A service evaluation of the feasibility of a community-based consultant and stroke navigator review of health and social care needs in stroke survivors 6 weeks after hospital discharge

The Department of Health Stroke Strategy (2007) recommends that post stroke patients are reviewed within 6 weeks of discharge. Historically, a 6-week outpatient appointment was offered. This was primarily a medical review and not a full assessment of health, social care status and secondary prevention needs. An innovative joint domiciliary clinic was developed in order to meet these recommendations. The joint clinic reviews were conducted by a stroke consultant and an allied health professional. There were no readmissions at 6 weeks and 6 months post stroke. User satisfaction was very high and there were no missed appointments. Patient health and social status was fully captured, reported and acted upon holistically following each review. This form of integrated partnership working seems to promote seamless life after-stroke care, while enhancing patients' understanding. It includes the provision of secondary prevention and self-management strategies. This 'one-stop shop' approach would warrant formal evaluation.