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 the physiological, neurological, and psychological effects of stroke to inform long-term care
e13k_2:
the range of potential impacts of stroke on the patient, carer, and family, the need to assess these, and assessment methods
e13k_3:
the implications of stroke for lifestyle; driving; occupation, including voluntary work or education; and social participation
e13k_4:
risk factors for further vascular events
e13k_5:
pharmacological and non-pharmacological interventions for secondary prevention and to promote recovery after stroke; and their potential adverse effects
e13k_6:
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
e13k_7:
the range of methods, resources, and approaches available to facilitate communication with those affected by stroke
e13k_8:
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...
e13s_1:
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
e13s_2:
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
e13s_3:
assess, discuss, and review goal-setting and outcomes with those affected by stroke
e13s_4:
identify need and when to refer for more specialist or differing interventions and treatments when necessary
e13s_5:
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
e13s_6:
assess post-stroke apathy and readiness for behaviour change, and use approaches to support behaviour change
e13s_7:
deliver and evaluate self-management programmes for those affected by stroke
e13s_8:
assess adherence to treatment and rehabilitation in long-term care after stroke and facilitate improved engagement
