National priority project: Stroke
NHS Lewisham stroke redesign: delivering an integrated pathway for improved transfer of care
NHS Lewisham, University Hospital Lewisham and the London borough of Lewisham have joined together with SLCSN support to redesign stroke services for patients and carers in Lewisham.
'The new integrated service is based on enablement, empowering the patient and care network through patient-defined outcomes and earlier discharge planning...'
The project, to be completed in April 2010, aims to deliver an integrated care pathway for Lewisham residents who experience stroke enabling an improved transfer of care from the acute setting to the community.
By redesigning the post-acute phase of the pathway, we can promote a seamless transfer between the range of care settings and teams. This will ensure that appropriate high quality stroke rehabilitation and enablement services are available in a patient's own home as soon as possible.
Project objectives in the care pathway redesign include integration of acute and community teams and improved transfer of care from these teams.
This will be achieved through:
- increased continuity of care through a reduction in the number of handovers between care teams
- patient-defined outcomes which to improve services
- a clear process for defining ongoing review and re-referral
- longer term rehabilitation services which respond to each clients' individual needs
- improved support for people with communication disabilities
The new integrated service is based on enablement, empowering the patient and care network through patient-defined outcomes and earlier discharge planning, similar to the Stepping Out project. The earlier we can establish these concepts in patient care, the better the outcome.