Sub acute management (SAM) pathway for patients with complex neuro-disability
Introduction:
During 2009, a sub acute management (SAM) pathway will be developed to improve the intensity and co-ordination of services for people with complex neuro-disability. This will be accessible to appropriate in-patients under the care of the neurology, neurosurgery or stroke team at the Royal Free London NHS Foundation Trust.
What the SAM pathway offers:
Patients on the SAM pathway will receive an average of 6-8 weeks specialist and intensive, goal based multidisciplinary (MDT) assessment and management in order to optimise their function and inform future rehabilitation and discharge options.
Following this period it is anticipated that patients will transfer to their local hospital, rehabilitation unit, interim placement, their home or continue their rehabilitation or community discharge planning with the ward team.
A key role of the SAM team will be to work closely with relatives, neuro-rehabilitation or step down facilities and referring hospitals within the neurosciences network, regarding the ongoing management of patients. This will include outreach visits where appropriate, to offer advice and training.
The SAM pathway will operate as a virtual ward and manage up to six patients at any time, with beds allocated according to clinical need.
The service is suitable for patients with complex neuro-disability who:
- Would benefit from a co-ordinated MDT approach
- Will require further inpatient specialist neuro-rehabilitation, interim transfer to their local hospital
- Have significant cognitive/behavioural deficits affecting their ability to be safely discharged to the community
- Have the potential to achieve community discharge after 6-8 weeks intervention (if no other suitable service is available)
The service is not suitable for patients who:
- Are ready for discharge (home or to another healthcare facility) in two weeks or less
- Have other suitable rehabilitation plans
- Have their clinical needs effectively being managed