Coordinating complex neurorehabilitation using the Shared Care Record

This case study demonstrates how the Shared Care Record supported complex discharge planning for a stroke patient with multiple needs.

A patient was admitted to a stroke unit with acute stroke symptoms and assessed as having Level 1 specialist neurorehabilitation needs, requiring intensive inpatient rehabilitation from a specialist multidisciplinary team due to the complexity of their condition. Multiple complex challenges were identified, including physical, cognitive, and speech impairments, alongside challenging behaviours.

During the hospital stay, the NHS Mid and South Essex neuro navigation team maintained close contact with the treating team, and the patient showed some improvement with therapy. Referrals for level 1 specialist neurorehabilitation were made, and the patient was accepted for a place.

While awaiting a bed at the neurorehabilitation centre, the patient was transferred to a community therapy bed. The neuro navigation team remained involved and accessed the Shared Care Record to supplement ward updates with community health information, helping them build a clearer picture of the patient’s ongoing needs.

Following a fall at the community hospital, the patient was readmitted to a different acute hospital, nearer to the community bed location. The neuro navigation team supported a smooth transition by sharing clinical details and updates with the new treating team. While the patient’s presentation was consistent with previous handovers, the new treating team felt that recovery had plateaued and were unsure about the suitability of further neurorehabilitation, given their shorter involvement. The neuro navigation team, having followed the full journey, agreed, but uncertainties remained about the patient’s pre-morbid function and social circumstances.

Using the Shared Care Record

To resolve these uncertainties, the neuro navigation team accessed the Shared Care Record and identified a history of progressive neurological decline and longstanding functional difficulties. This was shared with the treating team and discussed with the patient’s family, who confirmed that the patient had been struggling significantly prior to admission.

Impact and outcome

With access to detailed historical and cross-sector information, the multidisciplinary team, in partnership with the patient’s family, agreed that specialist rehabilitation was no longer the most appropriate pathway. Instead, a discharge to assess pathway (where care needs are evaluated in a community setting) was pursued to find the right long-term care setting.

• Enabled accurate decision-making based on a fuller picture of the patient’s health journey.
• Reduced delays by eliminating the need for multiple information requests to other care settings.
• Helped ensure the appropriate commissioning of services by the ICB.

The difference it made

The Shared Care Record was critical in supporting a joined-up, timely and well-informed discharge plan. By linking information across acute, community, and historical records, the system empowered clinicians to make better decisions, avoid unnecessary referrals, and ensure the patient received the right support at the right time.