Quality statement 7: Regular review of health and social care needs

Quality statement

Adults who have had a stroke have a structured health and social care review at 6 months and 1 year after the stroke, and then annually. [new 2016]

Rationale

Reviewing the health and social care needs of adults who have had a stroke enables health and social care practitioners to identify any problems or difficulties the person who had the stroke and their family or carers may be experiencing. This can help adults who have had a stroke and their family or carers to make changes to their care according to their needs.

Quality measures

Structure

Evidence of local arrangements and written protocols to ensure that adults who have had a stroke have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.

Data source: Local data collection.

Process

a) Proportion of adults who have had a stroke who have a structured health and social care review at 6 months after the stroke.

Numerator – the number in the denominator who have a structured health and social care review at 6 months after the stroke.

Denominator – the number of adults who have had a stroke.

Data source: Local data collection. Data can be collected using the Royal College of Physicians' Sentinel Stroke National Audit Programme (SSNAP) question 8.1.

b) Proportion of adults who have had a stroke and had a structured health and social care review at 6 months after the stroke who have a review 1 year after the stroke.

Numerator – the number in the denominator who have a review 1 year after the stroke.

Denominator ‑ the number of adults who have had a stroke and had a structured health and social care review at 6 months after the stroke.

Data source: Local data collection.

c) Proportion of adults who have had a stroke and had a structured health and social care review at 6 months and 1 year after the stroke, who have annual reviews thereafter.

Numerator – the number in the denominator who have annual reviews.

Denominator – the number of adults who have had a stroke and had a structured health and social care review at 6 months and 1 year after the stroke.

Data source: Local data collection.

Outcome

a) Quality of life for adults who have had a stroke.

Data source: Local data collection.

b) Readmission rates of adults who have had a stroke.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers (such as primary, secondary and community care providers) ensure that systems are in place for adults who have had a stroke to have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.

Health and social care practitioners ensure that adults who have had a stroke have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.

Commissioners (such as clinical commissioning groups, NHS England and local authorities) ensure that they commission services that enable adults who have had a stroke to have a structured health and social care review at 6 months and 1 year after the stroke, and then annually.

Adults who have had a stroke have a check at 6 months and 1 year after their stroke, and then once every year to make sure they are getting the care and support that they need.

Source guidance

Stroke rehabilitation in adults (2013) NICE guideline CG162, recommendation 1.11.5 (key priority for implementation)

Definitions of terms used in this quality statement

Structured health and social care review

These reviews should address the person's ability to participate in daily activities and their role in their community, as well as secondary prevention and continuing rehabilitation. An agreed local structured health and social care review tool can be used, for example the Greater Manchester Stroke Assessment Tool (GM-SAT).

[NICE's guideline on stroke rehabilitation in adults, recommendation 1.11.5, and expert opinion]

Equality and diversity considerations

Any review should take into account any additional needs, such as physical, sensory or learning disabilities, and the needs of people who do not speak or read English. People should have access to an interpreter or advocate if needed.