On this page:
Planning your discharge from hospital
Your community stroke team
Reviewing the support you need

Your recovery from a stroke isn't limited to the time you spend in hospital. When you're ready to leave hospital, your stroke team will work with you to agree and arrange the support you need to continue your recovery at home. 

Planning your discharge from hospital

When you are ready to leave hospital, your stroke team will work with you to agree what support you will need at home and put together a discharge plan. This will cover all the arrangements for your continued rehabilitation and care at home, including the community services that will be helping you and any aids or equipment you need.

Early supported discharge (ESD) allows you to receive the same rehabilitation care you would get in hospital at home. ESD isn't suitable for everyone, so it's only likely to be offered to you if you have a certain amount of movement (if you're able to safely move yourself from a bed to a chair, for example) and your stroke team is sure that you have a safe and secure environment to go to. 

Your social worker should work with you to arrange any practical help that you need at home. This could include carers coming in to help you get washed and dressed, or adaptations for your home. So they should complete a community care assessment with you to work out what help and support you need.

Your social worker also needs to ensure that anyone who is helping to care for you gets the right support too. So any friends or family members that are providing unpaid support need to have a carer's assessment.

These assessments should happen before you leave hospital, but sometimes they happen afterwards. When you have an assessment, be honest about your needs. 

The kind of help that's available varies from area to area, but could include:

  • advice about and help applying for financial support
  • equipment or changes to your home to help with day-to-day life
  • a place at a day centre
  • a home help or care assistant
  • home services such as meals on wheels and a laundry service
  • respite care (such as a short stay in a care home or special centre to give carers a break).  

Your community stroke team

Your community stroke team will help you with your continued care and rehabiliation once you leave hospital. Like your hospital stroke team, your community team will be made up of different healthcare professionals, including:

  • community stroke nurses
  • physiotherapists
  • speech and language therapists
  • occupational therapists
  • dietitians
  • psychologists.

Your community team will continue to work with you to assess your rehabilitation needs and check your progress against the goals that have been set for you whilst in hospital, as well as any subsequent goals that were agreed. 

Reviewing the support you need

  • In England, Northern Ireland and Wales anyone who has had a stroke should have a review with someone at six weeks, six months and 12 months after their stroke. This is to make sure that you are continuing to receive the care and support you need. If you've not had one of these reviews you need to speak to your GP or someone in your community stroke team.
  • In Scotland each health authority has its own guidelines about the follow up you should expect to receive after your stroke.