Improving community neuro rehabilitation services

Community rehabilitation is hugely variable in our region and provided via different models of care (i.e. Early Supported Discharge (ESD), Community Neuro Rehabilitation or Community Stroke teams). A few areas have no specialist services at all. 

Led by our Community Clinical Lead Tracy Walker, we are working with local commissioners to introduce a standardised model of community rehabilitation, so that Greater Manchester residents receive the same high level care regardless of where they live.

Working with our sister network for neuro rehabilitation, we have collaboratively developed a model for specialised neurological community rehabilitation that supports all stroke patients leaving hospital, regardless of their level of dependency (i.e. not just those who meet ESD criteria) or where they will reside (e.g. care home).

The model is within a service specification that mandates the professionals needed within the core team and provides guidance on staffing levels. It details three pathways of care and where possible (based on the evidence), outlines what care should be provided and by when. The model advocates early involvement of the voluntary sector to support life after stroke, and also details access to key NHS support services such as orthoptics.

A similar service specification has been developed for neuro-rehabilitation that can be delivered as part of a single neurological specialist service. Both networks are now also collecting data in community to help understand the quality of care being provided in each area.

Stockport recently commissioned both service specifications and has launched a new community team that sees both stroke and neuro-rehabilitation patients, with support from the Stroke Association embedded. You can hear why this support is much needed from Beryl, a local patient who did not have access to community support after her stroke.

You can view short talk or a webinar explaining this work.

You can download both service specifications, exemplar job descriptions and our dashboard of community measures and find our more about our ongoing work to improve community care by registering on our website and accessing our Resources section (in rehabilitation).

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