Dorset Stroke and Neuro Service (DSNS) is an integrated community stroke and neuro service, which acts as a single point of access for stroke and neuro specialist advice, support, rehabilitation and complex management.  Services are provided at home, in clinics, virtually (online) and in local community facilities.   The objective of DSNS is to provide a service for all patients who require neuro specialist input in response to NHSE Integrated Community Stroke Service (ICSS) specification (2021).

DSNS (West) – North and West Dorset

A neuro specialist multi-disciplinary team including Occupational Therapists, Physiotherapists, Speech and Language Therapists, Nursing, clinical Psychology, and Rehabilitation Assistants. It includes:

  • Intensive Rehabilitation supporting early discharge from hospital for people with stroke or rapidly improving neurological conditions who are able to tolerate intensive rehabilitation
  • Urgent Discharge to Assess/complex outreach to facilitate discharge from hospital and immediate management at home
  • Establishment of a management plan to prevent deterioration/secondary complications including specialist spasticity management
  • Specialist Rehabilitation where rehabilitation needs can only be met by neuro specialist staff- this may be in a group setting; may include self management
  • 6 week and 6 month stroke reviews
  • Annual review service for complex cases
  • Stroke and Neuro navigators providing advice and support to navigate your care and local services
  • Vocational Rehabilitation
  • Spasticity management- including injection therapy where appropriate
  • Driving assessment
  • Joint working with local community rehabilitation teams, and disease specific services such as MS team, Neuromuscular conditions service
  • Consultation/support for stroke/neuro patient in community hospitals

Acceptance criteria:

  • Patient must have a neurological diagnosis confirmed by stroke physician, neurologist or rehabilitation medicine consultant
  • Patients are over 18
  • Patients who are 17 and have a transition plan in place via paediatric consultant/transition service- in this instance we would joint work with children’s services until the patient is 18 years of age
  • We accept referrals throughout the lifetime of the condition, if they meet all other requirements
  • Primary needs are neurological in nature and can only be met by neuro specialist staff/intervention
  • Patients must have a Dorset GP
  • We accept referrals for Functional Neurological Disorder for goal specific interventions
  • We accept referrals for Vestibular Rehabilitation with a central cause
  • We accept referrals for episodic rehabilitation for those with MS, working alongside MS service

 

Exclusions: (however for these we can provide advice and support as required)

  • Programmes of rehabilitation not requiring neuro specialist skills
  • Basic splinting including resting splints, replacement splints and those that can be provided off the shelf
  • Parkinson’s disease
  • Epilepsy
  • Vestibular rehabilitation- with peripheral cause
  • Rapidly progressing degenerative neurological conditions such as MND / those in palliative stages of condition
  • Patients requiring uni disciplinary, non-intensive speech and Language Therapy should be referred to Adult Community Speech and Language Therapy Service.
  • **Patients with a traumatic brain injury should be referred to Acquired Brain Injury Service (ABIRS)**

 

DSNS (West) Contact Details:

Duty Phone – 01305 361200 (mobile) 07880 271122

Consultant Therapist- Clinical lead – 07771 371372

DSNS Email – dhc.dorsetstrokeandneuroservice@nhs.net

 

Team lead: Pippa Wright / Janet Hornby

Service manager: Luisa Hardy

Clinical lead/ AHP consultant: Louise Clark

 

DSNS (East) – BCP and East Dorset

A neuro specialist multi-disciplinary team including Occupational Therapists, Physiotherapists, Speech and Language Therapists, and Rehabilitation Assistants. It includes:

  • Urgent Discharge to Assess/complex outreach to facilitate discharge from hospital and immediate management at home
  • Establishment of a management plan to prevent deterioration/secondary complications including specialist spasticity management
  • Specialist Rehabilitation where rehabilitation needs can only be met by neuro specialist staff- this may be in a group setting; may include self management
  • 6 month stroke reviews
  • Vocational Rehabilitation
  • Driving assessment
  • Joint working with local community rehabilitation teams, and disease specific services such as MS team, Neuromuscular conditions service
  • Consultation/support for stroke/neuro patient in community hospitals

Acceptance criteria:

  • Aged 18 and over.
  • Patients who are 17 and have a transition plan in place via paediatric consultant/transition service- in this instance we would joint work with children’s services until the patient is 18 years of age
  • Registered with a East Dorset GP (BCP, East Dorset)
  • Eligible for ongoing NHS healthcare in the community.
  • Patient is aware of referral to service and consent has been discussed.
  • Referrer has sent a completed referral.
  • Suitable and safe environment for patient and team to work towards goals.
  • Needs and goals best met in the community (and not by Level 1/2b inpatient rehabilitation services).
  • We accept referrals throughout the lifetime of the condition, if they meet all other requirements
  • Primary needs are neurological in nature and can only be met by neuro specialist staff/intervention
  • Confirmed diagnosis of stroke or neurological condition by Stroke physician, neurologist or rehab medicine consultant.
  • No confirmed diagnosis but presenting with neurological symptoms that would be better managed within a specialised neurological service.
  • Stroke and Neuro specific impairment/s with functional change and goals requiring specialist Community Stroke & Neuro Team intervention.
  • Patients with ongoing non-intensive rehabilitation need, safe to wait for rehabilitation, with rehab plan and self-management advice where appropriate
  • Longer-term rehabilitation goals supporting recovery and adaptation to living with stroke/ neuro conditions e.g. return to work/driving, slower return of function and building functional ability.
  • Support with early, episodic condition management  – advice, guidance and support
  • Signposting on to opportunities to support longer term self-management in living with stroke/ neuro condition, linking to wider community services
  • Stroke 6-month reviews

Exclusions:

  • TBI – to ABIRs
  • Programmes of rehabilitation not requiring neuro specialist skills
  • Basic splinting including resting splints, and those that can be provided off the shelf
  • Epilepsy as main diagnosis (not in PMH)
  • Vestibular rehabilitation with peripheral cause with no clear neuro-rehabilitation need
  • Patients requiring uni disciplinary, non-intensive speech and Language Therapy should be referred to Adult Community Speech and Language Therapy Service.
  • If patient is known to another condition management service, refer back to that service first who can then liaise with the Stroke and Neuro Team.
  • If patient has a long term progressive neurological conditional (excluding stroke, PD and MND) and needs support and monitoring only for condition management, please refer to the community neurology service.
  • Spinal conditions/diagnoses including spinal stenosis, peripheral neuropathy, disc related and spinal MSK in the absence of another stroke and neuro related diagnosis
  • Contracture management that isn’t related to a stroke and neuro condition

 

DSNS (East) contact Details:

Tel:  01202 646090

Email:  dhc.eastdorsetstrokeandneuroservice@nhs.net

Team Lead – Jenny Chidley

Service Manager – Luisa Hardy