Post Hospital Stroke Care

The goal of this work stream is to ensure that all individuals within the Network who have experienced a stroke or TIA will have timely access to appropriate post hospital care as set out in the National Stroke Strategy.

In light of this, the Network aims to:

• Promote efficient and appropriate referral for early/timely supported discharge through a streamlined process and pathway for stroke and TIA

• Improve equity of access to early supported discharge and ongoing support for long term care across Greater Manchester and Cheshire

• Engage health and social care professionals to continue to improve the provision of care in partnership with patients, taking account of their individual needs and preferences, and ensuring that patients (and carer and families) can make informed decisions about their care and treatment

• Develop the role of the specialist stroke early supported discharge team

• Audit the number of assessments carried out and outcomes achieved following this intervention

• Increase patient and carer involvement within local stroke service improvements

• Increase the stroke specific multi-disciplinary community teams/services for this client group to reduce the amount of hospital readmissions

• Explore the models of community stroke care to support long term care

• Identify the needs of stroke survivors and their carers

• Develop a workforce that is competent to deliver care at all parts of the patient pathway

• Identify workforce gaps and develop action plans to overcome them

• Engage with staff to establish education and training packages to ensure a competent workforce

• Forge stronger links with local authorities and adult social care

The measurements for success will be:

• An increase in the number of assessments for stroke long term management

• Increase the number of carers receiving assessments

• A reduction in the length of stay for stroke and TIA patients

• A reduction in the waiting times for community therapy services

• A reduction in readmission to hospital for stroke

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