Neuro rehabilitation and early supported discharge stroke service

We are a multidisciplinary team comprising of physiotherapists, occupational therapists, speech and language therapists, psychologists, and assistant practitioners, who are specialists in neurological and stroke rehabilitation within a community setting. Our approach is individualised, patient centred, and evidence based.

The neurological rehabilitation or neuro rehab team (NRT) accept referrals for patients who have long term neurological conditions, or strokes who require a specialist rehabilitation program in a community setting. The Bedfordshire stroke early supported discharge service (ESD) facilitates those admitted to acute stroke units to be discharged home sooner by providing up to six weeks of rehabilitation, similar to that provided in the hospital. Working as one team allows us to be flexible in our continuity of care for stroke survivors between ESD and NRT teams.

Where our service is based

Hours of operation

Monday to Friday 08.00 – 16.00

How to contact our service

To query a referral or to speak to a team member, please:

• call 0300 790 6832
• email for general enquiries ccs.beds.adults.neuroesd@nhs.net
• email for referrals only ccs.bedsneuro.referrals@nhs.net

How to refer to our service

To make a new referral (referrals accepted from all professionals and self referrals), please call 0300 790 6832 or email ccs.bedsneuro.referrals@nhs.net

Who can be referred to our service?

For early supported discharge service

• Registered with a Bedfordshire GP
• 18 and over
• Medically stable
• Able to transfer from bed to chair with 1 person or independently if living alone
• Primary diagnosis of stroke (within 6 weeks from date of onset)
• Patients should be engaged with a rehabilitation programme and have their initial goals identified prior to discharge from hospital.
• Home environment suitable for rehabilitation
• Safe at night
• Adequate cognitive ability to maintain own safety when at home alone
• Adequate nutrition – modified diet acceptable (includes PEG feeding)
• Continence well managed or returned to usual level of continence
• Communication – able to raise alarm and have basic ability to communicate
• Medication management – system in place to safely manage medication and appropriate systems in place to manage any changes that may be required.
• Extended early supported discharge stroke support for patients who need two carers to assist in their daily activities and therapy support. These patients are discharged home from the hospital and are provided with intensive therapy in their own home, as per their clinical need. 
• Self-management is encouraged and overtime the amount of therapy input reduces as goals are achieved. 
  
   

For the neuro rehab service

• Registered with a Bedfordshire GP
• 18 and over
• Medically stable
• Newly diagnosed long term neurological conditions or following a deterioration in their existing neurological condition who will benefit from multidisciplinary therapy and are able to make functional gain with the intervention.
• Patient is able to make consistent progress
• Has got adequate rehab potential to make progress
• Has the ability to participate in the rehabilitation
• Understands the concept of rehabilitation and is able to work towards a goal.

Bedfordshire Stroke Six Month review

As part of ongoing service development and in line with ESD services across Luton and Milton Keynes, Bedfordshire ESD service started providing six month post stroke reviews from 1 June 2022.

The locally agreed model provides a comprehensive review by a stroke review coordinator within 4-8 months of stroke to assess progress and identify any unmet needs across recognised health, psychological, leisure, social and work domains. Choice of telephone or face to face session (home or clinic environment) is given to support varying mobility requirements, transport and communication or cognitive difficulties. 

• Six month post stroke reviews provide background to compare new or ongoing environmental, physical and/or psychological difficulties that may arise 
• Provides consistency and continuity to the patient and carer 
• Specialist knowledge and experience of reviewer working within local stroke pathway with ability to provide further reviews as appropriate to patient/carer needs
• Impact to reduce risk of re-admission to hospital and referral to other services through immediate action on issues identified
• Stroke review coordinator has strong interdisciplinary approach within the neuro therapy services in Bedfordshire to support the stroke survivor within the community 
• Address secondary stroke prevention, stroke recovery and disability management as part of the review

Stroke review coordinator can be contacted on 0300 790 6832, Mon to Fri, 8am to 4pm.