Bedfordshire Neuro Rehabilitation and Early Support Discharge Stroke Service
Our services help people who have long term neurological conditions, or strokes who require a specialist rehabilitation program in a community setting.
Working as one team allows us to be flexible in our continuity of care for stroke survivors between early supported discharge service and neurological rehabilitation teams.
Neurological rehabilitation or neuro-rehab team (NRT) - provide a specialist rehabilitation program in a community setting. This helps patients who have long-term neurological conditions or strokes.
Bedfordshire stroke early supported discharge service (ESD) - provide up to 6 weeks rehabilitation that's similar to what is in the hospital. This helps patients admitted to acute stroke units to be discharged sooner.
We are a multi disciplinary team (MDT). We have physiotherapists, occupational therapists, speech and language therapists, psychologists, and assistant practitioners, who are specialists in neurological.
Bedfordshire stroke 6 month review
As part of ongoing service development and in line with Early Stroke Discharge services across Luton and Milton Keynes, Bedfordshire Early Stroke Discharge service started providing 6 month post stroke reviews from 1 June 2022.
The locally agreed model provides a comprehensive review by a stroke review coordinator within 4 to 8 months of stroke to assess progress and identify any unmet needs across recognised health, psychological, leisure, social and work domains. Choice of telephone or face to face session (home or clinic environment) is given to support varying mobility requirements, transport and communication or cognitive difficulties.
- 6 month post stroke reviews provide background to compare new or ongoing environmental, physical or psychological difficulties that may arise.
- Providing consistency and continuity to the patient and carer.
- Specialist knowledge and experience of reviewer working within local stroke pathway with ability to provide further reviews as appropriate to patient and carer needs.
- Impact to reduce risk of readmission to hospital and referral to other services through immediate action on issues identified.
- Stroke review coordinator has strong interdisciplinary approach within the neuro therapy services in Bedfordshire to support the stroke survivor within the community.
- Address secondary stroke prevention, stroke recovery and disability management as part of the review.
Referrals
We will accept referrals from:
- patients (self-referral)
- all professionals
To make a referral call 0300 790 6832 or email ccs.bedsneuro.referrals@nhs.net
Neuro rehabilitation service eligibility criteria
We provide support to adults who:
- are aged 18 years old and older who are registered with a Bedfordshire GP
- are medically stable
- newly diagnosed with a long-term neurological condition or following a deterioration in their existing neurological condition who will benefit from multidisciplinary therapy and are able to make functional gain with the intervention
- are able to make consistent progress
- are able to participate in the rehabilitation
- understand the concept of rehabilitation and is able to work towards a goal
Early support discharge service eligibility criteria
We provide support to adults who:
- are aged 18 years old and older who are registered with a Bedfordshire GP
- are medically stable,
- are able to move from bed to chair with 1 person or independent if they live alone
- have a primary diagnosis of a stroke within 6 weeks from date of onset
- have a home environment that is suitable for rehabilitation
- have the adequate cognitive ability to maintain their own safety when at home alone
- have adequate nutrition, a modified diet like PEG feeding is acceptable
- have their continence well managed or have returned to their usual level of continence
- have the basic ability to communicate and are able to raise an alarm
- has a medication management system in place to safely manage medication and any changes that may be required
- have extended early supported discharge stroke support for patients who need 2 carers to assist in their daily activities and therapy support. These patients are discharged home from the hospital and are provided with intensive therapy in their own home, as per their clinical need
Contact us
You can contact our service Monday to Friday 8am to 4pm.
Telephone number - 0300 790 6832
Email address - ccs.beds.adults.neuroesd@nhs.net
Referral email address - ccs.bedsneuro.referrals@nhs.net
