This guidance is designed to help you identify what interventions you provide as a service to help with registration in SSNAP and what to call your service.
EARLY SUPPORTED DISCHARGE (ESD)
Does your service:
- Have a multidisciplinary team structure
- Have stroke specialist staff
- Work closely with inpatient stroke unit staff to coordinate transfer of care of stroke survivors from hospital to home or place of residence
- Provide rapid and responsive face to face assessment at home or place of residence ideally within 24 hours of hospital discharge if required
- Provide intensive (at least several times a week) stroke rehabilitation at home or in place of residence
- Have a fixed (e.g. six week) time limit
- Have eligibility criteria based on stroke severity/disability
- Your SSNAP service type is a stand-alone ESD service or ‘ESD’
- Call your service a stroke ESD service
COMMUNITY STROKE REHABILITATION
Does your service:
- Have a multidisciplinary team structure
- Have stroke specialist staff*
- Provide community stroke rehabilitation at home or in place of residence at a low level of intensity on a needs-led basis for patients not meeting ESD eligibility criteria
- May take referrals from services other than hospital discharge (e.g. ESD)
- Can have a waiting list
- Your SSNAP service type is a community rehabilitation team or ‘CRT’
- Call your service a community stroke service
* If you do not have stroke specialist staff call your service a community rehabilitation service
INTEGRATED COMMUNITY STROKE SERVICE (ICSS)
You need to meet all the criteria below to be defined as an ESD-CRT service. If you don’t meet these criteria, please refer back to the ESD and CRT definitions to find your team type.
Does your service:
- Have a multidisciplinary team structure
- Provide access to rehabilitation for all stroke patients, irrespective of their level of disability or discharge destination
- Support the needs of all stroke patients both on discharge from hospital or in the community who need rehabilitation
- Provide both intensive ESD and lower intensity community stroke rehabilitation at home or in place of residence
- Have a single point of access/referral route
- Have a shared clinical caseload for patients accessing ESD and those that do not, with no internal re-referral required
- Have one governance system for all aspects of the service
- Your SSNAP service type is a combined ESD-CRT service
- Call your service an Integrated Community Stroke Service
The following criteria will be assessed as part of the SSNAP organisational audit and will contribute to your services ability to deliver a fully evidence-based ICSS as measured by the SSNAP clinical audit.
- Provide combined ESD-CRT as defined above
- Provide vocational and psychological rehabilitation
- Work collaboratively with other NHS and social services and the voluntary sector to provide support services to meet the needs of all stroke survivors
- Provide six month reviews
- Have flexible staffing
- Provide needs-led stroke rehabilitation for up to 6 months
- Have 7 day working
- Call your service an Integrated Community Stroke Service
Definitions
Early Supported Discharge
An Early Supported Discharge (ESD) service provides ESD only to eligible patients. ESD is an intervention delivered by a coordinated, multidisciplinary team that facilitates the earlier transfer of care from hospital into the community and provides responsive (within 24 hours) and intensive stroke rehabilitation in the patient’s place of residence over a fixed, time-limited period (e.g. 6 weeks).
Community Rehabilitation Team/Service
A Community Rehabilitation Team / Service (CRT) is a multi-disciplinary team that provides community stroke rehabilitation to stroke patients requiring a lower level of intensity, condition, disability or case management. This may be following hospital discharge, after a patient has been discharged from an ESD team or at any point post stroke where rehabilitation needs are identified. The intensity or duration of this service is determined by patient need.
Integrated Community Stroke Services
An Integrated Community Stroke Service (ICSS) co-ordinates transfer of care of stroke survivors from hospital and, through a specialist, multidisciplinary team (MDT) structure, provides early, effective and community-based specialist stroke rehabilitation and disability management to all stroke patients leaving hospital who need it. The ICSS brings existing service configurations together, including Early Supported Discharge (ESD) and community stroke rehabilitation, into one integrated seamless service – combined ESD-CRT. Integration is demonstrated by a shared clinical caseload, one management structure, a single point of access/referral route, flexible staffing and no internal re-referral required. The ICSS offers three pathways of care tailored to patient need: (1) home with ICSS input, (2) home with ICSS input combined with social care support, (3) discharged to a residential /nursing home. ICSS is provided for up to six months with the option for re-referral after discharge if rehabilitation needs and goals are defined, and with access to support services on discharge.
An ICSS, could be one service/team which comprehensively manages all pathways/aspects of the ICSS OR could be a collection of services that work together to deliver the whole ICSS model.
Stroke-specialist team or service
A stroke specialist team or service is defined as a group of specialists who work together regularly to manage people with stroke, and who between them have the specific knowledge and skills to assess and manage most stroke-related problems. This does not require the team exclusively to manage people with stroke, but the team should predominantly treat stroke survivors and have specific knowledge and practical experience of stroke.