Integration of primary and secondary care stroke rehabilitation into one continuous MDT pathway.


To modernise segregated stroke rehabilitation teams working along a care pathway in line with current NHS strategic planning and best practice. Commissioner restructuring for Stroke Care in Rotherham NHS Foundation Trust amalgamated multi-disciplinary care teams from primary and secondary care.

The new service was designed to allow staff to journey with their patients from entering to completion of the pathway. The preceding and updated services were evaluated using pre-existing quantitative and qualitative measures.


Following amalgamation of the primary and secondary care teams the updated pathway was designed using outcomes of staff surveys, away days and patient focus groups. Initially there was a large resistance to change especially in relation to different skill sets and a reduced understanding of the acute and community services respectively.

The team developed a shared statement and vision which evolved into the current pathway. The process has evolved over 4 years due to many challenges regarding staffing, vacancies, staff members' preferences to working in specific settings and reduced confidence.

Integration was fragmented as the two MDTs worked from different locations with individual disciplines not embracing the new pathway at the same time. A number of methods were used to help integrate the team alongside a move to a shared office space. This helped break down barriers and ensure a more collaborative approach to working.

Designated locality working and shared caseloads now aid time efficiencies and support more inexperienced staff. A stable pathway was established for a six month period before undertaking evaluation of SSNAP data and patient focus groups compared to that taken prior to integration.


SSNAP ratings have improved within 7 out of 10 patient-centred domains over the 4 year period. Qualitative focus group data showed every member in the group reported positive experiences with regards to their community therapy (including Early Supported Discharge).

All therapy staff now deliver care throughout a patients journey from admission to six month review which is a variation from traditional rehabilitation pathways.

The service provides ESD and community input based on patient need and realistic achievement of goals. There are no waiting times between services with seamless transfer of care due to a reduced need for handovers or referrals. The flexibility of the service allows for changing demands in capacity between the different elements of the pathway.

This service evaluation has demonstrated improved clinical measures and patient satisfaction following the implementation of a pathway that has strengthened the patient and health professional relationship. This has only been achievable due to the resilience and adaptability of the team. We are proud of our service and continue to be patient focused in the services that we provide


We have been informally sharing our work regionally and now want to share this nationally. We believe ourselves to be a unique service but are keen to find out about similar pathways that may exist.

Funding acknowledgements

Unfunded service evaluation.

Additional notes

This work was presented at Physiotherapy UK 2019