Clinical Guidelines for Acute Stroke Management - Living on the EDge

8.6 Community rehabilitation
Often rehabilitation will need to continue after
discharge (either as part of an early supported
discharge program or general community
rehabilitation) and can be undertaken in various
settings depending on availability of transport, patient
wishes and family/carer and local resources. Evidence
<strong>for</strong> community based rehabilitation is still consistent
with that in the <strong>Clinical</strong> <strong>Guidelines</strong> <strong>for</strong> <strong>Stroke</strong>
Rehabilitation and Recovery which described high
level evidence <strong>for</strong> community rehabilitation services
<strong>for</strong> people with stroke. The needs identified by the
stroke team and the patient/family/carer (via the
pre-discharge needs assessment) and availability of
local community services will determine which
option is preferred.
CONSUMER
8.6 COMMUNITY REHABILITATION GRADE LEVEL RATING
Rehabilitation in the community is equally effective if delivered in the A Level I 63, 9.4/10
hospital via outpatients, or day hospital, or in the community, and should
458, 459
be offered to all stroke patients as needed.
8.7 Post discharge support
The level of services available following discharge from
hospital can be poor, and people with stroke and their
families often report being dissatisfied with the
in<strong>for</strong>mation, support services and therapy available. 460
A number of follow-up services have been evaluated
including:
> social work;
461, 462
> specialist nurse support;
53, 54, 57, 59, 60, 463
> the <strong>Stroke</strong> Transition After Inpatient Care (STAIR)
program; 464
> stroke family care worker; 465
> mental health worker; 466
> home visits by physician or physiotherapist; 467 and
> stroke family support organisers. 468-470
Such services are usually multidimensional and can
include emotional and social support, assistance with
referral to other services, and the provision of
in<strong>for</strong>mation to people with stroke and their families.
The evidence is difficult to interpret and no one service
has been shown to be clearly beneficial. Studies
suggest modest advantage when providing tailored
education although no clear functional benefits have
been found and further studies are needed. A simple
approach often incorporated into other
multidimensional interventions is the use of telephone
contact after discharge. While one recent systematic
review failed to demonstrate consistent benefits from a
range of non stroke populations, 471 two stroke related
studies involving 3 telephone calls from a nurse in the
first 3-5 months post discharge provided some
benefits. 53, 60 As the early post discharge period is
consistently reported by stroke survivors and their
family/carers to be a difficult time, the provision of
simple and relevant services appears important.
Section 8 Discharge Planning, Transfer of Care and Integrated Community Care
CONSUMER
8.7 POST-DISCHARGE SUPPORT GRADE LEVEL RATING
a) Contact with and education by trained staff should be offered <strong>for</strong> C Level II 53, 54, 57 –
all stroke survivors and carers after discharge.
59, 60, 463, 468-470
b) People with stroke and their carers should be provided with a D Level I 471 & –
contact person (in the hospital or community) <strong>for</strong> any post-discharge Level II
53, 60
queries.
55