Beyond the Bathboard:Work and Community Participation after Stroke
Yashashree BedekarOccupational Therapist, Vocational Rehabilitation
Tower Hamlets [email protected]
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??