Our community neurological (neuro) rehabilitation services are for adults, over 16, with a primary neurological diagnosis which is the reason for their referral.

We assess the patient's healthcare needs and work with them to plan and agree a rehabilitation programme to help them achieve their goals.

Our teams include the following clinical specialities

  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
  • Clinical Neuro-psychology
  • Rehabilitation assistants
  • Stroke Support Workers (for Westminster and Kensington & Chelsea)

We provide assessment, treatment and advice to clients and carers regarding

  • Indoor/outdoor mobility and supporting you to access your local community.
  • Balance and falls.
  • Exercise prescription, and links to other services to support you to be as active as possible.
  • Promoting independence with daily activities, e.g. meal preparation, bathing
  • Swallowing, eating and drinking
  • Communication – including speaking, understanding, reading and writing
  • Cognition - e.g. memory and attention
  • Emotional difficulties relating to the neurological condition
  • Fatigue management
  • Work (for clients who are employed at the time of intervention), education and leisure

Clients are triaged onto four pathways:

Neurorehabilitation: rehabilitation of newly acquired neurological disorders

Disability Management: specialist therapy management of chronic or progressive neurological conditions promoting self-management

Assessment and Advice: focused intervention where the goal relates to education or promotion of self-management.

Rapidly Deteriorating: specialist multidisciplinary input for rapidly deteriorating conditions where needs are ongoing

We provide two high-intensity pathways. These referrals must be made by a healthcare professional:

Specialist Neurological Rehabilitation Outreach Service (SNROS): Partnership with Imperial Health’s level 2B Specialist Neurological Rehabilitation Service for clients with complex multidisciplinary neurological rehabilitation needs. Referrals are through the Badgernet online referral system. Should you wish to discuss a possible referral to this pathway please call on 0208 102 3879.

Early Supported Discharge for Stroke (ESD): People are seen shortly after hospital discharge for intensive community therapy after stroke. Referrals must be discussed with the ESD coordinator on-call during business houurs (0208 102 3879).

Our community neuro-rehabilitation services are for people over the age of 18 years of age who have neurological conditions or have had a neurological event requiring rehabilitation.

We assess the patient's healthcare needs and work with them to plan and agree a rehabilitation programme to help them achieve their goals. Our services are provided for people with neurological impairments caused by conditions such as stroke, traumatic brain injury, multiple sclerosis, Parkinson's disease and motor neurone disease.

Who we are

Our teams include, or have access to a range of clinical specialties including:

  • Physiotherapy
  • Occupational therapy
  • Speech and language therapy
  • Neuro rehabilitation specialist nurse
  • Parkinson’s disease specialist nurse
  • Rehabilitation assistants
  • Dietetics

Patient contact number: 0333 241 4242

ESD referrals must be discussed with the coordinator before they will be accepted, please call 02081023879. SNROS referrals must be made via Badgernet after discussion with the coordinator and rehabilitation consultant.

Referrals to other pathways may be made by:

  • Health and Care Professionals
  • Patients previously known to the service can self-refer.

Referrals can be made via our Single Point of Access

  • Phone (option 1): 0300 033 0333
  • eFax: 0300 008 3251
  • Email: CLCHT.SPA@nhs.net

Queries regarding referrals or patient enquiries can be directed to:

  • Phone: 020 8102 3879
  • Email: clcht.neuroadmintri-b@nhs.net

Referral form

Please contact the Single Point of Access to request the appropriate referral form:

 

Inclusion

  • People with acquired neurological difficulties (stroke, acquired brain injury, spinal cord injury, meningitis & encephalitis, brain tumours, bell’s palsy, etc.)
  • People with progressive, congenital or chronic neurological difficulties (e.g. Multiple Sclerosis, Parkinson’s Disease, Parkinson’s Plus syndromes, Motor Neurone Disease, Huntington’s, etc.)
  • People with diagnosed functional neurological disorders
  • Speech therapy also sees: clients with COPD, dementia, frailty, or palliative/end-of-life needs are triaged and provided with appropriate input. We do not see people with voice, stammering or head & neck cancer issues. Please contact the team to discuss these referrals.

Exclusion

  • People with case management needs only
  • People whose main presenting pathology or need is not neurological and do not require specialist neurological intervention
  • People with dementia (for PT and OT referrals)
  • People who only require equipment or adaptations (unless they are funded by Continuing Healthcare).
  • Vocational rehabilitation for clients not in already in employment

Referrers unsure about their client’s suitability can discuss the referral by calling 0208 102 3879.

This service is for:

  • Housebound patients although some outpatient clinics are available
  • Over 18 years of age
  • Registered with a GP in Merton
  • Patients where neurological diagnosis is the reason for the referral

Inclusion

The main reason for referral is due to a new neurological diagnosis or deterioration in a long-term neurological condition.

Patients who require input from two or more neuro disciplines. However, uni-disciplinary referrals are accepted for occupational therapy for cognition or splinting, neuro physio for domi or outpatient clinic and referrals to our Parkinson’s disease nurse.

Exclusion

  • People who require acute medical care
  • Referrals for vocational rehabilitation only
  • Referrals to vestibular rehabilitation only
  • Referrals for equipment only

This service is not for:

  • Provision of equipment or housing adaptations

Patients can be discharged when they have reached their full rehabilitation potential, have achieved their rehabilitation goals, or where there is no clinical benefit to continued rehabilitation. Patients will be discharged back to their GP if they fail to attend appointments without first contacting their treating therapist.

We provide assessment, treatment and advice to clients and carers regarding:

  • Active rehabilitation (physical therapy) e.g. indoor/outdoor walking practice.
  • Balance group.
  • Interventions for prevention of secondary complications and health promotion, including BP, smoking cessation, cardiovascular risk factor assessment, urinary/bowel dysfunction and follow-up of medical needs following discharge from acute setting.
  • Home exercise prescription.
  • Re-education and pacing of activities of daily living.
  • Equipment provision, basic fitting and adjustment, and instruction in equipment use.
  • Education of service users and carers in condition management.
  • Relaxation and anxiety management.
  • Splinting.
  • Cognitive rehabilitation.
  • Other SLT interventions (e.g. communication therapy, dysphagia management).
  • Coordination of end of life care in line with health need, including advanced care planning

The teams include an early supported discharge for stroke service, providing intensive rehabilitation at home for up to four weeks following discharge from hospital. We carry out reviews of the needs of stroke survivors at six months after their stroke.