Assisted Discharge Stroke Service
The Assisted Discharge Stroke Service (ADSS) aims to assist earlier discharges from hospital for patients within Lincolnshire who have been admitted with a diagnosis of stroke. They are also able to provide specialist advice to Integrated Community Therapy and Transitional Care Teams.
Description of service
The main aims of ADSS are to reduce the length of stay of patients within stroke units, to improve the patient and carer rehabilitation experience following a stroke, and to offer a seamless transfer of care from hospital to home.
ADSS works closely with the acute stroke units in Lincolnshire hospitals, as well as across borders in hospitals with stroke units who take Lincolnshire patients.
The service is time limited to approximately six weeks and works towards achieving patient centred goals. ADSS have close links with Integrated Community Teams and Transitional Care Teams to ensure any ongoing rehabilitation needs continue to be addressed. The team also works closely with GP, nursing, Social Services and voluntary sector colleagues to provide a holistic approach to recovery following stroke.
ADSS is divided into four hubs across the county: Lincoln, Louth, Sleaford and Boston. The team comprises:
- speech and language therapists
- occupational therapists
- assistant practitioners
- rehabilitation assistants.
The experienced therapists offer specialist assessment of the patient and carer’s needs and wishes, and support goal setting to assist maximising recovery as much as possible. Following this, the highly skilled assistant practitioners and rehabilitation assistants are then able to visit patients regularly through the week to support therapy sessions through care plans.
Dependent upon capacity within the team, ADSS can offer specific support for completion of daily living activities as part of the rehabilitation process; clinicians are happy to discuss this on a case by case basis.
Emphasis is placed on education for healthy living, patient and carer involvement and supporting with both appropriate information and signposting to relevant professionals and voluntary organisations.
Service operating times
The ADSS team can be contacted between 8am to 4pm Monday to Friday, with an answer machine to record messages outside of these times.
The team can offer a seven day a week rehabilitation service between the hours of 8am and 6pm; Therapists work Monday to Friday, and Assistant Practitioners and Rehabilitation Assistants work Monday through to Sunday.
To speak to clinicians within the hubs:
- North West area (based in Lincoln) : 01522 308766
- North East area (based in Louth): 01507 631423
- South West area (based in Sleaford): 01522 307241
- South East area (based in Boston): 01205 367358 ext. 320
Waiting times for the service
Patients will be assessed following referral within as short a time frame as capacity allows; the team aims to visit the patient at home within 24 hours of discharge from hospital, unless otherwise informed.
Referrals are only accepted from professionals within specified stroke units on completion of the referral form. The referral form is available by contacting the teams via the numbers above, as well as from visiting clinicians within the service. As ADSS is an early supported discharge team, they can accept patients under the following conditions:
- registered with a Lincolnshire GP
- transferring with a maximum of one person – if with equipment, please discuss with clinicians if two are required for treatment
- a safe and appropriate discharge has been planned, allowing the team to visit within 24 hours of discharge from hospital
- has rehabilitation goals
- the patient has consented to contact from the ADSS team
If you are a professional, care worker, family member or friend supporting a person who has had a stroke, or you have suffered a stroke recently or in the past, please see the links below for some useful information:
- Stroke Association – Charity association supporting people who have had a stroke. Wealth of information about all things stroke related. https://www.stroke.org.uk/
- Adult Social Care
- main website https://www.lincolnshire.gov.uk/adult-care/
- available services https://www.lincolnshire.gov.uk/adult-care/our-services/
- carers assessment https://www.lincolnshire.gov.uk/adult-care/carers/support-for-carers/carers-assessment-eligibility-and-direct-payments/129190.article
- Age UK – information about local groups and support http://www.ageuk.org.uk/
- Steps 2 Change – support with emotions and mood http://www.lpft.nhs.uk/steps2change
- Motability – information on support available for purchasing and adapting vehicles http://www.motability.co.uk/
- Telecare – information about lifeline pendants and additional technology to support safety at home https://www.lincolnshire.gov.uk/health-and-wellbeing/the-wellbeing-service/
- Nottingham Rehabilitation Supplies – information about returning equipment that is no longer in use https://www.nrshealthcare.com/about-nrs/returning-equipment
- Carers First – support for those who care for someone with a disability http://www.carersfirst.org.uk/