BEXLEY COMMUNITY NEUROREHABILITATION TEAM
Service Overview
The Oxleas Integrated Specialist Neurorehabilitation Service provides a convenient
single point of access via self and professional referral routes to one team of
specialist staff with the skills and knowledge required to assess and treat patients
with neurological conditions. The team will cover all pathways and services as
detailed below, and offer a period of time-specific patient-centred goal-mediated
rehabilitation.
The service operates a 4-bed in-patient unit, a Community service, and an outpatient
gym service.
4 INPATIENT BEDS
The inpatient beds are for patients whose primary problem is the acute deterioration
in their long term neurological condition (with or without inter-current illness), which
has caused an unrecoverable breakdown in their ability to manage at home with
community services.
Patients can be admitted to these beds for up to 14 days as an alternative to acute
hospital admission if they need rehabilitation and nursing or general medical input.
They are not for patients being discharged from hospital, and are not part of the
stroke patient pathway.
If medical care is still required following 14 days the patient will be discharged to
another service. If medical/nursing needs have been resolved, the patient will be
discharged home with continued rehabilitation with the community/outpatient service
as needed. Discharge will include on-going care plan for continued disability
management to maintain the patients function.
Inclusion Criteria for inpatient beds:
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Have a Bexley GP and live within the practice boundary of that their GP
surgery
Main diagnosis of a long term neurological condition with acute deterioration
Unable to manage / be managed at home
Need daily rehabilitation per discipline and/or more than one discipline
Consenting to transfer to the inpatient unit with agreement from carers
Estimated length of stay two weeks
Able to be managed on the inpatient unit with non-daily GP medical
intervention
Able to return home following inpatient stay
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Exclusion Criteria for inpatient beds:
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GP other than Bexley, or live outside the practice boundary of that their GP
surgery
Newly diagnosed Stroke
Those requiring long term complex in-patient rehab (more than two weeks).
Patients requiring diagnostic medical or consultant neurology assessments or
interventions.
Patients requiring daily medical review or intervention.
Awaiting placement or Continuing Care Assessment process.
COMMUNITY SERVICE
This service provides the bulk of the rehabilitation input, and incorporates the stroke
after-care pathway and the other neurological condition pathways as well as the
Community Specialist Nursing caseload. It provides rehabilitation in the location
most appropriate for the patient to promote recovery and to plan for discharge from
rehabilitation services, together with an on-going care plan for continued disease and
disability management by the patient. The Specialist team is supported by an
Occupational Therapist from the Bexley Social Services Reablement service.
OUTPATIENT GYM SERVICE
This service provides specialist neurological gym-based physiotherapy to patients
with a deterioration in their neurological condition. Patients may be referred by their
GP, Hospital Neurology Consultant or Community Clinical Nurse Specialist as a new
patient or self-re-refer through the Triage Service once they are known to the
service. They will receive a package of up to 6 weeks physiotherapy rehabilitation to
return them to their previous function if possible. It is not an on-going maintenance
service
Acceptance criteria for community / gym:
 Adults over the age of 16 who have experienced a neurological illness or injury. If
the injury is due to a stroke this must have been diagnosed by a consultant and/or
CT scan result.
 Registered with a Bexley GP and live within Bexley or the practice boundary of
their GP surgery.
 Medically stable and fit for discharge home from the acute service (if relevant)
 Consenting to supported discharge at home or transfer from home to the inpatient
unit (if relevant) with agreement from carers
 Consenting to the treatment package, rehabilitation plan and goals provisionally
set on Initial Assessment
 Suitable home environment, as assessed by the MDT, if rehabilitation will take
place in the community
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Disciplines included within the service:
Neuro-Occupational Therapy
Neuro- Speech and Language Therapy
Neuro- Physiotherapy
Neuro-Community Nurses
Specialist Parkinson’s Disease Nurse
Specialist Multiple Sclerosis Nurse
Neuro-Psychology
Therapy assistants
Access to the service:
All referrals for the Neuro team should be sent to:
Fax: 020 8308 3152 or Email: oxl-tr.BCHS-NeuroTeam@nhs.net .
Referrals will be triaged by a senior clinician and allocated to the appropriate
pathway, or signposted on if not appropriate.
Hours of Operation:
The triage team will be available to receive referrals between 08:00 and 18:00 seven
days a week.
The Community service (and gym) will operate between 09:00 and 17:00 Monday to
Friday only, although treatment will be provided at the weekend for A&E admission
avoidance or HASU patients who are discharged at the weekend.
Pathways and Service components:
The Service delivers care to patients on five pathways:
 Stroke Care Pathway
 Acute Illness with a Long Term Neurological Condition pathway
 Disability Management for Long Term Neurological Conditions pathway
 Post-Acute Neurological Injury pathway
 Post Neurosurgery pathway
Each pathway offers one or more of the service components.
 Supported Discharge service
 Stroke Early Supported Discharge service
 Admission Avoidance
 Long Term Conditions Management Service
Regardless of designated pathway each patient will be allocated a key worker, who
will provide a case management role, overseeing discharge, follow-up, and engaging
external stakeholders.
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