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SE SCN Stroke Rehabilitation in the Community: Commissioning for Improvement

Stroke rehabilitation in the community: commissioning for improvement

Authors

Dr David Hargroves Stroke Clinical Lead

Mark Trickey Quality Improvement Lead

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Contents

1. Introduction and Background……………………………………………………….3

1.1 Introduction

1.2 Rehabilitation and Reablement

1.3 Rehabilitation services in the context of existing national programmes

2. Core Principles and Guidelines…………………………………………………….4

2.1 Core Principles

2.2 Current Guidelines

3. Integrated Community Stroke Rehabilitation: A Model of Delivery…………….6

4. Details of Pathways and Categories of Need for People requiring Stroke

Rehabilitation…………………………………………………………………………7

4.1 British Society of Rehabilitation Medicine Description

4.2 Core Multidisciplinary Team

4.3 Pathways of support description

5. Early Supported Discharge………………………………………………………..10

5.1 ESD and Seven Day Services

6. Standards for Pathways of Need…………………………………………………12

6.1 Staffing - Specialist stroke community rehabilitation MDT workforce

6.2 Other - Data/Audit

Appendix 1………………………………………………………………………………….19

Rehabilitation services in the context of existing national programmes

Appendix 2………………………………………………………………………………….21

Categories of need for people requiring rehabilitation (BSRM)

Appendix 3 …………………………………………………………………………………23

Models of how Early Supported Discharge can be provided

Appendix 4……………………………………………………………………………….…26

National Models

Appendix 5 …………………………………………………………………………………27

Psychology Provision for Community Stroke Services. Review of “Clinical psychology

provision for community stroke services – a proposed model” by Dr Jessica Read

and Dr Victoria Teggart

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1. Introduction and Background

1.1 Introduction

The South East Cardiovascular Clinical Network (SE CVD CN) is committed to working with

stakeholders to gain feedback and develop relevant work programmes in order to ensure

member organisations are appropriately supported to deliver the best possible care and

patient outcomes.

Following the reviews of stroke services across Kent & Medway, Surrey and Sussex,

commissioners have sought to gain a greater understanding of the stroke pathways of care

following discharge from the acute setting. The CN has produced best practice

commissioning guidance to support the stroke review process and has looked extensively at

life after stroke longer term support for stroke survivors.

After further consideration by both the review programme teams and the South East Stroke

Clinical Advisory Group, community based stroke rehabilitation guidance was identified as a

urgent need and a task and finish group was set up in December 2015.

The purpose of the group was:

To review models of community (out of acute hospital) rehabilitation for stroke

survivors, and from this to agree a model which can be utilised for commissioning or

service redesign across the South East

To establish standards of service, care and patient experience from the proposed

South East model

The task and finish group was comprised of patients, carers, clinical commissioning group

members and third sector organisations, as well as a wide range of healthcare professionals

from the rehabilitation therapies, acute and community providers - all of whom were directly

involved in developing and shaping this work. This resulting best practice advice and

suggested pathway model, is aimed at helping commissioners and providers of stroke

rehabilitation to better understand their services and identify where potential gaps may exist

in the provision of community stroke rehabilitation.

1.2 Rehabilitation and Reablement

There are many definitions of rehabilitation and reablement. For the purposes of this

document the working definition adopted by NHS England1 and developed in partnership

with a range of clinical experts will be used.

Rehabilitation: ‘the restoration, to the maximum degree possible, of an individual’s

function and/or role, both mentally and physically, within their family and social networks and

within the workplace where appropriate.’ For example rehabilitation after a stroke may help

the patient walk again and speak clearly again. The word comes from the Latin ‘rehabilitare’

meaning ‘to make fit again’.

1 IMPROVING ADULT REHABILITATION SERVICES IN ENGLAND http://www.nhsiq.nhs.uk/improvement-

programmes/acute-care/recovery,-rehabilitation-and-reablement.aspx

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Reablement ‘is the active process of an individual regaining the skills, confidence and

independence to enable them to do the things for themselves, rather than having things

done for them.” Reablement can be available to people with lower level needs, or who have

had a gradual deterioration. Reablement is relearning the skills necessary for daily living

following illness. Reablement focuses as much on a person’s emotional and social needs as

on their medical needs2.

However, it is recognised that there are many other definitions of rehabilitation and

reablement.

1.3 Rehabilitation services in the context of existing national programmes

An understanding of the role stroke rehabilitation has within local and national priorities will

strengthen the alignment and positioning of stroke rehabilitation within the whole system of

transformational improvement work. Some national priorities, for instance The NHS England

Improving Rehabilitation Services programme (IRS) and 7 day services, may dictate how

certain services are delivered in the future (See Appendix 1).

2. Core Principles and Guidelines

2.1 Core Principles

Community rehabilitation should be a simple, coherent service

that is easy to navigate. This service should have a single

point of entry, no waiting lists and be accessible to all stroke

survivors. It should be designed around the needs and goals

of the individual, so the stroke survivor is assessed by a

specialist stroke multi-disciplinary team who will determine the

best use of the team’s resources3. Community rehabilitation

teams should also assist appropriate stroke survivors to

access vocational rehabilitation.

Those with minor neurological impairments following a stroke

may progress satisfactorily with the support of the local

general rehabilitation services. Most others are likely to benefit

from a referral to their local specialist rehabilitation services. A

small number of patients with highly complex needs require

the staff expertise and facilities of tertiary specialised (Level 1

see below) rehabilitation services. This is out of the scope of

this guidance4.

Patients may require and should have access to follow up reviews5. If performed

systematically for all stroke patients, reviews will facilitate a clear pathway to specialist

2 Reablement a guide for front line staff. Available at www.opm.co.uk/?s=reablement

3 Stroke rehabilitation guide: supporting London commissioners to commission quality services in 2010/11

4 https://www.england.nhs.uk/?s=rehabilitation+commissioning+spec

5 Greater Manchester Lancashire and South Cumbria SCN Integrated Community Stroke Team (ICST) including

Early Supported discharge (ESD) and None ESD rehabilitation provision 2015.

The use of specialist and non-specialist services The National Stroke Strategy states, ’specialist teams may be more important in the early stages of rehabilitation, while generic teams can be appropriate for the later stages. However, the configuration of community teams is less important than ensuring that these teams are multidisciplinary and all staff have the right specialist skills to help rehabilitate people who have had a stroke.’

http://www.opm.co.uk/?s=reablement

https://www.england.nhs.uk/?s=rehabilitation+commissioning+spec

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rehabilitation services, if further intervention is thought to be beneficial. In addition, patients

should be able to make direct contact with specialist stroke services, between reviews, if they

need to, ensuring further access to stroke specialist rehabilitation if the length of rehabilitation

was not sufficient at the time they received it6.

2.2 Current Guidelines

Clear standards exist for stroke rehabilitation, for instance as described by the 'National

stroke strategy'7 and reflected in the NICE quality standards8. There is general agreement

that this rehabilitation approach described by the standards and individual interventions is

effective. How stroke rehabilitation services should be organised is less clear and will depend

on the needs of the individual stroke survivor, resulting in a huge variability in the provision of

services in practice. Following recent work carried out by NHS Improving Quality and Greater

Manchester, Lancashire and South Cumbria Strategic Clinical Networks this document sets

out a needs based delivery model for community stroke rehabilitation (see Appendices 3, 4

and 5). The model detailed below is based on a review of other models nationally and

summarises the interfaces along the stroke pathway with all stakeholders9. The South East

CVD CN has published additional guidance, Six Month Reviews for stroke survivors and

longer term support through Life after Stroke commissioning guidance, and a service

specification for stroke services that incorporates the whole pathway including rehabilitation10.

Clinical psychology provision for community stroke services – a proposed model by Dr

Jessica Read and Dr Victoria Teggart.

The document described in Appendix 5 (“Clinical psychology provision for community stroke

services – a proposed model”) has been reviewed by the South East CVD CN Stroke

Rehabilitation Task and Finish Group. It was agreed that this document described a

"comprehensive embedded model" of clinical psychology into community stroke services

which is required in the South East region.

As an adjunct, it should be reiterated that the precise banding of the clinical psychologist

working into any community stroke service will be decided within a local context, dependent

on the requirements of the post and the skill set necessary to fulfil the role. However, a

clinical psychologist carrying out this specialist role may be expected to have completed, or

at least be working towards, completion of the Division of Neuropsychology Qualification in

Clinical Neuropsychology (or overseas equivalent), thereby demonstrating the required

degree of specialist knowledge and clinical experience required. A clinical psychologist

working within this service would require direct clinical supervision and strategic direction

from a neuropsychologist with this expertise and skill set.

6 Evidence-Based Community Stroke Rehabilitation Marion F. Walker, PhD; Katharina S. Sunnerhagen, MD,

PhD; Rebecca J. Fisher, PhD 7 National Stroke Strategy (Department of Health, 2008)

8 NICE Clinical Guideline 162: Stroke Rehabilitation Long term Rehabilitation after stroke (NICE, 2013)

9 Greater Manchester Lancashire and South Cumbria SCN Integrated Community Stroke Team (ICST) including

Early Supported discharge (ESD) and None ESD rehabilitation provision 2015. 10

Six Month reviews, Life After Stroke commissioning guidance and Stroke Specification http://www.england.nhs.uk/ourwork/part-rel/scn/

http://www.england.nhs.uk/ourwork/part-rel/scn/

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3. Integrated Community Stroke Rehabilitation: A Model of Delivery

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4. Details of Pathways and Categories of Need for People

requiring post Stroke Rehabilitation

4.1 British Society of Rehabilitation Medicine Description

In this document a ‘’pathway of support’’ approach has been used but it is recognised that

many rehabilitation professionals reference the BSRM description of patient need and how

rehabilitation services are currently organised and delivered within the UK11. Not all

professionals working in stroke rehabilitation will be familiar with these descriptions and the

details are referenced in Appendix 2.

4.2 Core Multidisciplinary Team

Clinical Psychologist/ Neuropsychology

Occupational Therapist

Physiotherapist

Speech and Language Therapist

Nurse

Dietician

Social worker

Rehabilitation support workers/assistant practitioner

Access to consultant stroke/GP for med support post discharge

4.3 Pathways of Support Description

Stroke survivors leaving hospital vary in dependency levels therefore pathways of support

mirror the varying complexity of presentations, physically, cognitively, psychologically and

environmentally, taking into consideration family/carer needs and dynamics (holistic

assessment). Analysis from previous work around the country identified the need for

development of four pathways to support differing levels of dependency12. This model is

based on these pathways and delivered by one integrated community stroke team (ICST) or

neurology team. Integrated care takes many different forms and this paper assumes a focus

on health and social care for which a number of models exist1,13.

The percentage of stroke patients eligible for rehabilitation and expected to access each of

the 4 pathways was established following a recent audit of Blackburn Community and Early

Supported Discharge (ESD) services14. This is likely to vary in other regions depending on

the demographics and structure of rehabilitation services. As described, patients will move

between pathways depending on ability and attainment of rehabilitation goals. Below is a

detailed description of the types of presentations within the pathways to enable a greater

understanding of which patients should follow which pathway, with the decision made jointly

between acute staff, the integrated specialist community stroke team ICST, the patient and

family:

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British Society of Rehabilitation Medicine (2010), Levels of specialisation in rehabilitation services Available at: www.bsrm.co.uk/ClinicalGuidance/Levels_of_specialisation_in_rehabilitation_services5.pdf 12

Stroke rehabilitation in the community: commissioning for improvement. (NHS Improvement, 2012) 13

Integrated Care. What is it? Does it work? What does it mean for the NHS? The Kings Fund 2011. 14

Greater Manchester, Lancashire & South Cumbria Strategic Clinical Networks (GMLSC SCN’s)

http://www.bsrm.co.uk/ClinicalGuidance/Levels_of_specialisation_in_rehabilitation_services5.pdf

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Pathway 1: High functioning – discharged home with community stroke team input over 6

days per week or weekend therapy if needed and daily visits by therapists and rehabilitation

support workers as needed. Day hospital outpatient therapy may be offered where

appropriate and available.

Patient presentation:

Able to manage at home following risk assessment

Usually mobile or able to independently transfer with assistance

Able to manage activities of daily living independently, with carer or care package

No cognitive issues which may cause risk at home

Good family support and able to toilet independently or with carer support

No night time issues, able to access toilet independently or with carer

Able to manage activities of daily living independently or with carer with the ICST

providing therapy visits daily as per need and patient wishes

Early supported discharge level of impairment with higher levels of functional ability

Pathway 2: Home with ICST and re ablement service support up to four times a day for six

weeks to enable safe management and rehabilitation at home. Patient may then be stepped

down to pathway 1.


Requires daily reablement support in activities of daily living to remain at home

following programmes set by the ICST

Meets the needs of lower functioning patients who may live alone with reduced family

support but who are able to manage and toilet on their own overnight and in between

visits from carers

The patient may have some cognitive impairment, affecting their ability to engage in

rehabilitation, which is supported in rehabilitation activities of daily living by

reablement support workers. Reablement staff will follow ICST reviewed programmes

to reduce any risk of safety issues for patients

Patients must be able to manage to toilet independently or with carers in between

visits and have no overnight issues

Daily visits reduce as patient becomes more independent and continued

rehabilitation post six weeks reablement support will be as per pathway 1 delivered

by ICST team and support workers on ICST team once independence increased

The patient must be cognitively and physically able to manage with acceptable safety

risks minimised and independent with reablement support daily, with carer or

independently. This flexible working with specialist ICST input into reablement

pathway enables earlier discharge of the more complex patients whilst maintaining

specialist stroke rehabilitation

Can be early supported discharge level but usually more complex and lower level of

functional ability and requiring assistance over 7 days with activities of daily living to

be able to remain at home to receive rehabilitation

Pathway 3: Stepped down from hospital into an intermediate care bed. The patient may be

under the care of a general rehabilitation MDT team but with specialist stroke rehabilitation

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input for a maximum of 6 weeks, the patient is then able to step down to pathway 2 or 1

depending on ability following rehabilitation in the intermediate care unit.


This pathway is for patients who are not at a level to be able to go home for

rehabilitation due to problems physically with transfers, stairs or cognition.

These groups of patients may, as with generic intermediate care patients, live alone

or are not at a level for carers to support them safely in activities of daily living

ICST team in-reach into the intermediate care unit to provide assessment and

treatment plans for the IC unit staff to follow, ICST attend weekly multidisciplinary

team meetings to discuss and manage patients with the IC unit staff or GP

Home visits carried out by the ICST team as part of the stepdown to home process

These groups of patients usually step down to pathway 1 or 2 following discharge

home to support with re-integration in the home environment until goals have been

achieved.

This flexible working with specialist ICST input into the intermediate care units enables

earlier discharge of the more complex patients whilst maintaining specialist stroke

rehabilitation. Additionally more complex patients who are unable to be managed at home

for rehabilitation but have high potential for improvement in activities of daily living and

returning home are catered for.

Pathway 4: Discharged into a residential or nursing home

setting with support from the ICST as per need.

This pathway is for patients who are discharged into

residential/nursing home care to ensure they have

timely access to specialist rehabilitation and

management post discharge.

ICST assess to ensure correct management

and rehabilitation programme as needed to

reduce the risk of re-admission and to deliver

advice/interventions to reduce likelihood of

longer term problems with spasticity,

positioning, swallowing, communication and

transfers

Additionally to ensure care home staff are able

to meet the needs of stroke patient

appropriately.

Following discharge from ICST re-referral and

access back to the ICST if needed to support

the patients’ changing needs i.e. spasticity

management, swallow or mobility issues.

Any patients who are newly admitted to a

nursing home who have the potential to return

home and it’s the patients/family wishes to do

so will be given sufficient rehabilitation by the

Extended Rehabilitation

Some patients, who require 24 hour care, may have the potential to achieve significant functional improvement over a longer period than the six weeks provided by an intermediate care placement. This extended and continued inpatient therapy gives some people more time and opportunity to achieve their goals outside of a nursing home or specialist rehabilitation setting. Given the facility of appropriately skilled staff in an environment with suitable resources e.g.: a gym, tilt table, hoist, standing frames etc., this slower pace will enable them to increase their independence and make sure that they do not lose

the gains they have already made.

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ICST to achieve this goal or test that this is

possible.

Severely impaired patients who need 24 hour care. This pathway includes patients

discharged back to their residency at nursing home who have had a stroke and now

require active rehabilitation with ICST assessment and goals.

For some patients requiring 24 hour care a more extended and lower intensity

programme may be required with the input of appropriately skilled therapy staff and

suitable facilities.

Adopters of this integrated model include: Warrington, Leeds, Northampton, Essex, Hull, North

Lincolnshire, Wandsworth, and Blackburn ICSTs.

Review at 6 Months – All pathways

Any patient with residual impairment after the end of initial rehabilitation should be offered a

formal review at least every 6 months, to consider whether further interventions are

warranted15, and should be referred for specialist assessment if:

new problems, not present when last seen by the specialist service, are now present

the patient’s physical state or social environment has changed

5. Early Supported Discharge

Where effective community rehabilitation teams are in place, Early Supported Discharge

(ESD) services should be offered. ESD services should have appropriate staffing levels to

provide ESD for suitable patients. Services should meet the performance standards for ESD

in community rehabilitation16, where this is appropriate to the needs of the stroke survivor.

The transition into ESD services from the acute setting should be seamless. While initial

assessment of the stroke survivor is carried out by qualified professionals, in order to use the

workforce in the most effective, safe and cost-effective manner, consideration should be

given to which therapies and interventions could be delivered by assistants under the

supervision of qualified professionals17.

ESD enables appropriate stroke survivors to leave hospital early through the provision of

intense rehabilitation in the community at a similar level to the care provided in hospital. An

ESD team of nurses, therapists, doctors and social care staff work collaboratively and with

patients and families, providing intensive rehabilitation at home for up to 6 weeks. This

reduces the risk of re-admission into hospital for stroke related problems and increases

independence and quality of life, with support from the carer and family. Stroke patients,

who do not fit the criteria for ESD, including those stroke survivors who go home or into

nursing or residential homes, also require rehabilitation in a timely manner post discharge18.

15

Re-referral see page 47 of SNAPP post acute audit: https://www.strokeaudit.org/ 16

South Coast SCN Stroke Specification 2015 17

Healthcare for London, 2009 and NICE Practice Based implementation advice 2013 18

NICE Quality Standards: Statement 5. (NICE, 2010)

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There are several models of how ESD can be provided19 with 5 core options for delivery in

the literature (Appendix 3). Options 3 or 4 are seen to have the most benefits for stroke

survivors and are efficient in resource use with one integrated community stroke team (ICST)

providing stroke rehabilitation to all stroke patients leaving hospital and to community based

patients with an identified need for rehabilitation. This will encompass ESD appropriate

patients as well as those not fitting ESD criteria therefore providing an equitable service.

The ICST in these models can be provided by a community stroke service or community

neurological services, which have the knowledge and skills to manage stroke patients (NICE

2013).

Benefits include:

Access for 100% of stroke survivors leaving hospital compared to 40% for ESD

service including nursing and residential care stroke survivors

One team coordinating discharge planning rather than two separate ESD/CST teams

Provision of service is longer i.e. for up to 6 months rather than 6 weeks

Fewer hand-offs for stroke survivors with one service managing the community

rehabilitation pathway from hospital discharge to end of the stroke survivor’s

rehabilitation phase with re-referral back to the team if needed

Flexible approach with the ability to work across reablement and intermediate care

services to provide specialist multidisciplinary stroke rehabilitation

Integration across health and social care services to meet stroke survivors needs on

discharge with a coordinated approach

Effective use of resources and cost effective

In summary, ESD is acknowledged to be an integral part of community stroke rehabilitation

and there is evidence of varying interpretation and understanding of what ESD entails. An

awareness that the different models provide varying levels of rehabilitation provision is

important and selection of a model will depend on local need, funding and resources already

available. Some models may be more equitable and cost effective than others but the key

consideration should be the need and support required rather than the model.

5.1 ESD and Seven Day Services

The drive to deliver NHS services across seven days has increased over the past few years,

with the publication of a number of national guidance documents to support the

implementation of seven day services across England20. Within stroke care, there are a

number of published examples of services that deliver a seven day therapy service within the

hospital and community environments21, as well as studies that have compared a five day

per week stroke rehabilitation programme to a seven day per week stroke rehabilitation

19

http://www.slideshare.net/NHSImprovement/stroke-rehabilitation-in-the-community-commissioning-for-improvement-16337455 20

NHS Improving Quality (2013) NHS services - open seven days a week: every day counts. NHS Improvement (2012) Equality for All: Delivering safe care - seven days a week 21

NHS Improvement (2011). Mind the Gap: Ways to Enhance Therapy Provision in Stroke Rehabilitation.

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programme22. Seven day availability of services has been shown to realise a number of

benefits including:

greater improvements in patients’ functional abilities

reduction in hospital length of stay

reduced backlog of work on a Monday resulting in less staff stress

reduced time from admission to initial therapy assessment, resulting in the earlier

provision of therapy

more opportunities to deliver a greater proportion of therapy23 and Joint working with

social care can increased capacity to support more patients home earlier and reduce

the care package in the longer term24

Further information and support is available from NHS Improving Quality

http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx

6. Standards for Pathways of Need

The following community rehabilitation requirements and service outcomes are set out in the

South East Stroke Service Specification. This aims to achieve a step change improvement in

the quality of stroke and transient ischaemic attack (TIA) services and related outcomes for

patients. The overarching vision for stroke services across the region is to ensure that all

patients who experience a stroke/TIA have access to high quality acute care 24/7 and high

quality life after stroke rehabilitation. This should be as part of a stroke pathway focused on

providing patient and carer centric care, empowerment and facilitation of self-management

leading to meaningful participation in daily life after stroke.

The multidisciplinary team (MDT) staffing requirement is based on the minimum staffing

requirement set out in the SE Stroke Specification and standards which are based on

currently limited nationally mandated and agreed thresholds or quality standards for stroke

rehabilitation services. The Group recommends the following are added to the SE stroke

standards (due for review July 2016).

6.1 Staffing - Specialist stroke community rehabilitation MDT workforce

Clinical Psychology see appendix 5

Core MDT should include a Dietician (WTE to be determined locally)

Dedicated administrative support should be available to enable the team to manage

effectively particularly in teams that have a high volume of referrals to their services

and where it is not viable to use an alternative administrative support function. Many

teams have dedicated systems, processes and mandatory functions including data

input and Royal College of Physicians (RCP) Sentinel Stroke National Audit

22

Rapoport J and Judd-Van Eerd M (1989). Impact of Physical Therapy Weekend Coverage on Length of Stay in an Acute Care Community Hospital. Physical Therapy, 6932-6937. 23

http://www.londonscn.nhs.uk/publication/weekend-stroke-therapy-commissioning-guidance/ 24

Stroke rehabilitation in the community: commissioning for improvement Jill Lockhart - NHS IQ, Tracy Walker – Lancashire Care NHS Foundation Trust

http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx

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Programme (SSNAP) returns which need to be maintained by staff who understand

these systems.

A stroke co-coordinator role should be established. This could be allocated or shared

across the core MDT but should be a clinically based role

6.2 Other - Data/Audit

Commissioners/Providers of rehabilitation services should agree on standard sets of data

that should be collected and recorded routinely including the data required for the RCP

SSNAP.

There should be a protocol agreed with the acute trust(s) on the transfer of patient records

to the ICST on the SSNAP system to ensure compliance with the audit.

All patients’ outcomes are entered onto the SSNAP database and locked to transfer at the

appropriate SSNAP deadlines for quarterly reporting.

An annual report is collated presenting the outcomes of the service in terms of service

delivery, patient’s outcomes and satisfaction with action plans for service improvement.

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Appendix 1

Rehabilitation Services in the context of existing National Programmes

7 Day Services

Everyone Counts: Planning for patients 2013/14 committed the NHS to move towards

routine services being available seven days a week. Stroke is a 24 hour condition and

therefore requires a 24 hour pathway with supporting services and processes to deliver it,

seven days a week. It is what patients want, even if they are not able to use it every day.

Services that operate only across five days can, at times, create a backlog for patients and

deliver inequality of care. Research, national clinical guidelines and the National Stroke

Strategy agree that stroke rehabilitation delivered at the right time, by the right people and in

sufficient quantities makes a difference.

NHS England Improving Rehabilitation Services programme (IRS) Expectations of

Rehabilitation Services

Nationally, expectations of good rehabilitation services have been developed by NHS

England through patient and stakeholder engagement:

1. I have knowledge of, and access to, joined up rehabilitation services that are reliable,

personalised and consistent.

2. My rehabilitation will focus on all my needs and will support me to return to my roles and

responsibilities, where possible - including work.

3. My rehabilitation experience and outcomes are improved by being considered by

everyone involved with my health and wellbeing working in partnership with me.

4. My rehabilitation supports me and gives me confidence to self-care and self-manage,

making best use of developing technologies and stops me being admitted to hospital

unnecessarily.

5. The goals of my rehabilitation are clear, meaningful and measured and there is

recognition that my goals may change throughout my life.

6. My rehabilitation supports me in my aspirations and goals to reach my potential.

7. I can refer myself to services easily when I need to and as my needs change.

8. There is a single point of contact available to me where there is the knowledge and skills

to help me.

9. People who are important to me are recognised and supported during my rehabilitation.

10. I am provided with information on my progress as I need it and information is shared,

with my consent, with those who I agree are involved in my rehabilitation.

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Also, the following principles of good rehabilitation services have been defined at a national

level:

1. Optimise physical, mental and social wellbeing and have a close working partnership with

people to support their needs.

2. Recognise people and those who are important to them, including carers, as a critical part

of the interdisciplinary team.

3. Instil hope, support ambition and balance risk to maximise outcome and independence.

4. Use an individualised, goal-based approach, informed by evidence and best practice

which focuses on people’s role in society.

5. Require early and ongoing assessment and identification of rehabilitation needs to support

timely planning and interventions to improve outcomes and ensure seamless transition.

6. Support self-management through education and information to maintain health and

wellbeing to achieve maximum potential.

7. Make use of a wide variety of new and established interventions to improve outcomes e.g.

exercise, technology, Cognitive Behavioural Therapy.

8. Deliver efficient and effective rehabilitation using integrated multi-agency pathways

including, where appropriate, seven days a week.

9. Have strong leadership and accountability at all levels - with effective communication.

10. Share good practice, collect data and contribute to the evidence base by undertaking

evaluation/audit/research.

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Appendix 2

Categories of Need for People requiring Rehabilitation (BSRM)

Within each locality (Level 3) Local non-specialist rehabilitation services, which include generic rehabilitation for a wide range of conditions, provided in acute, intermediate care and community facilities or other specialist services (e.g. stroke units). These include: • Level 3a services: Other specialist services led or supported by consultants in specialties other than rehabilitation medicine - e.g. services catering for patient in specific diagnostic groups (e.g. stroke) with Category C needs; therapy / nursing teams have specialist expertise in the target condition • Level 3b services: Generic rehabilitation for a wide range of conditions, often led by nonmedical staff, provided in acute, intermediate care and community facilities, for patients with Category D needs. Local (district) specialist rehabilitation services (Level 2) Led or supported by a consultant trained and accredited in rehabilitation medicine, working both in a hospital and community setting. The specialist multi-disciplinary rehabilitation team provides advice and support for local general rehabilitation teams. These include: • Level 2a services: Led by consultant in rehabilitation medicine serving an extended local population of 600,000 to 1 million people, mainly for those areas which have poor access to level 1 services. Level 2a services take patients with a range of complexity, including Category B and some Category A with highly complex rehabilitation needs. • Level 2b services: Led or supported by a consultant in rehabilitation medicine, these services predominantly provide for patients with Category B needs, and tend to cover a population of 250,000 to 500,000. Tertiary specialised rehabilitation services (Level 1) High cost/ low volume services provided for patients with highly complex rehabilitation needs that is beyond the scope of their local and district specialist services. These are normally provided in coordinated service networks planned over a regional population of 1-3 million through collaborative (specialised) commissioning arrangements. O

U

T OF

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Where patients receive their rehabilitation depends on their identified and assessed level of need. As outlined by the British Society of Rehabilitation Medicine (BSRM), there are four identified categories of need in relation to rehabilitation. These are:

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25

British Society of Rehabilitation Medicine (2010), Levels of specialisation in rehabilitation services Available at: www.bsrm.co.uk/ClinicalGuidance/Levels_of_specialisation_in_rehabilitation_services5.pdf

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Appendix 3 Models of how ESD can be provided

Option 1 Stand-alone ESD

Option 2 ESD with CST/ CNRT

Option 3 Integrated ESD within CST

Option 4 Integrated ESD with CNRT

Option 5 ESD hybrid

Timeframe of rehabilitation

Usually six weeks Typically six weeks ESD then referral on to the community stroke, or neurology team for continued rehabilitation of approximately three months

Typically goal directed approach, so available for as long as required (range three months to one year)

Typically adopt a goal directed approach, so the services are available for as long as required (range three months to one year)

Usually time limited (range six weeks to 12 weeks)

Proportion of patients who fit criteria

Up to 40% Up to 100% of rehabilitation patients

Up to 100% Up to 100% of patients Varies depending on individual criteria but usually there are higher percentages of patients than traditional ESD models, but lower than 100%

Number of pathways from acute provider to home

Two – ESD and non ESD Two – ESD and non ESD One pathway for all patients, through a coordinated discharge/rehabilitation process led by the team

One pathway for all patients; coordinated discharge/rehabilitation via the team

Two pathways, ESD and non ESD pathway

Stroke dependency level catered for

Mild to moderate dependency levels

All dependency levels catered for, mild to complex severe

All dependency levels, from mild to complex severe

All dependency levels of stroke patients mild – complex severe, and neurological patients

All dependency levels of stroke patients mild to complex severe

Potential patient wait

•Yes – to access the service, if the team does not contain a dedicated social worker there may be waits for care package/enablement • Yes - potential waits between cessation of ESD and access to generic rehabilitation depending on capacity of generic services

•Yes – potentially to access the service, if the team does not contain a dedicated social worker there may be waits for care package/enablement to access either component from acute care • Yes - potentially between ESD and follow on rehabilitation depending on the capacity of stroke and neurology community teams

•Usually no wait and immediate access to supported discharge/rehabilitation. •Typically these services coordinate and lead the transfer from hospital to home

•Usually no wait and immediate access to supported discharge/rehabilitation. •Typically these services coordinate and lead the transfer from hospital to home • Where the team does not include a dedicated social worker, there may be delays accessing service from acute care awaiting packages/enablement support • There is an example of wait of up to three weeks for non ESD patients within this group

•Yes, potentially a wait for the non ESD patients who do not fit the criteria • Yes, potentially a wait for follow on rehabilitation depending on the capacity of follow on rehabilitation teams in intermediate care services

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Groups of stroke patients unable to access service

• Complex/ severe dependency cohorts of patients • Care home based patients • Community based patients who have not been admitted to acute care first (declined)

Usually all groups of patients can access rehabilitation via the ESD and non ESD pathways including ESD/Non ESD from acute care, care home and community based locations

All groups of patients can access timely rehabilitation including, ESD/non ESD from acute care, care homes, and community-based patients

All groups of patients can access the service including, ESD/non ESD from acute care, residential care and community based locations

Patients who do not meet the criteria • Community-based patients who have not been admitted to acute care

Additional support infrastructure that may be needed

• Follow on access to a community stroke/neuro/ generic team for continued rehabilitation • Community stroke/neuro/generic team for patients who do not meet the criteria • Social care enablement/care packages: seven day patient support to enable early discharge and intensive daily rehabilitation

Social care enablement/care packages providing seven day patient support to enable early discharge and intensive daily rehabilitation

Social care enablement/Health domiciliary rehabilitation support staff: Seven day patient support to enable early discharge and intensive daily rehabilitation

Social care enablement/Health domiciliary rehab support staff, or seven day patient support to enable early discharge and intensive daily rehabilitation

Social care enablement/health domiciliary rehabilitation support staff, to provide seven day patient visits to enable early discharge and intensive daily rehabilitation • Follow on support from community stroke/neurology teams or generic rehabilitation teams

Stroke skilled management for whole rehabilitation pathway

No - only for duration of service ( two to six weeks) with referral onto generic services

No - only for the length of the service (typically six weeks – three months). Further referral can be made onto generic services

Multidisciplinary stroke skilled therapy for whole pathway, including staff from intermediate and social care

Yes - multidisciplinary stroke skilled therapy for whole pathway

Usually time limited for as long as the service is provided. This may cease on transfer into the community, depending on other local services’ availability for example, community stroke/neurology or generic intermediate care services

Cost per patient *

Between £2,580 and £1,132 Between £1,157 and £1,868.95

Between £1,336 and £2,502 £770 £5,162

* As at 2013

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Summary of ESD Models

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Appendix 4

National Models

Detail of all national models is available on the Clinical Networks website.

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Appendix 5

Psychology Provision for Community Stroke Services. Review of “Clinical

psychology provision for community stroke services – a proposed model” by

Dr Jessica Read and Dr Victoria Teggart.

This document has been reviewed by the South East Cardiovascular Disease Strategic

Clinical Networks Stroke Rehabilitation Task and Finish Group. As part of this group it was

decided that this document described a "comprehensive embedded model" of clinical

psychology into community stroke services which was required in the South East region.

As an adjunct, it should be reiterated that the precise banding of the clinical psychologist

working into any community stroke service will be decided within a local context dependent

on the requirements of the post and the skill set necessary to fulfil the role. However, a

clinical psychologist carrying out this specialist role may be expected to have completed, or

at least be working towards, completion of the Division of Neuropsychology Qualification in

Clinical Neuropsychology (or overseas equivalent), thereby demonstrating the required

degree of specialist knowledge and clinical experience required. A clinical psychologist

working within this service would require direct clinical supervision and strategic direction

from a neuropsychologist with this expertise and skill set.”

Full paper is available on the Clinical Networks website.

Version History

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Version Author Sent to Comments

V1 Mark Trickey based on Greater Manchester and NHS IQ work

Nicky Jonas, David Hargroves

Amended introduction

V2 Jackie Huddleston Comments and amendments incorporated

V3 Task and Finish Group

Incorporated 7 day services

V4 Mark Trickey, Nicky Jonas, Aimee Hayter

Task and Finish Group

Incorporating comments made at and following the task and finish group meeting. The agreed Psychology paper with SECSCN adjunct is embedded

V5 As above CAG Further work on pathway More detailed change history circulated

V6 Proof Read David Hargroves, Jackie Huddleston

11/03/2016 Awaiting diagram from CSU

stroke rehabilitation in the community: commissioning · pdf filese scn stroke rehabilitation...

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