DIR Return Create A Forum - Home
       ---------------------------------------------------------
       Commissioning Forum
  HTML https://commissioningforum.createaforum.com
       ---------------------------------------------------------
       *****************************************************
   DIR Return to: Community Care
       *****************************************************
       #Post#: 88--------------------------------------------------
       What are the implementation details for Stroke REDS Service?
       By: admini5 Date: May 11, 2015, 5:22 am
       ---------------------------------------------------------
       Camden REACH has a history of providing ESD since 2004. Although
       previously this has not been stroke specific, the networking and
       experience developed by discharging patients on an ESD pathway
       from the local hospitals gave Camden REACH experience to provide
       an ESD pathway for patients with stroke. Following confirmation
       of funding for a 2-year pilot, Camden REACH started recruiting
       stroke specialist staff into posts from October 2008, either by
       advertising posts or restructuring staff from the community
       team. The enabling care staffs were already in post.
       However, more staff was recruited with specific stroke
       experience. By January 2009, when the service went live, most
       staff was in their posts and the service was fully operational.
       From October 2008 onwards, all the stroke units were presented
       with an ESD pathway description and consulted the ESD pathway
       does not have any referral forms and referral can be made via
       phone, secure email or using the Camden REACH single point of
       access. The Stroke REDS team ‘in-reaches’ into the Camden stroke
       units by attending weekly ward rounds and also family meetings
       if needed.
       Once a client is suitable for rehabilitation with Stroke REDS,
       the team coordinates, facilitates and organises the following to
       ensure a safe transition from the stroke unit to the client’s
       home:
       -
       care through Carelink, which is part of the Camden REACH team.
       The team consists of health workers who are trained to provide
       enabling care focusing on maximising a person’s independence.
       The enabling carers are crucial in the rehabilitation that the
       Stroke REDS team offers for clients who require care at home.
       -
       sure that the home environment is suitable for rehabilitation
       and safe discharge including provision of any equipment.
       -
       (MDT) to ascertain a discharge date.
       -
       discharge planning, focusing on organising communication with
       client and family, informing the MDT in regard to issues such as
       a client’s ability to administer medications, and giving
       feedback to the MDT for safe discharge.
       On the day of discharge, Stroke REDS has its own transport and
       meets the client on the ward to take them home. Final checks are
       performed before leaving the ward to ensure medication,
       outpatient letters and client’s belongings are taken home.
       Clients do not have to rely on hospital transport and avoid
       waiting in the discharge lounge for up to 4 hours.
       Once at home the following therapy programme is implemented:
       -
       care, outcome measures.
       -
       -
       -
       -
       liaison with post-discharge teams.
       -
       measures + discharge.
       There is potential to extend to 8 weeks for therapy only, if
       appropriate. Throughout the 6 or 8 weeks of intervention,
       interdisciplinary team meetings and meetings with enabling
       carers are conducted weekly.
       For further information, please visit :
  HTML http://arms.evidence.nhs.uk/resources/qipp/116737/attachment
       *****************************************************