About this service

Stroke – early supported discharge service

Stroke – early supported discharge service


From 1 April 2021, the stroke early supported discharge service will be provided by the Suffolk Alliance, which is a partnership of ESNEFT, West Suffolk NHS Foundation Trust and Suffolk County Council, with support from a variety of third sector partners.

The service provides up to six weeks of intensive stroke rehabilitation in patients’ own homes following their discharge from an acute hospital, helping them to regain their mobility and independence.

The team is made up of experienced therapists and rehabilitation assistants who work together with patients and their carers to deliver rehabilitation programmes which are designed to meet each individual patient’s needs.

Stroke education and training for our patients and their carers is an essential part of early supported discharge. Through the service, we will share our knowledge and learning with other health professionals, and work in partnership with existing health and social services, to ensure stroke patients get the best possible long-term outcomes.

The team provide a patient-centred service and include the carer as much as they wish to be involved. Therapeutic interventions, stroke education and training are used to enable independence and longer-term self-management. The patients’ progress is monitored throughout the programme, and activities and support are adjusted to fit their changing needs.

Some patients may be discharged before six weeks, as the rehabilitation programme we create with them will be based upon their goals and clinical needs. Other patients may need further intervention which is less intensive and will therefore be referred on to other local services. This would be discussed with them as part of their discharge planning from the ESD service.

Our team consists of:

  • Physiotherapists
  • Occupational therapists
  • Speech and language therapists
  • Clinical psychologist
  • Rehabilitation assistants
  • Service manager
  • Administrator and team coordinator

The team will have links to other health teams and social services.

Who is the service designed for

Patients who have had an acute stroke.

The team will work closely with hospital stroke services to identify patients who would benefit most. To be eligible for this service, it is essential that the patient is safe within their home, with or without a carer present, and is able to tolerate an intense programme of rehabilitation for up to six weeks.

Referrals to the stroke early supported discharge service

Patients are referred to the service from the hospital stroke service.  When they are discharged from hospital, we will provide therapy, treatment, care or advice, as needed, to help their recovery and improve their independence.

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