Early Supported Discharge Service (Stroke)

The Early Supported Discharge (ESD) Service is a multi disciplinary team providing specialist stroke input to patients in the community. The aim of the service is to support early discharge from the hospital setting. It is a 6 week service and the team can then refer on if further input is required.

Our Team

• Consultant
• Physiotherapists
• Speech and Language Therapists
• Nurse
• Rehabilitation Assistants
• Occupational Therapists
• Stroke Association
• Psychologist.

We receive referrals from Ward A6 UHW and the Stroke Rehabilitation Centre UHL.  We also accept referrals for stroke patients who are admitted to other wards within the UHB if they meet the ESD criteria and have ongoing rehabilitation goals.

Referral Criteria

To access this service, patients must meet the following criteria:

• Over 18 years of age.
• Clinically diagnosed new stroke confirmed by consultant or scan within the last 12 weeks, not TIA.
• Registered with a GP with in the Cardiff and Vale area.
• Must live in the Cardiff and Vale area.
• Consent to referral to ESD.
• Able to actively participate in rehabilitation at home and be able to identify goals.
• Adequate cognitive ability and communication to be safe at home with appropriate support.
• All necessary equipment in place prior to discharge home.
• Medically stable for discharge.
• Stroke impairments are assessed to be mild to moderate.
• As a minimum the patient should be able to transfer with assistance of 1+/- equipment (this means that the patient must be able to transfer with the aid of one person or without the assistance of a piece of equipment, eg a hoist)
• The patient should be continent, or if necessary a continence plan needs to be in place.
• Ensure the patient has the prescribed medication and a Green card/ Blister packs provided if required. A medication plan needs to be in situ.

We do not accept patients living in Residential or Nursing Homes.

We also receive referrals from in-patient settings via their Multi-disciplinary Team.