E14: Review

Those affected by stroke are offered a review of their health and social care status and secondary prevention needs from primary care services, typically within around six weeks and six months of leaving hospital. (Key: e = element | k = knowledge | s = skill)

Knowledge and understanding of…

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
Advocates for stroke patients when there is a legal duty to instruct an IMCA, taking account of religious and cultural aspirations
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
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)
The impact of stroke on the individual, carer and family
The implications of stroke for lifestyle, driving, work and family
Risk factors for further vascular events (e.g. type and aetiology of current event, lifestyle, socioeconomic, cultural, vascular, familial, genetic, concurrent medications, comorbidities)
Pharmacological and non-pharmacological interventions for secondary prevention and how to help recovery after stroke
Side effects of risk factor interventions and treatments to help with recovery after stroke
Methods to help communication with those affected by stroke when conducting a review
Concordance: how to assess; how it is affected by individual preference; how to motivate; how to manage non-concordance

Skills and ability to...

Take and interpret thorough history, including information from carers, relatives and other agencies where possible, and assess mental capacity
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
Monitor the individual’s progress and agree or change a maintenance or management plan
Assess, discuss and review with those affected by stroke: goal-setting and outcomes
Plan assessments and treatments; provide information, relevant to individual needs and aspirations (personalise information)
Identify need and when to refer for more specialist or differing interventions/treatments where necessary
Review process in your area and act on the review
Assess and facilitate concordance