Stroke service - community
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The Community Stroke Team provides specialist stroke rehabilitation for adults aged 18 and over across East and North Hertfordshire for up to six months following a stroke. Rehabilitation is tailored to individual needs and may be delivered in the patient's home, within outpatient clinics, through group programmes, or virtually.
The service offers the following pathways:
Early Supported Discharge (ESD): Home or clinic-based rehabilitation for individuals who have experienced a mild to moderate stroke and have identified rehabilitation goals. This support is typically provided within the first six weeks following stroke.
Supported Discharge (SD): Home or clinic-based rehabilitation for individuals who have experienced a moderate to severe stroke and have more complex rehabilitation needs requiring multidisciplinary input. Patients may be referred following discharge from an acute hospital or inpatient rehabilitation setting.
Disability Management (DM): Specialist short-term support for individuals living with the effects of a severe stroke who require ongoing management following discharge. These patients do not typically have active rehabilitation goals but benefit from specialist advice and support to optimise management within their care setting.
Six-Month Reviews: Comprehensive reviews for all stroke survivors across East and North Hertfordshire, delivered in partnership with the Stroke Association.
The team accepts referrals from local acute hospitals, GPs, community healthcare professionals, tertiary centres, and self-referrals from patients or family members who have previously been known to the service within the last 12 months.
Referrals should be sent to: HCNT.EastandNorthHertsESD@nhs.net
Contact the service
Hub Tel: 0300 123 7571 (Select option 2, option 2, and then option 2)
Monday – Friday 9am-5pm
- Address: Queen Victoria Memorial Hospital (QVM), School Lane, Welwyn, AL6 9PW, , Welwyn, AL6 9PW
- How the service is provided
- Who is eligible for the service
- What will happen at your appointment
- Useful information
- Making a referral
- Patient experience
How the service is provided
The Integrated Community Stroke Service provides specialist multidisciplinary rehabilitation and support for adults following stroke, from discharge through to longer-term recovery.
The service includes physiotherapists, occupational therapists, speech and language therapists, nurses, psychologists and rehabilitation assistants.
Care is delivered across early supported discharge (ESD), supported discharge and disability management pathways, with interventions provided in patients’ homes, care homes, community venues and virtually where appropriate.
The team focuses on maximising independence, improving function, supporting communication and psychological wellbeing, reducing complications, and enabling patients to achieve meaningful recovery goals within their own communities.
Who is eligible for the service
The service is available to adults following a stroke who require specialist multidisciplinary rehabilitation after discharge from acute or inpatient care.
Patients must be over 18 and registered with a GP in East and North Hertfordshire
Patients are supported through Early Supported Discharge, Supported Discharge and Disability Management pathways, ensuring rehabilitation, support and review are tailored to their individual recovery needs, functional abilities and goals.
The service provides specialist stroke rehabilitation and support for up to six months post-stroke, helping patients maximise independence and achieve the best possible recovery outcomes.
What will happen at your appointment
All patients receive a welcome home visit where a holistic multidisciplinary assessment is completed.
A rehabilitation programme is then set up with the patient to enable progress towards identified goals.
Useful information
Making a referral
Referrals are primarily received from acute stroke services and inpatient rehabilitation units when a patient is discharged and requires ongoing specialist community stroke rehabilitation.
Please complete a digital referral, in order to access the service .
The service also accepts referrals from other healthcare professionals involved in a patient's stroke care, provided the patient meets the service eligibility criteria and is within six months of their stroke.
Patients are referred into the most appropriate pathway, including early supported discharge, supported discharge or disability management, based on their rehabilitation needs, level of disability and recovery goals.
Patient experience
We encourage all patients and carers to complete the NHS Friends and Family Test to tell us about their experience of the service. Feedback can be provided through the Trust's FFT survey, which can be completed electronically or via other methods offered by the team.
All feedback is reviewed by the service and contributes to ongoing quality improvement. Positive feedback is shared with staff to recognise good practice, while themes, concerns and suggestions are analysed to identify opportunities for service development and improve patient experience. FFT results are regularly reported, monitored and used to inform local improvement initiatives and Trust-wide patient experience reviews.
The team also runs patient and carer focus groups, providing an opportunity for more in-depth feedback, discussion and co-production of service improvements. Patients and relatives who are interested in participating in a focus group can speak to any member of the team for further information and to register their interest.
You can also share your story by contacting the Patient Experience team on 01707 388036 or email hct.patientexperienceteam@nhs.net.
