Community stroke services

We make sure all patients who have had a stroke or TIA continue to have access to stroke assessments and appropriate care following their discharge home from hospital.

The service will be informed of your discharge from hospital. We will contact you within 72 working hours of discharge. We will then arrange to see you, according to your clinical needs, either at home, or in a local clinic. We will provide therapy, advice, support or information as required. If you have had a stroke, you will also have a formal review after 6 months.

Support will be provided in variety of ways including:

• home visits
• telephone and video calls
• clinic appointments
• lifestyle advice

To promote and aid your recovery, the team will work with your GP to prevent a further stroke or TIA. This could include reviewing your medication and discussing changes with your GP. They will also work with other healthcare professionals and other organisations which are supporting you to provide them with expert advice.

Our team will provide you with the skills to manage your condition. They will be a lifelong resource for you, your family and carers. They can also advise you and your carers on how to access additional support from our statutory, charity and voluntary organisations.

The clinic is a one-stop, multi-disciplinary, rapid access service for patients with transient ischaemic attack (TIA) or mini-stroke.

The clinic provides secondary prevention to reduce the incidence of stroke and unnecessary acute hospital admissions.

Clinics are held 7 days a week at the Royal Cornwall Hospital in Truro.

They are staffed by a:

• consultant
• stroke nurse
• clinical vascular scientist
• clinic nurse

Referrals are triaged on receipt and if assessed as high risk, we aim to see the patient within 24-hours.

After the clinic, the Stroke Specialist Nurse Team will be informed of patient’s diagnosed with TIA or stroke. They will then arrange a follow-up appointment either at home or in clinic according to the patient’s clinical needs.

Resources

• TIA clinic patient information leaflet

There are 2 specialist stroke rehabilitation units where a multi-disciplinary stroke team will care for you and provide further therapy to help prepare you for going home.

The specialist stroke rehabilitation units are:

• Woodfield Stroke Rehabilitation Unit at Bodmin Community Hospital
• Lanyon Stroke Rehabilitation Unit at Camborne Redruth Community Hospital

You will be assessed on your arrival and your personal treatment plan will be reviewed and developed by the team ensuring. The team will ensure that:

• individual problems and issues are clearly identified
• measurable goals are agreed with you and included in the treatment plan
• the individual treatment plan is regularly reviewed with you, your family and carers

For those who need rehabilitation, there is a range of therapy that includes:

• occupational therapy
• physiotherapy
• speech and language therapy

Each patient will have an agreed personal development plan. The plan will include their goals and the type and frequency of therapy required to achieve the goals.

When it is time for you to be discharged from hospital, or when you reach the end of care from the Early Supported Discharge Team, your ongoing care will be carefully planned by the Specialist Stroke Team. They will work closely with your GP, community health care teams and social services.

You and your family and carers will be given information about your diagnosis, your likely prognosis and advice about care at home. As well as helpful contact details in case you encounter any problems.

If necessary, a home assessment will be undertaken to make sure that any adaptations to your home are made before you arrive. The Specialist Stroke Team will work with you and your carers to plan the details of the care you will need at home.

Some patients will have active input from a social worker. The social worker will help with discharge from hospital. This includes patients who are going to a nursing or residential home. Some who are discharged home from hospital will require ongoing therapy from either:

• the rehabilitation team
• a specialist neuro occupational therapist
• a neuro physiotherapist

Your GP will also be able to help with any further support you may need. Your GP will be informed about your admission and your care needs when you return home. Following your discharge, they will then become the doctor responsible for your care.