Community Neurological Service

East Ham Care Centre, Ground Floor
Shrewsbury Road,
Forest Gate,

London  E7 8QP

The Community Neuro Service is a multidisciplinary team specialising in rehabilitation and management for people who have a neurological condition including stroke. Therapy is provided in the patients’ own home or 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 an 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 service provides a seamless transfer of care from hospital to home and allows patients to continue rehabilitation in the home environment.

The aims of the CNS are to:

• Provide time limited specialist neuro-rehabilitation 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
• To provide on-going care management for complex cases

Referral Criteria for CNS
• Patient is a resident of the London Borough of Newham.
• 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 10 | P a g e
• Patient and or their carers is willing to participate in a programme of rehabilitation / management of their condition

Referral Criteria for ESD:
• Patient is a resident of the London Borough of 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.



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.




Clinical

Conditions:

Neurological conditions
Stroke


Clinical speciality:

Community Health Services