Supported Discharge is a Service that provides specialist therapy, rehabilitation and support at home to people who have had a stroke. Our team includes:
Specialist Stroke Nurses
Occupational Therapists
Speech & Language Therapists
Physiotherapists
Stroke Physician
Rehabilitation support worker
Before going home all the necessary arrangements will be made to enable you to manage at home. Any equipment that you need will be put in place, and your care needs will have been agreed and support in place. We will make appointments for the first few visits and make further appointments once you are at home. Once you are at home one or more members of the team will visit you as soon as is necessary. We will review any arrangements that have been made prior.
How often will the team visit?
We will set rehabilitation goals tailored to your individual needs to help you to reach your maximum potential. These will form the basis of the Early Supported Discharge team input and how often we will visit.
How long will the team be involved?
The purpose of the Early Supported Discharge is to help you to return home at the earliest possible opportunity with the support of the specialist stroke team. This is a short-term service. If you require further rehabilitation at home we will work with our colleagues in the community to ensure that your ongoing needs are handed over to them.
Confirmed diagnosis of a new stroke.
Over 18 Years old.
Registered with GP In the Chesterfield, North East Derbyshire or Dales localities.
The patient and their family/carer agree to the rehabilitation process continuing at home Including the necessary installation of necessary equipment and care to support the process.
The home environment is conducive to community-based rehabilitation.
Achievable rehabilitation goals can be identified.
The patient can transfer independently If living alone, or if not living alone can transfer with the assistance of a relative/carer using equipment where necessary.
Document acknowledgement that the patient Is sufficiently well enough from a medical perspective to be managed in the community.
Medications can be suitably managed at home.
On oral diet and fluids or PEG feed.
Nutritional plan established.
The continence management plan is In place if required - any issues can be addressed with the assistance of a relative/carer.
Equipment is In place for discharge.
The patient's language and/or cognitive skills are at a level for them to manage on their own for periods as necessary.
01246 277 271
