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…

e13k_1:
The assessment and management of problems: psychological and emotional; social and relationship; cognitive and communication; physiological, physical and functional; neurological, visual and sensory impairments and pain; medical
e13k_2:
Advocates for stroke patients when there is a legal duty to instruct an IMCA, taking account of religious and cultural aspirations
e13k_3:
The needs and aspirations of those affected by stroke, particularly those related to the problems listed above, and how these needs and aspirations can be met
e13k_4:
The impact of stroke on the individual, carer and family
e13k_5:
The implications of stroke for lifestyle, driving, work and family
e13k_6:
Risk factors for further vascular events (e.g. type and aetiology of current event, lifestyle, socioeconomic, cultural, vascular, familial, genetic, concurrent medications, comorbidities)
e13k_7:
Pharmacological and non-pharmacological interventions for secondary prevention and to facilitate recovery after stroke and their side effects
e13k_8:
Support services, organisations and resources available (e.g. health, social, voluntary, independent sector; packages of care, finance and personal budgets, self-management, respite care, equipment, adaptations, rehabilitation, psychological, educational, employment, housing, transport)
e13k_9:
Assistive technology and other therapy interventions (e.g. functional electrical stimulation, orthotics)
e13k_10:
Methods to facilitate communication with those affected by stroke
e13k_11:
Concordance: how to assess; how it is affected by individual preference; how to motivate; how to manage non-concordance

Skills and ability to...

e13s_1:
Take and interpret thorough history, including information from carers, relatives and other agencies where possible, and assess mental capacity
e13s_2:
Communicate and discuss: current event; risk of future vascular event; need for assessments/investigations, interventions/ treatments and their timeframes; rationale for treatment and possible side effects of treatment; and provide timely information, advice and support
e13s_3:
Monitor the individual’s progress and agree on or change a maintenance or management plan
e13s_4:
Assess, discuss and review with those affected by stroke: goal-setting and outcomes
e13s_5:
Identify need and when to refer for more specialist or differing treatments when necessary
e13s_6:
Identify relevant rehabilitation and social support services after discharge: inform the individual about services and how to access them and agree referral
e13s_7:
Identify the individual’s motivation and take steps to modify behaviour
e13s_8:
Know of local services, their waiting times and implications for those affected by stroke and ensure that the individual is aware
e13s_9:
Understand how those affected by stroke can be empowered (e.g. through self-management programmes)
e13s_10:
Assess and facilitate concordance