Challenge
To increase the proportion of patients who receive a six month review.

Solution

• Provided a nurse led service, integrated with Early Supported Discharge service.
• Kept a diary of people discharged into home care or alternative care.
• Completed six month reviews as home visits if patients found it difficult to attend an outpatient clinic.
• Offered reviews over the telephone.
• Arranged phone call reminders and follow up calls for patients who do not attend their scheduled review.
• Ensured close working with SSNAP audit coordinator to identify patients who are due a review.
• Stroke consultants gave reminders to patients at the stroke clinic to encourage patients to attend their six month review.

Impact
Since the start of our ESD service the 6 month clinic reviews are better attended. All of the above processes help us at Chesterfield Royal achieve the best outcome for our 6 month follow up of stroke patients.

Over 98% of Chesterfield Royal’s patients deemed applicable for a six month assessment received one as reported by SSNAP from April 2016 to March 2017.

Patient quote
"The stroke pathway at Chesterfield Royal is outstanding. I wouldn’t be where I am today without all the therapy and follow up assessment I have received. The amount of enthusiasm shown by the team really spurs you on. The team of familiar faces and the continuation of care throughout the stroke pathway at Chesterfield Royal Hospital is what makes it the wonderful, seamless service it is. The staff understand the length and breadth of the stroke journey, and their expertise and support is second to none." - Stroke patient at Chesterfield Royal Hospital.

This case study was written by Tina Potter (Stroke Services Matron), and Donna Evans (Stroke Services Sister), at Chesterfield Royal Hospital NHS Foundation Trust.


Click here to get back to the Long term case studies list