Stroke ESD referral form

Stroke Early Supported Discharge Referral Form

For healthcare professionals who wish to refer patients to the Stroke ESD team.

PLEASE ENSURE REFERRAL IS RECEIVED BY ESD AND ACCEPTED PRIOR TO DISCHARGE.

PATIENTS DISCHARGED BEFORE ESD REFERRAL HAS BEEN RECEIVED MAY NOT BE ACCEPTED

Referral Process:

Email referral forms MUST be sent from an nhs.net account to buc-tr.StrokeDischargeTeam@nhs.net

Phone ESD on 01494 425616 to discuss acceptance

Phone ESD to confirm patient has been discharged

Acceptance Criteria Checklist for the Buckinghamshire Stroke ESD Service.

• Patient is registered with a Buckinghamshire GP and being discharged to live at that address within the associated catchment area of that GP.
• Admitted to hospital with a confirmed diagnosis of a new stroke.
• Patient is medically ready to return home to care of GP.
• Patient has neurological deficits that can be managed at home.
• Patient has been assessed by the relevant therapy disciplines to establish needs.
• Rehabilitation potential has been identified by the Acute and/or ESD Multi-disciplinary team.
• Clear goals have been identified which can be achieved within the 6-week period.
• Patients are motivated and willing to actively engage in the rehabilitation process.
• The focus of therapy input is active rehab rather than disability management e.g. splinting regimes / posture management.
• Rehabilitation can be optimally delivered single-handed.
• The home environment is conducive to rehabilitation.
• Patient, family (who are living in the same house or providing care) and/or carer are agreeable to intensive rehabilitation at home and may involve many visits a day.
• Patients should receive appropriate risk assessment prior to being referred to ESD taking into consideration challenging behaviours and environmental factors.
• All equipment needed for safety and rehabilitation purposes should be provided prior to discharge.

When the mental capacity of the patient to make a decision re: ESD is in question, the decision for discharge should be made in the best interests of the patient by the MDT following appropriate assessment in line with the Mental Capacity Act 2005 and Code of Practice.

All patients will need to be assessed by the MDT from the acute ward, to be able to stay at home either on their own or with a family member/carer.