Discharge and Rehabilitation

After having a stroke, patients will need time to heal and recover. The time taken and extent of recovery is individual to each patient and is difficult to predict.

Rehabilitation helps you to make the best recovery possible and re-learn skills for everyday life. It starts in hospital and usually continues when patients go home via community rehabilitation services.

Rehabilitation teams include a number of different health professionals who all have specialist training and experience in stroke. They are often called the multidisciplinary team (MDT).

The MDT can include:

  • Physiotherapists
  • Occupational therapists
  • Speech and language therapists (SALT)
  • Specialist stroke nurses
  • Dieticians
  • Psychologists
  • Rehabilitation assistants or healthcare assistants

The team of therapists carry out assessments and work with patients to set rehabilitation goals.

Patients are assessed for the following effects of stroke:

  • Swallowing assessment: Patients are checked for swallowing problems soon after arrival in hospital, this ensures the patient is able to eat and drink safely.
  • Mobility assessments: The physical effects of the stroke will be assessed by the team for example movement, balance and mobility and how this effects activities of daily living.
  • Continence assessment: Patients will be assessed for any continence problems.
  • Communication and cognition assessments: Patients are assessed to find out if the stroke has caused any communication or cognitive problems, any help needed is identified.
  • Nutritional status and hydration: to ensure that patients receive the right nutrition and aren’t becoming dehydrated.

Many stroke patients are well enough to be discharged home from acute care after a short stay. However, some people will need further rehabilitation before they are able to return home and may be transferred to a rehabilitation ward or Stroke Recovery Unit (SRU).

Discharges from hospital after stroke are carefully planned. The stroke team work with patients to agree what support is needed at home, make arrangements for ongoing rehabilitation and care as required and help with any aids or equipment needed.

Some patients discharged from hospital are able to access an Early Supported Discharge (ESD) team. This is a rehabilitation service that enables stroke patients to receive rehabilitation in their own home at the same intensity as in hospital. It therefore provides a seamless transfer of care from hospital to home.

Once discharged from hospital and / or the ESD team, multi-disciplinary community stroke teams work with patients, their families and carers to maximise rehabilitation in the longer term. The team supports patients to achieve their quality of life and lifestyle goals, which could include enjoying hobbies and activities, driving and working.

Across the East Midlands, different community rehabilitation services are provided, we are working to ensure there is equity of care for all patients after their stroke.