Patient led home based stroke rehabilitation - Early Supported Discharge after Stroke

Early supported discharge for stroke patients


The service provides early supported discharge (ESD) for stroke patients with mild to moderate symptoms.Early stroke specialist multidisciplinary rehabilitation and support is provided in the community  (patient’s home).


The service provides a tailored, personalised approach for patients and their carers, including lifestyle management and support to reduce risk and to transition into lifelong support and integration in activities which enhance life after stroke. The project involves integrated team working across health, social care and the voluntary sector. The service is based on a number of UK policy statements in stroke. The
service has been piloted and evaluated over a 6 month period (report available).

• Innovation for patients: hospital rehabilitation in own home, innovative because of specialist intervention; short time in hospital; tailored specialist intervention with patients setting own goals; tailored specialist support and education for patients, carers and families at the appropriate time for them.

• Innovation for the health and social care economy: new ways of joint and specialist MDT working across health and social care economy; continuity of specialist management provides improved outcomes and prevention of readmission to hospital; highly specialised interdisciplinary team; on-going assessment of patient and equipment needs avoids waste, improves safety and is more cost effective.



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