Community Neurological Service

• 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

• 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

In 2012 the CNS launched an Early Supported Discharge (ESD) service 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. The ESD service provides a seamless transfer of care from hospital to home and allows patients to continue rehabilitation in the home environment.

Patients receiving the ESD service are seen within 24 hours of discharge from the inpatient setting and if appropriate receive 3 hours and 45 minutes of therapy from relevant professional areas, therefore meeting the London Stroke Rehabilitation Standards.

The CNS has a neuro rehabilitation gym on East Ham Care Centre site. This will enable patients to access gym equipment as well as having therapy at home, therefore progressing their rehabilitation and independence.

CNS is currently running clinics improving access to service users in an outpatient setting.

• 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

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