Quality standard
Quality statement 7: Regular review of health and social care needs
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
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from clinical protocols and service specifications.
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: The Sentinel Stroke National Audit Programme (SSNAP) collects and reports information in the clinical audit on the proportion of patients who have a follow-up assessment at 6 months post-admission.
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: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
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: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
Outcome
a) Quality of life for adults who have had a stroke.
Data source: Data can be collected from information collected locally by healthcare professionals and provider organisations, for example, from patient surveys. The SSNAP clinical audit includes a quality-of-life measure (EuroQoL EQ-5D-5L) at the 6‑month post-stroke follow up.
b) Readmission rates of adults who have had a stroke.
Data source: Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example, from patient records.
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 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. NICE guideline NG236 (2023), recommendation 1.17.5
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 1.17.5, and expert opinion]