Integrated community stroke service

Our service sees anyone aged 18 or over, registered with a Newcastle GP. We see people who have had a stroke and have on-going stroke rehabilitation goals or require secondary prevention advice.

About us

Our team includes several different health professionals who all have specialist training and experience in stroke.

Our role is to help support your recovery and rehabilitation (recovering and adjusting to life) in the first few weeks and months after you leave hospital. This includes helping you with adjustment and living well after your stroke. They can also help and support families and carers.

A member of the team will contact you following your discharge from hospital. The team will know about your stroke and the therapy you have been doing in hospital. The team will plan with you how to carry on with your rehabilitation.

Together, and with the help of your relatives or carers, the team will work on the things that are important to help you get on with your life again.

Everyone’s needs are different after a stroke. Some will require more rehabilitation than others.

Referrals to our team

You will be referred to us following your discharge from the acute stroke unit or stroke rehabilitation ward.

Occasionally, your GP or other care provider may also refer you back for further rehabilitation if it is within 1 year of your discharge from hospital following your stroke. GPs can liaise with the team to discuss the best community rehabilitation team for you as it may not be the stroke team.

The guidelines can be provided to external partners on request via email and our referral form.

Information and support

We have a dedicated stroke service information coordinator who can be contacted on 0191 282 6310 option 2.

They provide a single point of access for information on local support groups or information for as long as you need it. Visits and discussions can be conducted within your own home or in the community.

Information and support sessions are also provided on the rehabilitation ward at the Freeman Hospital on alternate Wednesday afternoons for those families and carers looking for support during in-hospital stays.

Our stroke wards also have leaflets about stroke and local services where you can find out more about stroke, recovery and help as you prepare to leave hospital.

Ongoing support

We will offer you a 6-month review after the date of your stroke. This can be completed via telephone, home visit or at the six-month review clinic.

This will be discussed with you as part of your discharge planning with the team.

Get involved

The involvement of patients and carers is essential to ensuring that we continue to provide a service that meets the needs of the people who use it.

We welcome feedback on your experience of the service you have received following your stroke from any point of the stroke pathway. We are also keen to work with you to get a better understanding of what really matters and is important to you.

A questionnaire, where responses are treated anonymously, about your stroke pathway journey will be sent out with your discharge letter from the community service. This is so that we can gather your thoughts at the earliest possible opportunity.

We also run bi-annual listening events which you may be invited to. These events gather your thoughts and feelings about your stroke journey and help shape the pathway for future stroke survivors. They are an excellent way of participating with the stroke team and future proofing our service to meet the needs of the local community. These events are also open to families and/or carers who may have an alternative perspective or understanding of what has happened during your rehabilitation.

If you would like to help us shape services for patients and carers living with stroke or would like further information on the ways you can become involved with our service, please contact the service on 0191 282 6310, option 2.