Early Supported Discharge Team (Stroke)

This service helps people who have had a stroke return home sooner from hospital. They work towards goals and rehabilitation with the help of physiotherapists, occupational therapists, speech and language therapists and nurses.

Patients are usually referred from the acute or community hospitals and other hospitals out of the area.

Patients must sign a consent form and be willing to work to agreed goals (carer included).

Referral Criteria:

  • Is resident or registered with a GP within Plymouth, South Hams & West Devon, or East Cornwall (ref SLA)
  • Should have a medical management plan that can be safely and effectively managed by primary care
  • Patients with a new clinical diagnosis of Stroke via Consultant or CT scan (including via Clinical Nurse Specialist / Stroke Coordinator)
  • Patients who require Stroke specialist intensive therapy more than twice weekly to achieve identified goals
  • Patients who can transfer independently or with assistance of one, with or without an aid / equipment
  • Patient and carer consent to Early Supported Discharge (ESD)
  • Together with their family / carer are able to support rehabilitation at home and the planned intensity level
  • Home environment has been risk assessed, and risks for discharge minimised
  • Patient has risks minimised between carers visits or who has family members present to mediate risks
  • Is able to transfer from bed to chair alone or with assistance of one carer, with or without equipment
  • Patient able to make basic needs known to trained staff
  • Must be able to receive safe and adequate nutrition

Exclusion Criteria:

  • Patients without a new diagnosis of stroke
  • Patients who do not have specific specialist rehabilitation goals which require therapy input more than twice weekly
  • Patients who do not consent for discharge with ESD
  • Patients who require assistance of two or more to transfer with or without an aid / equipment
  • Patient risks cannot be minimised between carer visits or does not have sufficient family support to mediate risks, e.g. ability to raise alarm
  • Home environment not suitable to safely facilitate discharge with ESD
  • Patients who do not have an oral diet or established PEG feeding regime


Service Lead: Amanda Eddy

Ground Floor,
Beauchamp Centre,
Mount Gould Hospital

Tel: (01752) 435413

Out of Hours: Answer machine.

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