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The integrated community stroke service (ICSS) is part of the National Stroke Service model, coordinating transfer of care of stroke survivors from hospital, and providing home-based stroke rehabilitation through a specialist multidisciplinary team structure.
The ICSS is an integrated seven days per week service, providing early supported discharge, high-intensive and needs-based community stroke rehabilitation and disability management.
Over 100,000 people have a stroke in the UK every year. Many of those who survive a stroke, with appropriate and timely rehabilitation and support, can make a full and complete recovery. However, a third will be left with some form of long-term disability, affecting mobility, cognition, vision, psychological wellbeing or communication. Recovery can continue for many years after a stroke, so it is important to consider how to provide a seamless transfer of care and access to services over the long term.
Current stroke guidelines outline the need for community stroke rehabilitation services to provide specialist stroke rehabilitation following transfer home from hospital, including access for those going into residential or nursing homes. There is strong evidence for the effectiveness of early supported discharge (ESD) for those who have mild-to-moderate disability, with trials and observational studies demonstrating that ESD can reduce long-term dependency and admission to institutional care and reduce the length of hospital stay.
ESD is only suitable for a proportion of the stroke population (up to 40% of patients) so the others (usually those with more complex disabilities), and also those going into residential or nursing homes need access to community stroke rehabilitation within 72 hours of discharge. The Integrated Community Stroke Service (ICSS) model ensures that all discharged stroke patients are seen in a timely way by an integrated multidisciplinary team (MDT), regardless of their disability. It builds on the principles and practice of ESD as well as the available evidence and guidelines.