Early Supported Discharge in Stroke (ESD) team

Who is the service for?

Our Early-Supported Discharge service offers up to 12 weeks of community-based rehabilitation for adults (18+) in the Gwent and Caerphilly areas who have been recently discharged from hospital following stroke.

Our ESD teams aim to begin working with people shortly after discharge from hospital. Often we are able to make contact within 24 hours after a person goes home. However, as this service is currently a 5 day service, people who go home on a Friday or the weekend may not be seen until the following week.

Some people require very little support and rehabilitation so may only need our support for a couple of weeks. Many of the people we work with see us for a little longer than this.
 

When do we see people?
 

• Sometimes people meet with members of our team (e.g. one of our Occupational Therapists or a Clinical Psychologist) whilst they are still in hospital. This “in-reach” allows us to get to know the person’s individual needs/abilities and more smoothly support their discharge home.
• We usually start with an assessment by phone or directly at home to establish what the person needs to help them get back to doing the things that matter to them. We agree goals together and therapy sessions are then planned to help the person reach these goals.
• We formally review everyone after 6 weeks of working with the team. If at this time all goals have been reached, then they may be discharged from our service. Sometimes, if there are further goals we can support with that cannot be achieved through self-management, a further 6 weeks of rehabilitation and support may be offered, to a maximum of 12 weeks.
• If further rehabilitation is required after 12 weeks this may be continued at a local hospital-based outpatient service.  However, we try to support people to become independent and confident in managing their own health needs.
   

Who can refer to us?

Not everyone who has a stroke will need support from an ESD service.

Our ESD referrals are usually received by us directly from the ABUHB stroke wards as part of their discharge planning process. If you are working with someone in the community who had a stroke within the last 12 weeks and who you think should be receiving ESD community rehabilitation, please get in touch with us to discuss this further.

Please note: Some people who have had a stroke resulting in more severe or complex changes to their physical or cognitive abilities may require a higher level of care than is provided by our ESD team. This would be discussed with them and their families during hospital discharge planning, and they would be referred to the most appropriate ABUHB services to meet these needs as part of the discharge process.