Saudi Stroke Standards

Community Assessment and Review Purpose Stroke patients and their family members/care givers should be offered a review from primary care services of their health and social care status and secondary prevention needs, typically within six weeks of discharge home or to care home, and again before six months after leaving hospital. This should be followed by an annual health and social care check, which facilitates a clear pathway back to further specialist review, advice, information, support and rehabilitation, where required. Rationale  Stroke patients and their family members/care givers would need information, advice and advocacy in accessing the right kind of support.  It will be important to bear in mind that those who have had a stroke may have additional communication or cognitive support needs to be able to participate in the assessment.  In addition, those affected want to know how to seek further support when they need it. Standards 1. Stroke patients should receive a multidisciplinary person-centered assessment of the individual’s needs and signposting to other services, such as housing or transport. 2. Family members or friends who may be taking on a caring role are entitled to an assessment of their needs in their own right. 3. Stroke patients should be reviewed for their community living skills and support needs upon discharge from acute hospital; these should be reviewed at least once a year to provide appropriate support. QM 5.5 Participation in the Community Purpose To enable stroke patients and their family members to live a full life in the community. Good level of community participation by stroke sufferers will be enhanced by improving their functional ability to be more independent and by making the community services more accessible to them. Rationale  Stroke patients and their family members need support to be able to return to varied roles they had before a stroke and to be involved in their local communities again.  Long-term assistance, review and rehabilitation are essential for patients to lead independent lives and overcome physical, psychological and attitudinal barriers and to engage and participate in community activities. To maximize emotional recovery, people need information and advice about local opportunities and resources, including hobbies, leisure, education and sports facilities.  Opportunities for peer support can also enable and empower patients, especially in relation to rebuilding the confidence that many stroke patients loose. Standards 1. Transport authorities and local governments should undertake accessibility planning and how they meet the needs of stroke patients, for example through their local transport plans process. 2. Stroke networks and specialist professionals in the clusters should provide training to providers of community services. Stroke networks should also consider providing training on stroke to a wider range of organizations that come into contact with individuals who have had a stroke. Allied health professionals and stroke voluntary organizations are particularly well placed to carry out this training. 3. Clusters should ensure that there are a range of services available locally for people to choose from when agreeing their care plan. QM