Assisted Discharge Stroke Service

The team aims to assist earlier discharges from hospital for patients within Lincolnshire who have been admitted with a diagnosis of a recent stroke

Description of Service

The service offers a time and patient specific, specialised rehabilitation service, with an element of personal care. The main aims of this service are to reduce lengths of stay within stroke units, improve the patient and carer rehabilitation experience following a stroke and to offer seamless transfer of care from hospital to home.

The service works closely with staff in the Acute Stroke Units in Lincolnshire Hospitals and across borders with units who take Lincolnshire patients.  The team also works closely with Nursing Complex Case Managers, Community Response and Rehabilitation Teams, Community Therapy Teams, Social Services and the voluntary sector.

Elements of the Service

The service is a time limited service of approximately six weeks; it offers specialist assessment by experienced Speech and Language Therapists, Occupational Therapists and Physiotherapists who work with Community Nursing colleagues.

The service provides personalised care plans and involves patients and their carers in specific goal setting to assist them in achieving their maximum rehabilitation potential within the six weeks.

The team includes Trainee Assistant Practitioners and Rehabilitation Assistants who support the clinicians in carrying out care plans, and is able to offer assistance with daily living activities as part of the rehabilitation process.

Emphasis is placed on education for healthy living, patient and carer involvement, supporting both with appropriate information and signposting to relevant professionals and voluntary agencies.

The team links closely to the Stroke Specialist Complex case manager in North West Lincolnshire and other Complex Case Managers across Lincolnshire who will monitor vital signs and medication.

Service Operating Times

 The SPA line is open 8am to 4pm Monday to Friday. There is an answer phone to record messages outside these times.

The clinicians offer a seven day a week Rehabilitation Service between the hours of 8am and 6pm.

 Main office telephone number: 01522 308686.

Waiting Times for the Service

Patients will be assessed following referral within as short a timeframe as capacity allows and be visited at home within 24 hours of discharge home unless otherwise informed.

Referral Details

Referrals are only accepted from professionals within specified stroke units on completion of the referral form. The referral form is available by contacting the single point of access and is also available from clinicians within the service.