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Neuro 2B Specialist Rehabilitation Pathway

A specialist neurorehabilitation service for patients after their immediate medical and surgical needs have been met.

Mildmay’s Level 2B Specialist Neurological Rehabilitation Pathway
provides goal-orientated rehabilitation for patients (aged 18 years
and over) facing challenges in their daily lives due to neurological
conditions or injuries requiring rehabilitation.


We offer personalised and intensive rehabilitation and management programmes tailored to each person's needs to fulfil and maintain their full potential within the community.


Our comprehensive service offers inpatient beds for patients from
across London and beyond.

Description of Service

Mildmay offers high-intensity, goal-orientated neurological rehabilitation and inpatient care for people with new and chronic progressive neurological conditions and life-changing illnesses or injuries, including, for example:

  • Stroke (CVA)

  • Hypoxic brain injury

  • Brain tumours

  • Traumatic brain injury (with and without polytrauma)

  • Multiple sclerosis and other progressive neurological conditions

  • Spinal cord injury (incomplete)

  • Inflammatory neurology (central and peripheral)

Service benefits

Our specialist neurological rehabilitation service helps to reduce or prevent serious illness and unplanned hospital admissions, making Mildmay more cost-effective than standard care.

The Neuro 2B Pathway plays a vital role by taking patients after their immediate medical and surgical needs have been met, maximising their recovery, and supporting a safe transition back to the community. We free up NHS beds, reducing the burden on acute and frontline services (and are, therefore, a critical component of the acute care pathway).

Admission criteria

  • We offer rehabilitation to medically stable, non-emergency patients.

  • This service is appropriate for adults with complex neurological rehabilitation needs that cannot be managed through standard community and social care programmes.

  • Patients should be ready and willing to embark on an intensive, goal-orientated rehabilitation plan before referral.

Admission criteria
Referrals

Referrals

To discuss or make a referral, please contact our Admissions Manager by telephone at 020 7613 6347 or by email: admissions.mildmay@nhs.net

Use the referral page to download forms for:

  • HIV Medical Referral

  • HIV Nursing

  • Homeless Medical Care Pathway

  • REBUILD Pathway

  • Social Care Questions for Admission

What is the Neuro 2B Pathway?

Specialist rehabilitation is the total active care of patients with complex disabilities by a multidisciplinary team who have undergone recognised specialist training in rehabilitation, led by a consultant trained and accredited in Rehabilitation Medicine. Early transfer to specialist centres and more intense rehabilitation programmes have been proven cost-effective, particularly in the small group of people who have high care costs due to severe brain injury.

 

Generally, patients requiring specialist rehabilitation are those with complex disabilities. Such patients typically present with a diverse mixture of medical, physical, sensory, cognitive, communicative, behavioural and social problems, which require specialist input from a wide range of rehabilitation disciplines (e.g. rehabilitation-trained nurses, physiotherapy, occupational therapy, speech and language therapy, psychology, dietetics, social work etc.)

as well as specialist medical input from consultants trained in rehabilitation medicine and other relevant specialities, e.g. neuropsychiatry.

​

The Department of Health Specialist Services National Definition Set (SSNDS) 3rd edition, published in 2009, defined four categories of patient need (A, B, C and D) and three levels of specialist service (1, 2 and 3). These form a useful framework for the planning and commissioning of specialist rehabilitation services.

After severe disabling illness or injury, a significant number of patients will have more complex (Category B) needs requiring more prolonged treatment in a specialist (Level 2) rehabilitation service.

​

Mildmay is deemed to be service level 2, and referrals are primarily in category B. Therefore, Mildmay's referrals fall within the commissioning remit of ICBs.

Care pathway

Our Multidisciplinary team assesses the patient's healthcare needs and works with them to plan and agree on a rehabilitation programme to help them achieve their goals.

 

Our service is provided for people with neurological impairments. Damage to the nervous system can lead to various difficulties that make it difficult for people to live a full life. We work with patients using a goal-orientated approach, helping them to improve their ability to do the things that have become difficult.

 

Our MDT provides assessment and rehabilitation around meal preparation, laundry, light housework, shopping, financial management and returning to or accessing work and education. We are able to provide assessment, treatment and advice to patients and carers regarding the following:

  • Balance and falls

  • Cognition - e.g. memory and attention, comprehension, concentration and orientation

  • Communication – including speaking, understanding, reading and writing

  • Continence and toileting

  • Emotional difficulties relating to the neurological condition

  • Exercise prescription and links to other services to support patients to be as active as possible.

  • Fatigue management

  • Indoor/outdoor mobility and supporting patients to access their local community, stair practice

  • Medicines management

  • Promoting independence with daily activities, e.g. meal preparation, bathing, grooming

  • Safety awareness

  • Swallowing, eating and drinking

  • Symptom control

  • Work (for patients who are employed at the time of intervention), education and leisure

Care pathway

How we help this group

Background to skills and knowledge

Through the delivery of the HIV, Step-down Homeless, and REBUILD Pathways, our medical, nursing and therapy teams have clinical expertise in the care and management of patients with complex neurological rehabilitation needs with complex co-morbidities and the relevant protocols to deliver the neuro-rehabilitation pathway safely.

A daily programme of one-to-one and group interventions provides meaningful occupation, whilst evidence-based psychosocial input engenders a deeper understanding and improves motivation to rehabilitate.

​

We aim for the programme we offer to be varied, and in addition to health promotion and talking therapy sessions, we provide holistic input such as art therapy, access to gym groups and spiritual support via our multi-denominational chaplaincy team.

​

Individual health and wellbeing needs are assessed and addressed through access to a multi-disciplinary team plus external referrals where necessary to ensure that all patients’ needs continue to be met post-discharge.

Safety is at the forefront of all our care delivery, and we ensure that local and national infection control guidelines are adhered to at all times. Therefore, it is possible that there may be periods when external guidelines may impact the delivery of group sessions; however, if this occurs, we endeavour to increase the delivery of 1:1 care input. Staff to client ratio is proportionately high, affording significant opportunities for planned and unplanned interventions.

​

We determine how well treatments work by looking at the different aspects of our measurement tools. These tools help us see how much someone is getting better, especially in terms of their ability to recover, and we pay special attention to the resources they have that
help them recover. Our rehabilitation work is focused on measurable outcomes, and we provide data to the UK Rehabilitation Outcomes Collective (UKROC). Mildmay is working towards the NHS Patient Safety Incident Response Framework (PSIRF).

 

With a longstanding proven ability to self-monitor our practices and outcomes and utilise qualitative and quantitative data reporting methodology, monthly and quarterly evaluation of outcomes inform commissioners of performance measures.

Managing complex co-morbidities

The people we support are diverse. We have decades of experience caring for patients with advanced HIV infection and its sequelae in terms of the physical complications of the disease and behavioural, psychological and complex psychosocial aspects.

 

Many people we support are from stigmatised communities (LGBTQ+, intravenous drug users, immigrant communities). Most service users within our HIV pathway have advanced HIV disease, and significant numbers are affected with HIV-related brain impairment.

 

Sensitivity to the Equality Act’s 9 protected characteristics, i.e., age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and sex, underpins Mildmay’s core values and the essence of care delivery.

 

Our considerable experience of working with people with a range of chronic or acute mental and physical health needs encompasses, across all our care pathways:

  • cardiovascular disease

  • respiratory illnesses, including COPD

  • hepatobiliary, musculoskeletal, and neurological complications of disease

  • Psychosis, depression, and schizophrenia

  • Korsakoff’s syndrome

  • Pancreatitis

  • Alcohol-related liver disease

  • Malnutrition

  • Drug and alcohol use

  • Learning disability

  • Neurocognitive impairment

Therapies and inputs

Mildmay uses a trauma-informed approach to care, and all patients' needs vary. These are some of the rehabilitation treatments, techniques, social work support and educational programmes used within the team:

  • Self-medicating and managing medicines

  • Pain control

  • Adherence

  • Increasing strength and exercise tolerance

  • Memory work

  • Increasing/maximising mobility

  • Decision-making and planning

  • Cognition work

  • Problem-solving

  • Orientation

  • Managing activities for daily living – washing, dressing etc

  • Healthy living/living well

  • Nutritional awareness and support

  • Using specialist care equipment

  • Cooking safety assessment

  • Finance management, applying for social support, housing and benefits

  • Art therapy

  • Using resources in the community

  • Counselling and emotional support

Mildmay’s Multi-Disciplinary Team

  • Medical Director

  • Art Therapist

  • Chaplain

  • Clinical Lead Nurse and a nursing team of Registered General Nurses and Healthcare Support Workers

  • Dietitian​

  • Junior Doctors

  • Liaison Psychiatrist

  • Occupational Therapist

  • Physiotherapists

  • Psychologist

  • Social Worker and Counsellor

  • Speech and Language Therapist

  • Substance Misuse Recovery Worker

  • Volunteers

Inpatient facilities

  • Twenty-eight ensuite single rooms (including two anti-ligature rooms)

  • Two wards, each with a communal lounge and fitted kitchens for patient use

  • A well-equipped physical rehabilitation centre

  • Occupational therapy assessment centre

  • Specialist therapeutic equipment

  • Laundry facilities

  • Tranquil courtyard garden

  • Chapel

Discharge planning

Discharge planning starts even before admission, coordinated by each patient's designated multidisciplinary key worker.

 

Mildmay has a designated Discharge Co-Ordinator nurse and a Social Work team who liaise with external teams regarding discharge support, e.g. care packages.

 

A final assessment is undertaken prior to discharge, with a care plan completed on departure that includes contact details for all providers involved in the individual’s care and ensures there is no gap.

Download the Neuro 2B Pathway booklet

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