1. Nottinghamshire County Community Stroke Team. June 2009

2. Background Established 1996 covered 1/6 of greater Nottingham RCT 2002 all of greater Nottingham Larger team split in 2005 to form City and County stroke teams Cover Nottingham North and East Consortia including Calverton, Nottingham West Consortia and Principia

3. Aim: To work in partnership with people who have had a stroke and their families/carers offering co-ordinated, specialist multidisciplinary rehabilitation tailored to the individual.

4. Referral criteria Clients: must have a diagnosis of stroke be aged 16 or over have been part of the stroke pathway (stroke wards or stroke clinic at NUH) have community focussed goals be registered with a G.P. in Nottingham East Consortia, Nottingham West Consortia or Principia

5. Staffing Feb 2010 Occupational Therapist 1.4 Physiotherapist 1.4 Specialist Mental HealthNurse 1.0 Speech and Language Therapist 1.2 Assistant Practitioner 1.0 Mat leave 0.26 Total 6.26 Head count 9 N.B Full time mental health nurse working as team leader Total Budget £306,000 for 6.85 WTE

6. Referral origin 20082009 Stroke unit 81125 Intermediate care 1617 Family/ self 1520 GP 710 Lings Bar 43 Primary Care Therapy 38 Community Matron 21 TIA clinic 10 Neuro outpatients 21 Social service OT 04 Family and Carer Support 2

7. Team activity 2006 5.76 WTE 2007 6.3WTE 2008 6.3 WTE 2009 6.3 WTE 2010 6.3 WTE Jan-Sept Referrals98111136195167 1st assessments7198124166143 Length of intervention179142118106108 Days to first visit31157.58.759 Average contacts per patient 2722.518.716.814.8

8. Length of Intervention 2009

9. Patient journey Initial team assessment Individual clinical assessments Set goals with the patient and their carer. EKOS Review goals Set new goals No new goals.Transfer care to GP Open access to team

10. Within the team Interdisciplinary working Joint clinical visits Patient specific goals not limited by time Mental health support for patients and carers Functional electrical stimulation Return to driving assessments Neurological splinting Return to work Dysphagia trained SLT’s Residential care Open access

11. National Stroke Strategy Individuals affected by stroke and their relatives need to receive good quality appropriate, tailored and flexible rehabilitation: this will affect long term recovery and reduce long term disability There is evidence that co-ordinated community stroke teams prevent people from deteriorating once they return home. QM10 Some people may move into care homes, but can still benefit from rehabilitation. QM 10

12. These teams should be multidisciplinary and have the specialist skills to help rehabilitate people who have had a stroke. QM10 People who struggle to adjust to the longer term effects( patient and carer) need access to emotional support services QM 13 People who have had a stroke,and their carers, are enabled to live a full life in the community QM 15 People who have had a stroke and their carers are enabled to participate in paid, supported and voluntary employment. QM 16

13. “MAKING A DIFFERENCE”

14. CASE 1 Joan 76 year old lady living with her 78 year old husband Poor sitting balance Hoist transfer Wants to walk OT,PT,SNMH intervention Limited progress for the first three months to safe rotunda transfer 12 months later walking with a stick with the supervision of her husband

15. CASE 2 Kevin 47 year old man with three children under 11 Walked short distances with a stick No DADL’s Did not want to be left alone Wanted to work Wanted to drive Intervention from OT,PT.,SNMH and out patient SLT

16. Five months later Increased confidence Taking children to school Assessment at Derby, now driving Interagency working with Work Directions Now working 9 hours a week over three days Taking his children to watch Forest Cooking for his family and general domestic chores