Transcript Document
Stroke Services at Eastern and Coastal Kent PCT Mel Woollaston - Stroke Specialist Nurse Julie Bradford - Occupational Therapist Introduction • • • • Intermediate care team Stroke pathway Stroke Specialist Nurse Ongoing developments Intermediate Care Team (ICT) • Teams • • • • • Ashford/ Tenterden Shepway/New Romney Canterbury/Herne Bay Thanet Dover/Deal Intermediate Care Team (ICT) • Referrals - from anyone and everyone. Pts can refer themselves, GPs, Acute trust, voluntary organisations • Role - rapid response, prevent admissions, post discharge rehab, palliative care, falls. It is a needs led service, not time limited, but pts must be referred on if long term follow up required • Team members - Nursing staff, OT, PT, RMN, Psychosocial OT, Dietetian, CM, SLT Stroke Pathway Regular attendance at MDT from stroke specialist nurse Handover to ICT of pending discharges ICT referral completed prior to EDD and faxed to relevant team Stroke Pathway Lead therapist to contact referrer to discuss referral, goals and urgency of input Need for Joint discharge visit identified Discharge summary faxed on day of discharge Stroke Pathway If no joint visit needed Telephone triage completed within 24h Appointment made following outcomes of triage – usually within 1 week Treatment phase commences Stroke Pathway Goals set from hospital reviewed and continued with/ revised if appropriate Intensity of therapy agreed – can be seen from daily by qualified staff for short periods to once a week by a support worker Discharged when clinically appropriate Referral on to other services Stroke Specialist Nurse • Discharge Summary faxed to Single Point of Access • Screened by Stroke Specialist Nurse completing the standard ICT screening paperwork as well as looking at stroke specific measures eg Including – QOL score, Fatigue, Mood, Cognition, Continence, Medicines (check on all appropriate stroke prevention drugs), outstanding investigations, Support and reassurance, Health promotion • Patients can be seen on a home visit or in a clinic Stroke Specialist Nurse • Referrals onto ICT, medicines management, Stroke Association, Neuropsychologist, East Kent Strokes, GP’s, Stroke Consultant • Letter to GP and in notes • Follow up appointments for review and ongoing support • Patient has contact details for any problems/issues Ongoing developments • Integrated Stroke document • Outcome measures • Local cross trust meetings - networking, discussion of cases, outcome measures, projects (getting out of the house, and service improvement project, training needs (competencies), implementation of stroke education framework. Aiming to work across trusts to prevent duplication of same work eg with competencies and the stroke ed framework