E13: Long-term care

A range of services are in place and easily accessible to support the individual long-term needs of those affected by stroke.

Key: e = element | k = knowledge | s = skill

Knowledge and understanding of…

the assessment and management of the physiological, neurological, and psychological effects of stroke to inform long-term care
the range of potential impacts of stroke on the patient, carer, and family, the need to assess these, and assessment methods
the implications of stroke for lifestyle; driving; occupation, including voluntary work or education; and social participation
risk factors for further vascular events
pharmacological and non-pharmacological interventions for secondary prevention and to promote recovery after stroke; and their potential adverse effects
the full range of local and national resources and services available for those affected by stroke - particularly those relating to long-term care, housing, transport, adjustments, supporting independent living where possible - including: health, social, voluntary, and independent; how to facilitate access and length of referral time
the range of methods, resources, and approaches available to facilitate communication with those affected by stroke
medication adherence: how to assess it; how it is affected by individual preference; how to motivate; and how to facilitate improved engagement

Skills and ability to...

recognise stroke-related communication difficulties and adapt methods of communication to discuss with the patient, carer, and family: current event; risk of future vascular event; need for and timeframes of assessments and investigations; rationale for interventions and treatments, their timeframes, and possible side effects; and provide timely information, advice and support
monitor progress and agree or change a maintenance or management plan in conjunction with those affected by stroke, identifying resources to facilitate participation and inclusion
assess, discuss, and review goal-setting and outcomes with those affected by stroke
identify need and when to refer for more specialist or differing interventions and treatments when necessary
identify the full range of local and national resources and services available to support long-term care for those affected by stroke; assess their relevance and suitability for the patient, carer, and family; liaise with services, working across agencies and sharing information where appropriate; communicate referral arrangements, availability and waiting times
assess post-stroke apathy and readiness for behaviour change, and use approaches to support behaviour change
deliver and evaluate self-management programmes for those affected by stroke
assess adherence to treatment and rehabilitation in long-term care after stroke and facilitate improved engagement