What we do
This service covers four of the local Clinical Commissioning Groups (CCG) consisting of 16 primary care networks (PCN) as below. In east Kent, joint stroke service delivery is provided by local Integrated Community Stroke Services (ICSS) by making seamless transfer.
Hospital-based care is provided within acute/hyper-acute and inpatient short-term rehabilitation beds including outpatient follow-ups in stroke consultant-led clinics by the East Kent NHS Hospital Foundation Trust (EKHUFT). Community based care is being provided by Kent Community Health NHS Foundation Trust (KCHFT).
KCHCT has Early Supported Discharge (ESD) and community stroke rehabilitation services (CSRT) based within each Intermediate Care Teams (ICTs) covering the CCGs.
This service aims to meet the recommendations in the Integrated Stroke Delivery Networks (ISDN) document in the community setting.
At present we do this by offering routine follow ups for people who have suffered an acute stroke and live in east Kent. Their GPs need to belong to one of the PCNs following their discharge from the hospital settings. They are offered six weeks, six months and 12 months reviews (or extra as required).
There are four SSN teams based in each CCG and they provide stroke nursing input from each community stroke/neuro rehabilitation teams.
Who we are
We are a team of specialist nurses based in our own CCG locality offices within community stroke/neuro rehab teams/ ICTs. We are autonomous practitioners with our own individual stroke caseloads. We work closely with east Kent acute hospital stroke teams based in Richard Stevens Ward at William Harvey Hospital, Harbledown and Kingston Ward at Kent and Canterbury Hospital and Fordwich Stroke Unit at QEQM Hospital and all the ICSS in the community.