Early Supported Stroke Discharge Team to help more patients gain independence

Stroke patients are getting on the road to recovery quicker, thanks to a partnership between health services.  The Early Supported Stroke Discharge Team is a collaboration between North Cumbria University Hospitals NHS Trust and Cumbria Partnership NHS Foundation Trust.  The teams work closely to manage the care and therapy of stroke patients to ensure they get home as early as possible with the appropriate package of care.

Now, a delivery board chaired by the Chief Executives of both organisations has recognised the innovative work already happening in Carlisle and agreed to roll the innovative model out across West, North & East Cumbria, to benefit more patients.

Dr Paul Davies, Elderly Care Consultant at North Cumbria University Hospitals NHS Trust, explains: “The team, consisting of physiotherapists, occupational therapists and speech therapists are all specialists in stroke rehabilitation. They can provide rehabilitation after a stroke in the patient’s own home at the same intensity as the patient would have received if they had remained in hospital. The patient has to have reached the level of recovery where they are mobile or almost mobile independently to be able to go home and receive care from the team. Almost half of all patients admitted with a stroke can benefit from the team.  

“In areas where rehabilitation in hospital and rehabilitation with an Early Supported Stroke Discharge Team have been studied and compared, there are clear benefits to rehabilitation at home.  Carlisle and Eden have had the benefits of these teams for a number of years but we now have the opportunity to build on these services so that stroke patients across West, North & East can benefit from an Early Supported Stroke Discharge Team. The challenge is in applying the knowledge and experience from these areas in designing a service that fits our mainly rural populations.”

Dr David Lewis, Associate Medical Director for Community Services at the Cumbria Partnership NHS Foundation Trust said “Janet’s story highlights the importance of early intensive rehabilitation which is being delivered by our Community Specialist teams across the County to patients who have unfortunately suffered a stroke or an acute neurological problem.

We recognise that this type of early intensive rehabilitation, in many instances, can help patients to recover a good quality of life after such an unfortunate episode. Along with all our partner organisations including the voluntary sector, the clinicians who deliver this excellent care are currently engaged in further developing and strengthening the service Countywide supported by the Success Regime”

Patient Story

Prior to a life changing stroke Janet Tootle, aged 63 from Carlisle had been working full time in a local biscuit factory, lived independently and enjoyed an active social life with friends and family.  With help from the Early Supported Stroke Discharge Team (ESSDT) Janet has improved significantly and her quality of life has improved since her stroke.

Janet explained: “When I left hospital, I was on my own and felt scared about the future. I live on my own and didn’t know what would happen to me. I wasn’t able to do anything for myself and had up to 6 visits every day and night. I felt despondent; it has taken a long time but the girls were brilliant, fantastic, gave me lots of encouragement on difficult days. They gave me confidence to get over my fears of falling and progress to managing everyday tasks as walking, dressing, using the washing machine and managing my medication. I didn’t want to spend Christmas alone so I was determined to reach my goal of staying with my family in Newcastle”.

Joanne Howard, Lead Physiotherapist with the ESSD team said: “Janet was admitted to hospital in 2015 following a severe stroke and was discharged home with support from the ESSD team. District Nurses, Neurology, Social Workers, and others worked together to coordinate the best care for Janet and some adaptations were made at home. She is a very determined lady and works hard until she has succeeded in achieving all of her therapy goals. She knew exactly what she wanted to achieve and made fantastic progress. Working with Janet has been a pleasure and rewarding for all involved.”

As part of her rehabilitation Janet was attending the exercise group at Botcherby Community Centre prior to the flooding. She is hoping to start the replacement sessions at a new community venue once they have new equipment. It is hoped she will then attend the Sands Centre for the Exercise on Referral Group.

One last step in Janet’s journey is looking forward to moving to a new home, without stairs, where she will be independent but with support should she need it.