Stroke Nursing Service

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.

What we do for direct patient care

We provide high level stroke specialist nursing to all acute ward discharges into the community for stroke related issues.

We work closely with ICSS within the community for each patient during their rehabilitation, contribute in MDMs regularly and offer profession specific expertise to internal teams.

All stroke patients are offered routine reviews in the community for their six weeks, six months and 12 months check-ups as required either at local clinics or home visits as appropriate for the patient in the community settings.

We liaise directly with stroke consultants on behalf of the patients and their own GPs including other stake holders and advocate to meet their specific needs directly or indirectly related to stroke event.

We help to optimise best medical/nursing management for secondary prevention, other stroke related complications such as post-stroke pain, spasticity (including referral for Botox therapy), and lifestyle modification through a wide range of options, tailored to meet individual patient needs/preferences such as weight management, giving up smoking, exercise referrals, support from the Stroke Association support worker, etc.

Make sure stroke patients have appropriate individualised care plans, empower patients/carer for self-management, make social prescribing and refer for specialist inputs as necessary.

Offer emotional support, point of contact and on-going reviews until their transfer of care to their own GPs.

Offer Commissioning for Quality and Innovation (CQUIN) framework related activity of six months review and complete national audit Sentinel Stroke National Audit Programme (SSNAP) data entry.

Referral criteria

Referrals will be accepted if the person is:

• Over 18 years old, with exceptions where the patient is 16 years or older whose needs have been identified as being best met by the local ICSS.
• Primary diagnosis of stroke or presumed stroke (those awaiting diagnosis may be eligible) within the last six months.
• The patient must be medically stable with appropriate medical investigations completed or planned with future medical review in place by the discharging teams.
• Referrals are accepted from local acute hospitals and tertiary care centres, other health professionals/teams in the community locality teams (internal/external) and GPs or self-referrals by patients.
• Patient should belong to the GPs within the local CCGs/primary care networks (PCNs) for acceptance into the specialist stroke nursing team (SSN).
• We may accept referrals on exceptional circumstances for patients who have had stroke more than six months ago and have issues directly related to the event or having any post-stroke secondary complications requiring SSNs input such as post-stroke neuropathic pain, spasticity, medicine issues etc.

How do I refer to this service?

All stroke referrals are processed by a centralised local referral unit (LRU) irrespective of the locality within east Kent. All referrals should be made by completing the form (see attached below) and sent to LRU. All referrals get re-directed to the correct teams using dedicated email addresses (see as below). Please attach stroke discharge letter or any relevant most recent stroke letter with the referral. This form can be used for making referrals to all areas/CCGs in east Kent.

• Local Referral Unit form

The phone numbers below can be used for contacting LRU:

• 0300 123 1959
• 0300 123 4462
• 0300 123 1956
• 0300 790 0386

LRU would then send SSN referrals to these email addresses for admin’s attention and allocate them on SSN caseloads within their locality on the electronic system. These email addresses are accessed by admins only and not the stroke nurses.

• kentchft.thanetssn@nhs.net
• kentchft.southkentcoastssn@nhs.net
• kentchft.canterburyssn@nhs.net
• kentchft.ashfordssn@nhs.net