1. EARLY SUPPORTED DISCHARGE FOR STROKE PATIENTS
NICOLA SAVAGE
Physiotherapy Clinical Team Leader

2. Definition
The provision of home based rehabilitation service following early discharge from acute hospital setting

3. Why Reduced length of stay.
Improved reintegration into the community setting.
No detrimental effect on patient outcome.
Supported by current published evidence by RCP, Cochrane review, NSF older person.

4. Who Will Deliver Supported by current teams Occupational Therapists
Physiotherapists
Supported by current teams
Nursing Staff
Medical Staff
Social Workers
SALT

5. Referral and Inclusion Criteria
Open referral through current teams
Criteria
Live within geographical area
Care givers support
Pre CVA functional level
Medically fit for Discharge

6. Who Will Benefit Patient
Return Home Quicker.
Continuity of Treatment in Home Setting.
Seamless Transition to Home Environment

7. Who Will Benefit Organisation
Reduced Length of Stay
Reduced Costs
Improved Discharge Process

8. Patient Journey Patient identified on Acute Ward setting
Assessed for appropriateness
Liaise with Multi Disciplinary Team
Joint Goal Setting

9. Patient Journey Discharge Planning
Treatment Continued within Home Setting
Transfer of Care to Other Community Teams
Discharge from Service

10. Patient Data 2010 Bersham Ward ESD Patients Number of Patient 274 90
Length of Stay 48
24.5

11. Patient Data 2011 Bersham Ward ESD Patients Number of Patients 257 74
Length of
Stay 23
18.8

12. Patient Data 2012 Bersham Ward ESD Patients Number of Patients 250 82
Length Of Stay
19.5
13.7

13. Patient Data -Barthel Score of Patients supported by ESD

14. Patient Satisfaction Survey
“You learn to do the things you need to do on a daily basis in your own home”
“My Partner appreciated the help and support”
“It was a great comfort”.
“The speed they sorted my discharge was very impressive”

15. Reasons for Discharge from the Team
Patient goals met and discharged from therapy.
Patient goals for discharge met and referred to other therapy services for continued intervention.
Change in medical condition.

16. Service Developments Access to Care Packages/Social Services
Access to SALT
Use of Generic Support Staff

17. Conclusion
ESD Team is an effective way of discharge Stroke patients home promptly.
The team being based in the hospital allows for seamless transition of care.
Patient and Care-givers felt supported.

18. Questions