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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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SE SCN Stroke Rehabilitation in the Community: Commissioning for Improvement
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.’
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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/
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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:
11
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)
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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.
Patient presentation:
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.
Patient presentation:
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
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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:
25
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