Stroke Early Supported Discharge 2020

NHS Ipswich and East Suffolk and West Suffolk Clinical Commissioning Groups are looking to commission a Stroke Early Supported Discharge (ESD) Service across Ipswich, East Suffolk (minus Waveney) and West Suffolk.

This service has been designed to support people after stroke, transferring care from an inpatient environment to a primary care setting to continue rehabilitation at the same level of intensity and expertise that they would have received in the inpatient setting. This service will maximise rehabilitation potential for stroke survivors and lessen long term disability. A multi-disciplinary approach will ensure rehabilitation needs are met. Full integration of this service with other community provision is required to ensure all interactions are delivered in a collaborative and co-ordinated approach.

The overall aims of the Stroke ESD service are:

•To deliver specialised rehabilitation through a multidisciplinary and co-ordinated approach as per RCP Clinical Guidelines for Stroke 2016

•To provide a seamless pathway and continuity of care for the stroke survivor and their carers through the acute stay to rehabilitation and beyond

•To ensure a whole system approach that raises standards across the stroke pathway aligned with National and local strategy and guidelines.

•To ensure the stroke survivor and family/carer have access to support, advice, advocacy and information throughout the care pathway and beyond

•To ensure rehabilitation is delivered with a person-centred, goal planning approach

•To achieve maximum potential for independence in all aspects of the stroke survivors and their family/carer's lifestyle while, acquiring the skills to adapt to new situations.

•To deliver a five days a week ESD service as standard ,with 7 day working a future development

•To reduce premature admission into Long Term Care.

•To enable the stroke survivor to reach and maintain their optimum potential in their physical, psychological and social functional abilities.

•To integrate Health, Social and voluntary organisations, ensuring a high quality pathway from transfer from the acute setting through discharge home and beyond.