Early Discharge and Rehabilitation Service

The Early Discharge and Rehabilitation Service (EDARS) at Te Whatu Ora Waitematā screens well-being at multiple points during a person’s six week rehabilitation programme. The referral form for the services requires referrers to provide information about psychosocial well-being. Whilst this was primarily intended as a safety screener, it helps highlight issues around vulnerability, isolation and social supports, prompting and prompts the referrer to identify issues and consider these before the person is discharged home. It also means that the EDARS team have a better picture of who is coming into their services and who may be particularly vulnerable. The questions ask if the person is a primary carer for others, if they are a vulnerable adult or at risk of abuse or neglect; if they are socially isolated; and if there are any concerns about the person’s relationship.

This is supplemented through the nursing and social work screens. Their RN completes a comprehensive screening with every patient in the first week of rehabilitation. This includes asking questions about cognition, memory, mood, depression and anxiety. They ask about changes in body image, spiritual distress, feelings of grief and lost, and ask about the person’s adjustment to the impacts of stroke. In week 2 or 3, the social worker completes a phone screen for every patient. Through conversation, they explore mood changes to identify if there are any issues. Psychosocial issues are also commonly identified through the team’s goal- setting process. The goal-setting tool, the Schedule for the Evaluation of Individual Quality of Life (SEIQOL), prompts people to identify the areas of life most important to them, and uses this to help identify specific therapy goals using Goal Attainment Scaling. Talking about what matters most in life provides an opening for people to raise issues related to their psychosocial well-being.