From rehabilitation to the community

Stoke-on-Trent Adult Social Care, Health and Communities directorate has successfully transformed its support service for stroke patients following its redesign of the Stroke Care Pathway, the process used to move patients from rehabilitation back to living in the wider community.

Transformation objectives were to:

• establish a Community Stroke Team delivering services based on a hub and spoke model
• develop integrated personalised health and social care centres
• improve the quality of life for stroke survivors

Changes have led to:

• contact made with the hospital after admission to facilitate early discharge and ensure continuity of care in the community
• appropriate equipment or adjustments made at home at an early stage speeding up hospital discharge times
• a named contact person who will organise a range of support
• services designed to help individuals adjust to the physical and emotional effects of a stroke
• people receiving support from social care staff who have received specialist training and have regular contact with health colleagues specialising in rehabilitation services.

Staff have also benefited from new personal development opportunities, less paper work and access to an up to date database on the ward and in the community.

The next stage involves giving more health staff access to the database, and employment of a Stroke Liaison Officer who will be responsible for rolling out joint training programmes across health and social care.

Contact: jill.broomhall@stoke.gov.uk