Beyond the Bathboard:Work and Community Participation after Stroke

Yashashree BedekarOccupational Therapist, Vocational Rehabilitation

Tower Hamlets PCTYashashree.bedekar@thpct.nhs.uk

0208 223 8841

‘What are your goals?’

Go shopping with my daughter

Play cards Use my hair

straighteners Go on e-bay Run a marathon Go back to work

Context of stroke

25% strokes in those under 65 years

Most disabling condition with consequences in health, social services and benefits sectors

£1.8 billion in lost productivity and disability

Top three unmet needs reported by young people after stroke: provision of information; financial assistance and lack of intellectual fulfilment

(The Stroke Association, Kersten et al)

Work- definitions

Employment: paid work in a formal setting

Work: a range of purposeful activities, which may or may not be paid Volunteering Study Extended ADLs Participation in community life

Work matters

Quality of life and work Links between worklessness and poorer

health Representation of people with disabilities in

workforce DDA Incapacity benefits and mortality

What is Vocational Rehabilitation? “A process to overcome the barriers an individual

faces when accessing, remaining or returning to work following injury, illness or impairment” which includes: The procedures in place to support the sick individual

and/or employer or others (e.g. family and carers), Help to access vocational rehabilitation Help to practically manage the delivery of vocational

rehabilitation(DWP, 2004, p 14).

Vocational Rehabilitation for stroke Close interplay of:

Core stroke rehabilitation- MDT working Rehabilitation for work: retraining of skills,

adaptation to disability, task analysis, workplace assessment

Knowledge and application of employment law/DDA

Knowledge and application of benefits system Interlinked with family/carer needs

Key Documents: User views Different Strokes ‘Work After Stroke’ (2002)

74.8% respondents wished to return to work after stroke 42% were able to return to work

Barriers for return to work included: Lack of access to specialist staff Pessimistic attitude of healthcare professionals Rehabilitation goals aimed at minimal function Insufficient scope or duration of rehabilitation

Enablers for return to work included: Support and advice re: their condition and employment Liaison between rehabilitation professionals and employers Occupational therapists

Key Documents: Pensions and Health Working for a healthier tomorrow: Black,

2008

Vocational Rehabilitation Inter-agency Guidelines: BSRM/RCP/DWP, 2004

National Clinical Guidelines for Stroke, 2008

National Stroke Strategy, 2008

Putting guidance to practice: NCGS 6.49.1 Recommendations A Every person should be asked about the vocational activities they undertook

before the stroke.

B Patients who wish to return to work (paid or unpaid employment) should:• have their work requirements established with their employer (provided the patient agrees)• be assessed cognitively, linguistically and practically to establish their potential• be advised on the most suitable time and way to return to work, if this is practical• be referred to a specialist in employment for people with disability if extra assistance or advice is needed (a disability employment advisor, in England).

C Patients who wish to return to or take up a leisure activity should have their cognitive and practical skills assessed, and should be given advice and help in pursuing their activity if appropriate.

Practical application

1: Part of rehabilitation pathway NCGS- early identification of work issues Occupational therapy core remit MDT involvement in assessment process

Case Study: Elaine

Putting guidance to practice: National Stroke Strategy Commissioners will want to consider engaging a

wide range of provision, including provision from the third sector, to meet the needs of the local population. Services should also be appropriate for all ages; one quarter of people who have a stroke are under 65 and may have particular needs.

In 6 months post discharge, 50% receive the rehab they need… at 12 months 20% receive this.

Practical application

2: Intensity of core rehabilitation by appropriate professionals, and long-term support BSRM/NCGS/Stroke Strategy

Case study: Abdul Seen by specialist community team following

discharge (OT, SLT, Psych) Local community centre for resources

Putting guidance to practice: An Inter-agency Framework

Health team: Stroke rehab specialists

Voluntary/non-statutory sectorWork team: DEA etc

Practical application

3: Interagency links with DWP, non-statutory organisations Stroke Strategy, Inter-agency guidelines

Case Study: Carl Seen by community stroke team In-reach and follow-up by specialist voc rehab OT Referred to local disability gym- physio

involvement

Meeting long-term needs

Timeliness of intervention Intensive rehabilitation as well as long-term

adaptation Sharing of information across agencies

Understanding of stroke and consequences Employers, families, social settings…

Routes ‘back in’ for review and top-up input Retention of roles- not just acquisition Opportunity for 3rd sector partnership working

Vocational Rehabilitation models Specialist Vocational Rehabilitation Programs Stroke Pathway Teams with extended rehabilitation Local/ regional centre for long-term support- health

and voluntary sectors

Inclusion into mainstream healthcare: Intensive, specialist MDT stroke rehabilitation in the

pathway Specialist vocational rehabilitation staff (OT, psych) Extended therapy input for meeting participation goals Links with DWP/voluntary sector for long-term needs

Example of Stroke VR: THPCT Specialist vocational rehabilitation for stroke and

neurology client groups 1 WTE OT, 8a 1 WTE TA, 4 Sessional neuropsychology Based with stroke and neuro teams Inreach/outreach at acute, inpatient and community Developing partnerships with local voluntary group

organisations: Volunteer centre, Tower Project etc Promoting and developing voc rehab skills across relevant

teams

Measurement tools/outcomes

LTC working group/HfL: standards for vocational rehabilitation- in progress

LTC/BSRM: Implementation guidelines for vocational rehabilitation for people with long term neurological conditions- in progress

Audit of casenotes- RCP/NCGS Hierarchy of work outcomes Retention of outcomes: 12, 24 months

The bottom line:

Vocational rehabilitation should be part of mainstream healthcare for stroke

Assessment and treatment of work issues begin at inpatient level: OT/psychology staffing levels to support this

Consider links with voluntary organisations for long-term social participation needs

There will be auditable standards for VR interventions

What are our goals??