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Stroke early supported discharge

The Suffolk stroke early supported discharge service brings together hospital staff, experienced stroke-specialist therapists and rehabilitation assistants, and voluntary organisations to work together with patients and their carers. 

Our staff deliver intensive programmes of rehabilitation within patients’ own homes across Suffolk. These specialist rehabilitation programmes are designed to meet individual patient’s needs and are based on patient identified goals.

Stroke education and training for our patients and their carers is an essential part of our service, as is sharing our knowledge and learning with other health professionals.

Working in partnership with existing health and social care services in Suffolk, helps us to contribute to improving longer term outcomes for stroke patients.

The service is provided by an alliance of organisations, including West Suffolk NHS Foundation Trust, East Suffolk and North Essex NHS Foundation Trust, Suffolk County Council, working alongside charity and voluntary sector organisations.

What does the team do?

We provide a specialist stroke rehabilitation service, following an acute stroke to help patients achieve your optimal level of independence. The aim is to help you safely get back on your feet as rapidly as possible, in a supported way.

Who is in the team?

The team includes specialist physiotherapists, specialist occupational therapists, and rehabilitation assistants alongside a clinical psychologist. An administrator and a team coordinator help with arranging visits and matching patients up with the best people in our team.

What can patients and carers expect?

Once you are home, we will provide therapy, treatment, care or advice, as needed, to improve your recovery and independence after a stroke. This is an intensive service for up to six weeks, which provides individualised therapy programmes that reflect the your own personal goals, which we will help you set. The team provides a patient-centred service that also includes carers, friends, and loved ones where appropriate. The service includes therapeutic interventions, stroke education and training to promote independence and longer term self-management.

Does the service take all stroke patients?

Not all stroke patients are eligible. We take patients who have had an ‘acute’ stroke. Our team works closely with hospital stroke services to identify those patients who would most benefit from our service. To be eligible for this service, it is essential that you are safe within your home environment, with or without a carer present, and you are able to cope with an intensive programme of rehabilitation for up to six weeks.

How are referrals made to the service?

The service receives referrals from hospital stroke services, including West Suffolk Hospital and Ipswich Hospital.

How long will we work with you for?

Our service provides interventions with individual patients for up to six weeks. You may be discharged earlier, as your rehabilitation programme is created with you and reflects your personal goals and clinical needs. At the end of the programme we may refer you on to other local services to help you continue in your recovery. We’ll discuss this with you as part of discharge planning from our service.

Where is the team based?

There are two bases: one in Bury St Edmunds and another in Ipswich, but generally the team will be with patients in the community, supporting them you in your own home.

When is the team available?

The service runs from 9am until 5pm, Monday to Friday. We do not provide a weekend, bank holiday or overnight service. You can call us on 0345 5045421 or email suffolkesd.referrals@nhs.net

If you need support out of hours, please use other NHS services, including NHS 111 and your GP out of hours service. In an emergency, always call 999 for urgent help.

What happens after discharge from this service?

Our main aim is for you have achieved your agreed rehabilitation goals, and be on a good recovery path. If you still need support after your initial rehabilitation, we will put you in touch with appropriate services to support you.

Until April 1, 2021, the service was provided by Norfolk Community Health and Care NHS Trust. You can find previous details about the service on this website.

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