Service Protocol for Stroke Care (MSW) Introduction: Depending on individual circumstances and need, medical social services

are available to all stroke patients and their families. Medical Social services are provided to patients and their families to meet their medically related social and emotional needs as they impinge on their medical condition, treatment, recovery, and safe transition from one care environment to another. The primary goal of this Service Protocol is to improve the effectiveness of rehabilitation in helping the person with disabilities from a stroke to achieve the best possible functional outcome and quality of life. Overall speaking, this Service Protocol can be applied both for acute and rehabilitation institute. Nevertheless, some stages or functions are only applicable to either one setting. Goals of MSS in Stroke Care: 1. 2. 3. Enhance stroke patients and family's quality of life, psychosocial and emotional well-beings through provision of a range of psychosocial services. Promote the patient-and-family centred nature of rehabilitation and the importance of capitalizing on patient, family, and community strengths and potentials during the rehabilitation process. Facilitate community integration of the stroke survivor with disabilities.

Major Problems of Stroke Patient and Family 1. 2. 3. 4. 5. 6. Problems related to patient care and activities of daily living. Patient and family adverse reactions or dysfunctional adjustment to illness and change in functional status Family relationship problems due to the change of roles and functions in the family Emotional problems, including depression, anxiety and career stress Discharge problems Financial and housing problems

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Key Stages/Tasks Psychosocial Assessment

Principles MSWs should systematically assess the patient’s psychosocial conditions. Review or evaluate at key stages throughout acute care and rehabilitation.

Interventions Conduct Psychosocial Assessment Idenitify problem area Make intervention plan

Recommended Time frame Acute unit receiving the case referral. Rehabilitation Unit after admission to hospital or 3 working days upon receiving the referral. Response within 1 working day Response within 1 working day 2 working days upon Within the 1st week

Crisis Intervention There are times of acute difficulty after stroke, eg. Suicidal ideation, care (if applicable) problems of dependent family members. MSWs are expected to contact patients and their families and render necessary services within 1 working day Problem Solving Anxiety and emotional disturbances are common after stroke. Counselling service on patient and family's acceptance of illness and emotion is required.

Provide Crisis Intervention, contact family member/ caregiver (if available) Provide counselling on: 1. Social and emotional functioning of patient and family caregivers 2. Stress management/ handling of emotions

Response within 2 working days

Response within 3 working days

Social problems, like financial, accommodation, home care and discharge are common after stroke. Hence early mobilization of community resources to assist patient and family is necessary.

Mobilize appropriate community resources as early as possible Provide psychosocial education & intervention information

2

Key Stages/Tasks Goal Setting and Formulation of Rehabilitation Plan

Principles Facilitate the communication and participation among patient, family and rehabilitation team in goal setting and formulation of rehabilitation plan.

Interventions Reflect and discuss the patient's psychosocial needs and family circumstance in the multi-disciplinary care plan. Motivate patient and family participation in the rehabilitation process.

Recommended Time frame Acute unit On-going Rehabilitation Unit On-going

Discharge Planning Discharge planning should begin on the day of admission The ability of a stroke survivor to return home depends on the person’s needs and the availability of caregivers support. If patient’s need exceed caregiver’s capabilities, community support services and/or alternate long-term placement should be considered.

Finalize the discharge plan: 1. Review psychosocial conditions for formulating the goal of discharge plan. 2. Assess caregiver’s capabilities and other practical arrangement to care the stroke survivor.

2 working days before discharge

3 days working before discharge

Liaise and mobilize community Upon discharge resources. Share and discuss the discharge plan with the multi-disciplinary team.

Upon discharge

3

Key Stages/Tasks Transition to community

Principles MSWs should be sensitive to the impact of care arrangement to patient and caregivers. They should work with the patient and caregivers, to promote their problem solving ability and facilitate reintegration of the patient into community.

Interventions Complete the pre-discharge checklist and take necessary action as indicated. Complete transfer summary

Recommended Time frame Acute unit Upon discharge Rehabilitation Unit One working day before discharge

5 working days after 5 working days after discharge

# remarks

and send to other MSW/ Send discharge referral to welfare agencies, if applicable.

Post-discharge Case review and follow up (if applicable)

Based on existing screening mechanisms for high-risk case eg. CNS, homehelp team, informal carer, Allied Health Community Programme etc. to identify needy patient and family for case review. Review on psychosocial, emotional and family functioning. Follow up the identified problems and render appropriate services. # remarks

Conduct case review Review the pre-discharge checklist. Re-assess caregiver’s capabilities and other practical arrangement to care the stroke survivor. Liaise and mobilize community resources.

2 working days after 2 working days after receiving notification receiving notification

This protocol is based on the Clinical Practice Guideline Post-Stroke Rehabilitation: Assessment, Referral, and Patient Management published by U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1995.

Remarks: # Case can be closed when necessary social work intervention is completed.

4

Case Evaluation Form on Service Protocol for Stroke Care in Acute Unit (MSW) MSS No.: Key Stage/ Tasks I Psychosocial Assessment Age/Sex: Aged home resident: yes/no Specialty: Med/Geri/Rehab/Stroke Care Unit/ Other Intervention 1) Conduct psychosocial assessment 2) Identify problem area 3) Design intervention plan II
Crisis Intervention (if applicable)

Appendix 1 Length of Stay: Done Days N/A (State Reasons for Variance)

Done

Not Done State reasons

Time Frame 2 working days upon receiving the case referral

Provide Crisis Intervention

Response within 1 working day

III Problem Solving 1) Provide Counselling (pls refer to protocol p.2) 2) Mobilize appropriate community resources 3) Provide psychosocial education & intervention information IV Goal Setting & Formulation of Rehabilitation Plan V Discharge Planning 1) Reflect & discuss the patient’s psychosocial needs & family circumstances in the multi-disciplinary care plan 2) Motivate patient & family participation in the rehabilitation process 1) Review psychosocial condition & finalize the discharge plan 2) Liaise & mobilize community resources
3) Share & discuss the discharge plan with the multi-disciplinary team

Response within 2 working days

On-going

(Not applicable)

2 days before discharge Upon discharge

VI Transition to community

1) Complete the pre-discharge checklist and take necessary action as indicated. 2) Complete transfer summary & send to other MSW/ Send referral to welfare agencies, if applicable

Upon discharge

5 working days after discharge

VII Post-discharge Case review & follow up (if applicable)

Reason for post-discharge review eg. Financial problem, caring problem etc: 1) Conduct case review 2) Review the pre-discharge checklist 3) Re-assess caregiver’s capabilities & other practical arrangement to care the stroke survivor 4) Liaise & mobilize community resources
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2 working days after receiving notification

Name of Hospital:

Completed by :

Date:

Case Evaluation Form on Service Protocol for Stroke Care in Rehabilitation Unit MSS No. : Key Stage/ Tasks I Psychosocial Assessment Age/Sex: Aged home resident: yes/no Intervention 1) Conduct psychosocial assessment 2) Identify problem area 3) Design intervention plan II
Crisis Intervention (if applicable)

(MSW) Length of Stay: Done

Appendix 2 Days N/A
(State Reasons for Variance)

Specialty: Med/Geri/Rehab/Stroke Care Unit/ Other Done Not Done
(State reasons)

Time Frame
1 week after admission to hospital or 3 working days upon receiving the referral form

Provide Crisis Intervention

Response within 1 working day

III Problem Solving 1) Provide Counselling (pls refer to protocol p.2) 2) Mobilize appropriate community resources 3) Provide psychosocial education & intervention information IV Goal Setting &
Formulation of

Response within 3 working days

1) Reflect & discuss the patient’s psychosocial needs & family circumstances in the multi-disciplinary care plan

On-going

(Not applicable)

Rehabilitation Plan 2) Motivate patient & family participation in the rehabilitation process

V

Discharge Planning

1) Review psychosocial condition & finalize the discharge plan 2) Liaise & mobilize community resources
3) Share & discuss the discharge plan with the multi-disciplinary team

3 days before discharge Upon discharge

VI Transition to community

1) Complete the pre-discharge checklist and take necessary action as indicated. 2) Complete transfer summary & send to other MSW/ Send referral to welfare agencies, if applicable

1 working day before discharge

5 working days after discharge

VII Post-discharge Case review & follow up (if applicable)

Reason for post-discharge review eg. Financial problem, caring problem etc: 1) Conduct case review 2) Review the pre-discharge checklist 3) Re-assess caregiver’s capabilities & other practical arrangement to care the stroke survivor 4) Liaise & mobilize community resources
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2 working days after receiving notification

Name of Hospital:

Completed by :

Date:

MSW Transfer Summary
From : Ref: Fax/ Tel: Date: I) Particulars ( ) Sex: M/F* Age/D.O.B: To: Ref: Fax: Date:

Appendix 3

Name of patient: HKIC/BC No.: Address: Accessible by lift □ Yes □ No Climb Occupation: II) Income:

Marital Status: S / M / W / D / Cohabited / Separated* Tel. No.: floor. Type of accommodation Diagnosis: Dialect Date of Discharge/Transfer:

Particulars of Family Members: (Please provide telephone no. and address as far as possible.) Name Relationship Sex/Age Occupation/Income Telephone No. Remarks

III) IV) 1. 2. 3.

Problem Nature: Service rendered: Social Investigation/ Enquiry Counseling on: Marital Relationship from Child Care Others:

Financial assistance: A total sum of $ was granted on

Trust Fund for the purpose of

4.

Full/ partial waiver of medical charge (amount waived: $

per day / attendance) from/on

to

.

(for details pls refer to “Application for Waiving of Medical Charges”) 5. 6. Processing of: Referrals Made: MEF MAF(CSSA/SSA) SSFU ref: Day Care Centre for Elderly Halfway House Selective Placement MH Hostel

Residential Service for Elderly

Home help / Home care

Enhanced Home &Community Care Services Sheltered Workshop Long Stay Care Home Others: V) Suggested Follow Up Area(s): Supported Employment Day Activities Centre

VI) Remarks:

Signature: Name of Referring MSW: Telephone No.: * delete if not applicable Date:

Counter-signed by: Name/Post : Date:
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Appendix 3

Reply Note From : Ref: To: Date:

(Please Affix Patient’s Label Here)

We will follow up this case and render appropriate assistance to the above-name. For enquiries, please contact the responsible Medical Social Worker Mr/Mrs/Ms at . Other remarks:

Signature: Name of MSW:

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