National Institute for Health and Clinical Excellence (NICE)
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Joined-up working required for effective stroke rehab services

A multidisciplinary team consisting of both health and social care professionals is essential for an effective stroke rehabilitation service, according to NICE.

Stroke is a major health problem in the UK. Each year an estimated 150,000 people have a stroke - equivalent to one person every five minutes.

The majority of those who have a stroke survive, however this comes at the cost of long-term disability. Over 30 per cent of people who have had a stroke live with a persisting disability, and so require access to effective rehabilitation services.

In its first clinical guideline on stroke rehabilitation, NICE says that people with disability after stroke should receive rehabilitation in a dedicated stroke inpatient unit, and subsequently from a specialist stroke team within the community.

This stroke rehabilitation team should consist of a range of professionals with expertise in stroke rehabilitation, including consultant physicians, nurses, physiotherapists, speech and language therapists and social workers.

Health and social care professionals should work collaboratively to ensure a social assessment is carried out promptly, where needed, and before the person with stroke is transferred from hospital to the community.

This assessment should identify any ongoing needs of the person and their family or carer, such as access to benefits, care needs, transport and housing.

The assessment should be documented, and all needs recorded in the person's health and social care plan, with a copy provided to the person with stroke.

The guideline also includes recommendations on helping those who have had a stroke return to work. NICE says return to work issues should be identified as soon as possible after the person's stroke, reviewed regularly and managed actively.

Furthermore, the health and social care needs of people after stroke and the needs of their carers should be reviewed at 6 months and annually thereafter. These reviews should cover participation and community roles to ensure that people's goals are addressed.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, said: "Stroke can have a devastating and lasting impact on people's lives.

"This guideline makes practical recommendations about what should be provided as part of a comprehensive stroke rehabilitation service, what reviews and reassessments should be carried out, and what additional information, support or care to consider when delivering services or therapies."

Pamela Holmes, Practice Development Manager at the Social Care Institute for Excellence and member of the guideline development group, said: "Following a stroke, clinical concerns are the first priority, quickly followed by social care issues; people want to return, as quickly as possible, to a full and active life. This means getting them - and their family - involved in rehabilitation, and working out what they want to achieve."

She added: "This guideline advises on how to make sure people's care in the short and long term is coordinated. A joined-up approach is essential for getting the transfer of care from health services to social care right and the guideline highlights the need for a jointly written discharge plan incorporating both health and social care management."


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