PSR- Direct Award C - Stroke Association ELFT

The aim of the assessment is to identify what the stroke survivor, carer or family member would like help with and covers several different areas including:

Physical health

Secondary Prevention

Practical Support

Communication & Cognition

Daily Living

Emotional Wellbeing

Carer Support

As needs are identified, the coordinator supports individuals to identify what they would like to happen as a result of our intervention (their desired outcomes) and works with them to develop a Stroke Recovery Plan detailing the actions required to achieve those outcomes.

A review of needs is offered before we asses is someone is ready to move on from the service which is typically around 12 months, with service support given in between where required as the reviews will be provided embedded within an existing SRS service.

When Post Stroke Reviews are commissioned alongside our core Stroke Recovery Service, this also offers:

• Assessment of needs at earliest appropriate point following discharge
• Coordination and navigation of health and social care systems
• Personalised information and support
• Emotional support to improve psychological wellbeing by relieving the pressure stroke survivors and carers experience through the journey of recovery
• Stroke prevention advice and support to self-manage their condition
• Practical advice and support, for example around managing hospital appointments, managing equipment and ways to live as independently as possible at home
• Support to make a recovery plan, set goals and achieve them
• Support to address social isolation
• Representation and advocacy
• The opportunity to use our online self-management tool, My Stroke Guide

The aim of the assessment is to identify what the stroke survivor, carer or family member would like help with and covers several different areas including:

Physical health

Secondary Prevention

Practical Support

Communication & Cognition

Daily Living

Emotional Wellbeing

Carer Support

As needs are identified, the coordinator supports individuals to identify what they would like to happen as a result of our intervention (their desired outcomes) and works with them to develop a Stroke Recovery Plan detailing the actions required to achieve those outcomes.

A review of needs is offered before we asses is someone is ready to move on from the service which is typically around 12 months, with service support given in between where required as the reviews will be provided embedded within an existing SRS service.

When Post Stroke Reviews are commissioned alongside our core Stroke Recovery Service, this also offers:

• Assessment of needs at earliest appropriate point following discharge
• Coordination and navigation of health and social care systems
• Personalised information and support
• Emotional support to improve psychological wellbeing by relieving the pressure stroke survivors and carers experience through the journey of recovery
• Stroke prevention advice and support to self-manage their condition
• Practical advice and support, for example around managing hospital appointments, managing equipment and ways to live as independently as possible at home
• Support to make a recovery plan, set goals and achieve them
• Support to address social isolation
• Representation and advocacy
• The opportunity to use our online self-management tool, My Stroke Guide

Stroke Association

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This service will be provided embedded alongside the existing Stroke Recovery and Prevention Service, commissioned separately in Newham providing to provide:

Key worker support

The Stroke Recovery Service core provides support to navigate through the complexities of the stroke pathway giving advice and help to adjust to the changes that stroke brings.

Assessment of need

An assessment of need is offered to each person. The level of assessed need will determine the level of support an individual requires to meet their desired outcomes.

Planning for recovery

The Stroke Recovery Plan records an individual’s needs and desired outcomes and sets out the actions required to achieve those outcomes. If there is a need to cost options and the level of need is low options and costings can be presented.

Implementing the plan

The support needed from staff, volunteers and others to deliver the option selected is provided.

Emotional support

Stroke survivors and carers are supported with techniques such as active listening and problem solving. Where the need for more intensive emotional support is identified, coordinators ensure that they are referred appropriately in accordance with local pathways.

Supported communication

Stroke survivors with communication disabilities are supported to express themselves at each review point using supported conversation techniques. Where the need for more intensive support is identified coordinators ensure they are referred appropriately in accordance with local pathways.

Regular review

During a client review the Stroke Recovery Plan is reviewed and any new needs are identified and addressed. Support in between review points is offered as required according to the level of identified need.

Moving on

When the time is right the Stroke Recovery Coordinator works with individuals to help them find support within their own community so that they can move on with their life after stroke.

Stroke Association

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Service operating hours

The service is operational Monday to Friday between the hours of 9.00am and 5.00pm (excluding public bank holidays), as running alongside the existing Stroke Recovery Service.

The service remains flexible to the needs of the stroke survivors and their families. Where there is capacity, visits to a stroke survivor at home may take place outside of these core hours, as it may be more suitable to visit them in an evening or at a weekend, especially if they are in employment.

Staff will receive training in risk management and health and safety to enable them to work in line with Stroke Association’s policies of lone working, particularly when working in the community or undertaking out of hours work.

Locations of service delivery

The service will be delivered in a range of locations within the purchased area with an emphasis on assessment in their own home. However this could also include:

• Residential care homes, nursing homes
• Community settings, including libraries, colleges, community centres
• Other public venues as appropriate to the needs of the service users

Referrals

The Stroke Recovery Service operates an open referral system and as such referrals can be made at any stage following a stroke.

The majority of referrals to the service are received from the hospital; however we also accept referrals from:

• The stroke survivor themselves
• The carer, family or significant other of the stroke survivor
• GPs
• Social Care
• Stroke Association staff
• Other health and social care professionals

This is not an exhaustive list.