- Provide time limited specialist neurorehabilitation for individuals with realistic, achievable goals that may improve or maintain their ability to perform activities of daily living that are purposeful, functional and meaningful to that individual
- Empower and enable the individual and their carers to manage their own condition
- Facilitate appropriate, timely discharges from the Acute and Rehabilitation Units for patients requiring specialist neuro-rehabilitation
- Provide specialist neuro-rehabilitation to patients already in the community who may benefit from a specialist approach to intervention
- Provide specialist neuro-rehabilitation support and advice to colleagues in Extended Primary Care Teams and Virtual Wards within Newham.
- To assess and make recommendations to Commissioners with regards to the on-going care needs of Newham residents with neurological conditions
- To provide patients with relevant information and education about the condition and rights to ensure informed decision making
Community Neurological Service
The Community Neuro Service (CNS) Is a multidisciplinary team, comprising of physiotherapy, occupational therapy speech and language therapy and psychology. The team specialises in rehabilitation and management for people who have a neurological condition, including stroke. Therapy is provided in the patients’ own home or in an appropriate community location.
The service provides specialist, coordinated advice and treatment to maximise independence, limit disease progression, reduce hospital admissions and facilitate smooth transition home following a hospital discharge.
The CNS also provides a modified Early Supported Discharge (ESD) service. The ESD service is stroke specific rehabilitation provided in the patient’s home where the level of rehabilitation provided is comparable to inpatient rehabilitation provision.
The ESD pathway provides a seamless transfer of care from hospital to home and allows patients to continue intensive rehabilitation in the home environment for a period of 2 weeks.
Address
East Ham Care Centre
Shrewsbury Road
London
E7 8QP
United Kingdom
Email address
Telephone number
020 8586 6464
- Patient is a resident of the London Borough of Newham.
- Patient is registered with a Newham GP
- Patient must have a confirmed neurological diagnosis or confirmed diagnosis of stroke
- The primary needs of the patient must relate to the neurological diagnosis
- Patient is aged 16 years plus
- Patient is medically stable
- Patient is requiring neurological or stroke specific rehabilitation and support
- Patient must have the potential to benefit from specialist neuro input
- Patient and or their carers are willing to participate in a programme of rehabilitation / management of their condition
- Patient is a resident of the London Borough of Newham.
- Patient is register with a GP in Newham
- Patient is medically stable as determined by medical consultant
- Patient has mild to moderate level of disability post stroke i.e. Good outcomes for rehabilitation.
- Patient is able to transfer with moderate assistance of one person.
- Patient wishes to have ESD
- Patient/carer able to deal with an emergency
- Safe home environment
- Effective pressure area management, if appropriate
- Patient needs 3 hours 45 minutes of at least one therapy area weekly
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Initial referrals are accepted from health and social care professionals. Self- referrals are accepted once the patient is known to the service. |
All referrals for ESD are accepted from acute hospitals only. Usually the hyper acute, acute or rehab stroke units
Tel: 020 8586 6464
Community Neurological Referral form
Team Email: communityneuroservice.newham@nhs.net
In 2012 the CNS launched an Early Supported Discharge (ESD) service pilot in Newham. The ESD service is stroke specific rehabilitation provided in the patient’s home, where the level of rehabilitation provided is comparable to inpatient rehabilitation provision.
Patients receiving the ESD service will be seen within 24 hours of discharge from the inpatient setting (excluding weekends) and if appropriate, they then receive 3 hours and 45 minutes of therapy per week from relevant professional areas. The ESD pathway runs for two weeks. There is a further 8-week pathway which is less intensive, known as the community stroke pathway.
The CNS has a neuro rehabilitation gym at the East Ham Care Centre site. This enables patients to access gym equipment, as well as receiving therapy at home, therefore, progressing their rehabilitation and independence.
CNS is currently running clinics improving access to service users in an outpatient setting.
Service Lead: Claudia Bull, Clinical Lead Community Neuro Service Senior Manager: Gavin Shields, Lead Nurse
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