Enhanced community follow-up
A number of SCCs (n=22) provided post-hospital discharge
follow-up care to stroke patients living in the
community. A spectrum of approaches to service delivery
were provided, from those that were protocol-led to those
that were more flexible. At one end of the spectrum were
10 SCCs who offered a structured service using protocolbased
reviews provided at set time-points after the stroke
(e.g. 3, 6, and 12 months).
Most contacted patients before discharge from hospital
but. overall, had less individual patient contact than SCCs
at the other end of the spectrum. By contrast seven SCCs
who offered tlie more flexible service approach reviewed
patients at least three times after discharge fk)m hospital
but tended not to use structured protocols. Most did not
offer a review at a specified time point after stroke and,
although some did see patients before discharge from
hospital, this was restricted by available time and was limited
to certain wards. Case discharge was more prevalent
among the flexibly driven services, A mixture of these two
approaches was reported by five SCCs. Only four out of
the 22 SCCs mentioned working within a team.