Governing Body Meeting in Public

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1 Agenda Item No: 6.3 Date of Meeting: 27 th March 2014 Governing Body Meeting in Public Paper Title: Update from the Planned Care Programme Board Decision Discussion Information Follow up from last meeting Report author: Report signed off by: Purpose of the paper: Nicky Poulain Associate Director of Commissioning John Webster Director of Commissioning (i) To seek ratification and support from the Governing Body to approve the investment to implement an Early Supported Discharge service for Stroke (ii) To provide an update on progress being progressed by the Planned Care Programme Board Conflicts of Interest involved: None Recommendations to the Board / Committee To support the proposed Early supported Care Pathway for stroke as a 1 year pilot. To note the progress to date of the PCPB s work streams.

2 Update from the Planned Care Programme Board Meeting Date 27 th March Purpose of the Paper 1.1 To present the rational for piloting an Early Supported Discharge service and to provide an update to the Governing Body on the progress achieved within the Planned Care Programme Board 2 Appendices Appendix 1 Early Supported Discharge Business case Appendix 2 Clarification of investment/ costs Appendix 3 Specification for Early Supported Discharge Appendix 3a Patient pathway Appendix 3b Patient flow chart Appendix 4 Meeting notes/actions, 19/12/13, 09/01/14, 26/02/14 3 Terms / Acronyms Used in the Report this section is mandatory as papers are made available to the general public Initials ESD PCPB RCT MOM FLO HF LM LTC In full Early Supported Discharge Planned Care Programme Board Randomised Controlled Trials Map of Medicine Florence texting Heart failure Locality Managers Long term conditions 4 Early Supported Discharge for Stroke ESD is evidence based care providing early supported discharge home for stroke patients who are able to transfer independently or with assistance of one person. ESD is a specialist stroke service and consists of the same intensity and skill mix as available in a hospital (National clinical guidelines for stroke 2012). It should be available to patients who are able to transfer from bed to chair independently or with assistance, provided a safe and secure environment can be provided (NICE stroke rehabilitation 2013). Approximately 40% of all stroke patients would benefit from ESD. The business case for ESD (appendix1) was scrutinised and supported in principle by the PCPB on 19 th December with a further review of cost analysis and impact assessment on 9 th January to clarify the additional investment required (appendix 2). The PCPB then developed and agreed a service specification on 26 th February (appendix 3). The additional investment required is approximately 621k and appendix 2 shows that improvements in the pathway will result in a saving of 110k in Acute Services arising from reduced excess bed days and readmissions post 30 days. A key element of the business case (appendix 1) was assessing the current status of

3 commissioned services to accurately estimate the addition investment required. The summary of the additional investment required is: 1) Upgrade 5 beds at Danesbury 136k 2) Upgrade therapies at HEM/QVM 83k 3) Early support discharge team 511k Therefore, overall investment will require 730k. The PCPB recognise the existing local service deficiencies and gaps compared to national guidelines and are working in partnership with the county council as we believe that joint health and social care commissioned arrangements for an integrated ESD stroke service will offer most efficiency and provide the best outcomes to our patients. The PCPB invited Dr Tony Rudd, National Clinical Director for Stroke, to attend a meeting on 10 th March 2014, to support our work. He shared the findings from eleven RCT and his key messages were: 40% of selected stroke patients returned home earlier Patient s far more likely to be independent and living at home Greater patient and satisfaction with the service, less isolation No adverse effect on the mood of patients or carers Benefits seen with co-ordinated teams and recruitment of mild and moderate stroke 4.1 Longer term vision for stroke care At the December meeting, the PCPB endorsed a lead provider model for stroke care as a long term aim, whereby a lead provider would be accountable for the entire care pathway, i.e. from admission to a HASU until the six month post review check. This option requires considerable work, to unpick PBR tariff costs and to market test the model. Piloting the ESD service will be a useful step in assessing if a lead provider model would support the desired commissioning outcomes for stroke care. 4.2 Partnership working with social services The proposal for jointly commissioning ESD has been agreed in principle by the Health and Community Services Management Board. A fully integrated ESD team linked with specialist enablement roles is the preferred model. ESD Stroke services have already been identified as a potential area of inclusion in the Better Care Fund. 4.3 Next steps The governing body are to: Endorse the recommendations of the PBPB to invest in an ESD service Support the proposal to jointly commission the services with HCC Provide a steer on the longer term option of a lead provider for stroke service

4 5 Progress and achievements to date 5.1 Heart Failure Pathway Integrated care pathway for HF agreed in February and being piloted in Welhat locality for a six month period. The implementation of the pathway has required upskilling of primary and community staff and revisions to current referral and discharge processes. The intention is to roll out the new pathway, using lessons learnt in Welhat. 5.2 Improving the quality of End of Life care Dr Anita Ray Chowdhury, GP commissioning lead for EOL care, recruited on 28 th February. Options for establishing an EOL register have been considered by the PBCP and a recommendation made to use the ADASTRA platform. The EOL quality indicators within the CCG s commissioning framework have been clarified further and the outcomes of post audit deaths and ACPs will help inform revisions to existing care pathways. This work stream will facilitate practices/localities to inform changes to local commissioned care pathways. 5.3 Map of Medicine Implementation plan in progress and overseen by Esme Walsh. Currently all localities are being asked to identify a couple of GP champions per locality. The GP champion role will be funded to undertake the training and train neighbouring practices. This model of train the trainer is most effective in getting all GPs confident and competent to use the MOM system. 5.4 Diabetes Service Review Comprehensive consultation with all member practices completed. As a result a revised service specification has been produced and will be implemented via the CCG contracting team. Practice referrals for diabetes education have lacked inclusion of contact numbers and the providers are experiencing difficulty in contacting patients. Urgent communication has been cascaded via LTC leads and LMs. 5.5 Enhanced Recovery Programme proposal (appendix 4) A paper was supported by the PBCP and members will be asked to discuss this at the next CCG business meeting. 5.6 FLO (supporting patients to self-manage and adhere to health advise) The business case was approved by the PCPB in February. This enabling tool was launched at the March TARGET meeting in LLV locality. Other localities are invited to access this opportunity. 5.7 COPD/Integrated Respiratory Pathway The PCBP received the proposed model of care for the integrated respiratory care pathway work. There are challenges in clarifying current community services especially oxygen services, however, there is contract management support in place. The LTC leads continue to be the conduit of communication to localities. 5.8 Geriatric Interface Metrics agreed and ENHT informed to advertise the role. This project will closely align with the proposed care home project, the SAFER work programme and with the intermediate service review. The respective Associate Directors are working collaboratively to align the work streams.

5 5.9 Commissioning Framework 14/15 A finalised draft will be proposed at the next PCPB on 20 th March The PCPB held a development day on 13 th March to review the progress of the PCPB that was facilitated by the self-assessment tool. The top four objectives for 14/15 were agreed as improving patient outcomes for stroke, respiratory, EOL and cancer. 6 Risks and Mitigating Actions 6.1 Elective treatment thresholds was highlighted as a risk in the last report and the QIPP target will not be reached. The PCPB continue to request that GP chairs discuss practice variation in elective treatments with members. This matter requires wider discussion with GP board members. 7 Conclusion 7.1 The PCPB has a number of interdependent work streams across all four programme boards. The importance of effective communication must be highlighted to ensure member practices are aware of initiatives and their developments.

6 The Stroke Pathway Impact Assessment Option 1 : Specialist Integrated Service Pathway Utilising Current Resources Current Future Cost Cost Difference '000 '000 '000 Secondary acute care Acute care 3,319 3,209 (110) Reduced excess bed days and readmissions post 30 days potential to unbundle tariff Community care 10 community stroke beds, 5 upgraded IC beds 1,376 1, Cost to upgrade 5 beds at Danesbury ( 136k) and upgrade therapies at HEH/QVM ( 83k) Community outpatients Early supported discharge team embedded Total cost 5,272 5,

7 East and North Herts CCG Business Case Business Case The Stroke Pathway CCG Contact Gillian Catchpole and Rachel Joyce Date 13 th December 2013 Questions: Does the Planned Programme Board 1. Confirm agreement to the proposed stroke pathway? 2. Agree a lead provider model for specialist stroke service provision? 3. Intend to invest, as a transitional phase, in a new Stroke Early Supported Discharge plus the additional staff costs for community beds to meet stroke standards? (Recognising the procurement process will be in excess of 12 months.) 4. Recognise the need to undertake market testing for potential providers as recommended by the CCG s procurement hub? 5. Have a view of timescales and potential completion for commencing the new commissioning arrangements? 1

8 Introduction Incidence of stroke in the UK is between 174 and 216 per 100,000 (Mant et al 2004).Incidence in Hertfordshire is below national average, the 2012/13 East and North Herts CCG,HRG data indicates 692 new strokes with a 3 year average of 581 stroke survivors per annum. The aim of the Planned Programme Board is to ensure that people, who survive a stroke in East & North Herts, will receive optimal and equitable stroke care, regardless of location or provider. In-order to maximize this potential outline approval was given by the board for Commissioning of a specialist stroke pathway through a lead provider model Potential investment in community stroke services. This paper further defines the specialist stroke pathway from admission to hyper-acute care to 6 month reviews, identifies principal gaps in service requiring investment and seeks approval for changes in commissioning arrangements. The Midlands and East Stroke Review established a whole stroke pathway specification aimed at improving clinical outcomes. The model of change for East and North Herts Clinical Commissioning Group (CCG) is proposed in-order to improve clinical outcomes for all stroke survivors, regardless of severity reduce longer term dependency and maximize potential for independence provide care closer to home through improved access to stroke specialist care in the community improve patient and carer experience This invest to save proposal will facilitate: meeting stroke quality standards and guidelines 1 improved local traffic light and Stroke Sentinel National Audit Programme (SSNAP) performance improved service flows, reduced potential for blocked beds and improved transfers of care integrated working between health, social care, the third and the voluntary sector The Stroke Pathway Stroke is the third largest cause of death in the United Kingdom. Although approximately 30% will be independent by week 3, a third are left with long term disability 2, the effects of which can include aphasia, physical disability, loss of cognitive skills and depression. There is robust evidence that the clinical outcomes for stroke survivors are improved by organised and specialist stroke services working in partnership with existing community services. NICE Stroke: Longer Term Rehabilitation Guidance C162 (2013) recognises: All interventions should take place in the context of a comprehensive stroke pathway which recognises that early management, while critical, is a component of a process which aims to ameliorate the long term consequences of living with stroke for individuals and their families and to enable them to live at home, able to participate in as many activities as they are able. This paper addresses specialist stroke care from admission to acute care through to the 6 month review and includes: The Acute Phase Hyper Acute Stroke Unit (HASU) Care (0-3 Days) Acute Stroke Unit (ASU)Care Average Day (3-8+), includes early inpatient rehabilitation and 6 week out-patient review 1 NICE Quality Standards QS2 Stroke Issued: June 2010 NICE Clinical Guidelines for Stroke C68 & NICE Clinical Guidelines for Stroke162: Longer Tern Rehabilitation 2

9 The Community Rehabilitation Phase: The Longer Term Support Phase: TIA services(need to agree and include in costs) Community In-patient Rehabilitation ( up to 42 days) with some extended stays Early Supported Discharge(ESD) (up to 6 weeks daily, intensive intervention from each of the required therapies for those with mild-moderate disability, Suitable for 40% of all in-patient discharges) & Community Specialist Rehabilitation 6 month Holistic Reviews to address unmet need Self -Management and Vocational Rehabilitation& Information, Advice and Support Background Stroke is the highest cause of adult disability and the third highest cause of mortality in the UK, costing the NHS over 3 billion a year in direct care costs. Outcomes from benchmarking undertaken by the Care Quality Commission (2011), the National Sentinel Audit Programme and the Midlands and East Stroke Review, indicate the potential for improvement in clinical outcomes for local people through improved stroke services. Current health care costs of stroke care to East and North Herts CCG are estimated at 5,272,000. HCT have been requested to identify current stroke spend in order to establish robust stroke costs. 1. Current Services In East and North Herts CCG for 2012/13 (Appendix 1: Copy of ENCCG Summary by HRG.; Appendix 2: Summary of Current Stroke Services; Appendix 3: Current Scoped Stroke Pathway) Acute Care Stroke Admissions: 692 Stroke Survivors: 579 (3 year average of 581) Average Length of Stay: Hyper-Acute/Acute: up to 14days (HRG) i Community In-patient: 43 days (HCT Year to Date July 2013) 30 Day Mortality: 15.6% (CCG Q1&2 2013/14 3 ) (London average 12%; National Average 17% 4 ) Stroke mimics presentation in Beds and Herts 1:1 in comparison to a national average of 40% 5. Acute Stroke Beds: HASU: Lister: 5; PAH: 4 ASU: Lister: 21(increasing to 26);PAH 11 There are currently two principal pathways via Lister Hospital (62% of discharges and PAH (24% of discharges. 6 weeks reviews are undertaken in secondary care. PAH offer a 6 week, 6month and annual followup Lister a 6 week follow up only Community Care: Specific Community stroke rehabilitation has not been commissioned and has evolved as part of Hertfordshire Community Trust (HCT) and Hertfordshire County Council (HCC) services. Psychological Services are embedded in Neurological but not Integrated Care Services HCT Stroke Inpatient Activity: Equivalent to 5/6 Neuro-rehabilitation Beds and 10 ICT beds,small numbers are referred to Quantum Beds ICT Bed based services do not consistently deliver required 5x45 mins of stroke specialist rehabilitation per week There is no consultant cover in Neuro-rehabilitation services HCT operate a 72 hour response service for patients referred directly from acute care. Patients referred via alternative routes are subject to 18 week waiting lists HCT Neurological Service provides specialist clinics in line with stroke recommendations, such as Spasticity Clinics, Splinting and Functional Electrical Stimulation Enablement services are reporting increased numbers of referrals with stroke. The teams are not stroke specialist/skilled. There are no commissioned Stroke Early Supported Discharge Service or intensive intervention packages as recommended as part of the stroke pathway Longer-term Care (3-6 months post stroke) 3 Acute Provider Network Database: SSNAP Upload managed by CSU 4 National Sentinel Stroke Clinical Audit 2010Public Report for England, Wales and Northern Ireland Intercollegiate Stroke Working Party Published May 2012 page 48 5 Cap Gemini: East of England Data Modelling Stroke Service Reconfiguration model outputs and analysis v1.0 January

10 6 month reviews are required as part of the NHS Outcomes Framework. There are currently no 6 month specialist stroke holistic reviews being commissioned. 2. Current Estimated Stroke Pathway Costs The current cost of the confirmed stroke pathway is set out in Table 1 below. Volume Cost Comments '000 Secondary acute care Acute tarriff incl best practice 579 spells 2,960.8 Based on 12/13 activity and 12/13 tariff deflated to 13/14 + Excess bed days 574 days Based on 12/13 activity and 12/13 tariff deflated to 13/15 +Post 30 day preventable readmissions 151 spells week outpatient reviews 550 op atts Total acute care 3,318.6 Community care Community beds - neuro 42 spells }Based on 12/13 spells & length of stay; 13/14 Community beds - intermediate care 64 spells } contract cost per bed day Community outpatients - neuro 880 sessions } Estimated physio, OT and SLT costs + psychologist 50k Community outpatients - intermediate care 1260 sessions } plus 20% overheads Total Community Care 1,953.9 Total cost Current Service 5,272 This excludes TIA costs and equipment costs. HCT community activity calculations have been estimated based on known new stroke activity. HCT do not collect stroke specific data Key issues The potential for maximizing clinical outcomes, improving patient and carer experiencing and reducing long term costs are not being fully realised a) Principal Gaps in Health Service - Whole pathway Coordination - Stroke Early Supported Discharge and Intensive Specialist Community Rehabilitation - 6 month Reviews - 7 day working - Clinical Psychology in acute care b) Challenge to meet stroke quality and performance standards - Insufficient acute stroke and stroke rehabilitation beds within the system based on current length of stay resulting in bed blocks - No specialist resources focussed on the early discharge of moderate to high functioning patients reducing patient flows and outcomes - Lack of collaborative working and shared performance targets - Limited access to specialist community rehabilitation and psychological services in acute care Rationale for Case In-order to address issues with the current stroke pathway, maximize clinical outcomes and operational efficiency, there is a need to address principal gaps in service, primarily but not exclusively ESD. 1. Drivers/rationale and need for change a) Failure of current providers to work collaboratively to maximize resources The proposals provide a framework for integrated working between acute and community services. The current service configuration, in which providers work independently and to separate specifications can result in an inconsistent and fragmented service which does not maximize resources. This is supported by local feedback from patient, carers and stakeholders. Commissioning a stroke specialist pathway would ensure accountability for and joined up working across the first 6 months, the period in which outcomes can be optimized b) Need to improve access to and performance of HASU and ASU The quicker a patient receives treatment, the better their chance of survival and recovery. The HASU has 4

11 the potential to improve patient outcomes significantly. To achieve this, patients should be assessed and treated within 4 hours of admission, with discharge to an appropriate ASU/Home within 72 hours. The HASU therefore relies on a consistent outflow of patients. The local acute providers are challenged to meet stroke indicators and although improving continue to be tested by key performance indicators Acute Provider Performance Source CSU Acute Provider Database Stroke - 4 hours direct to stroke unit (ASI 2) Stroke - 90% of time on the stroke unit (ASI 3, IPMR) East &North Herts Q1&2 PAH % 47.3% 67.3% 14.1% 73.8% 77.7% 79.1% 72% 68.0% 90.9% 2013 Q1&2 68.6% Improving timely access to intensive, specialist intervention via either stroke specialist beds or rehabilitation at home would maximize the potential to release HASU capacity c) Increased timely access to specialist community services will improve clinical outcomes and reduce longer term dependency. The majority of community rehabilitation services for stroke survivors in East and North Herts CCG are not stroke specific. Therefore, it is not possible to provide the intensity or specificity of rehabilitation required to achieve the best possible outcomes. This means that some patients will remain longer than necessary or will be discharged to inadequate services. Without access to stroke specific community rehabilitation, stroke survivors are less likely to achieve their rehabilitation goals and live independently. The NICE Guidelines Stroke 162 Longer Term Rehabilitation (2013) reviewed of evidence for stroke specialist units and concluded Of the organised stroke units, the comprehensive and rehabilitation stroke ward showed a significant reduction in death; death or institutional care at five and ten-year follow-up; and a reduction in death or dependency at five-year follow-up. The evidence was found to be very robust for stroke rehabilitation units. An assessment of ESD services has shown a reduced risk of death or dependency equivalent to six fewer adverse outcomes for every 100 patients receiving an ESD service. 6 Based on estimated local volumes it would indicate between 11 and 14 fewer adverse outcomes. 6-month stroke reviews are a requirement of the NHS Outcome Framework 13/14. The UK Stroke Survivor Needs Survey, published by The Stroke Association in December , found that around half of long-term stroke survivors report on going unmet needs. The introduction of holistic specialist 6 month review would identify and manage un-met need, preventing potential complications and addressing changing needs, including potential for continued recovery. d) Preventing risks associated with in-patient stay: The HRG data indicates the average length of stay (ALOS) for stroke patients in Lister hospital 2012/13 was 14 days and PAH 12 days. Following the Cochrane review of ESD in it was identified that length of hospital stay was on average 7 days shorter for patients assigned ESD services than for those assigned conventional care. ESD has the potential to reduce both acute and community bed days. Given the HRG ALOS data this would suggest bed day savings of up to 1057 days (based on ALOS of 8 days for 40%). e) Care Home Admissions 11% of patients discharged from acute care are newly admitted to a Care Home (2012 Beds and Herts Stroke Network database) are higher than National Average of 10% (2010 National Stroke Sentinel Audit). Local data also fails to account for new admissions to Care Homes from Community In-patient Beds. 2. Evidence (Appendix 5 Summary of Evidence Base) Stroke is associated with significant costs associated with the management of disability. The majority of care in the community is from generic services although evidence indicates that these services are not as effective as a specialist service % are likely to have longer term needs which are often complex and become more difficult as time progresses, requiring considerable expertise to overcome. There is a strong argument for such treatment to be provided by therapists who do not also have to understand the best treatment techniques for a whole variety of other conditions as well % 6 Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews 2012, Issue Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews 2012, Issue 9 9 Intercollegiate Stroke Working Party (2011) National sentinel stroke clinical audit 2010 (round 7): public report for England, Wales and Northern Ireland. London: Royal College of Physicians 5

12 National Stroke Strategy, Policy and Guidelines include Department of Health (DOH): National Stroke Strategy (2007). Royal College of Physicians: National Clinical Guidelines for Stroke 4 th Edition (2012) National Institute for Clinical (NICE): Excellence Quality Standards Programme: Stroke (2010). NICE Clinical Guideline 68 (2008): Diagnosis and initial management of acute stroke and transient ischaemic attack NICE Clinical Guideline 162 (2013): Stroke Rehabilitation: Long term rehabilitation after stroke British Association of Stroke Physicians: Stroke Service Standards (2010) DOH: Cardiovascular Disease Outcome Strategy (2013): DOH: The NHS Outcomes Framework 2012/13 (2011). Care Quality Commission: Supporting Life after stroke (2011) NHS Midlands and East: Stroke Review and Specification (2012/13) Proposal 1. Commissioning specialist stroke pathway from decision to admit to HASU up to the completion of the 6 month reviews It is proposed that a Stroke Specialist Service is commissioned across the pathway from acute admission to provision of a 6 month review with a single lead provider to include: - Hyper-acute and Acute Stroke Services (for East and North Herts CCG and patients admitted to any acute provider directly commissioned by E&NHCCG - Post acute specialist in-patient rehabilitation (estimated at 20%) - Specialist Early Supported Discharge (estimated at 40%) - Stroke Specialist Community Rehabilitation - Specialist 6 week and 6 month Reviews This ensures a combined/merged provider approach to service delivery across the pathway. A single provider will be responsible for managing capacity and demand, quality standards and performance. Pooled resources will be used more effectively, with Clear leadership across the pathway, maximizing use of specialist and skill mixed workforce Shared provider risk and benefit Clear accountability for delivery of quality and performance indicators across the pathway Greater flexibility to manage capacity and demand flexing the workforce and resource to meet varying need e.g. for bed based or community provision. Rationalize administration and non-face to face contact It will benefit patients and carers by Simplifying the pathway and numbers of service handovers. Providing increased patient facing time Maximize the potential for home based rehabilitation Improving clinical outcomes In-order to facilitate potential procurement the following actions have been taken the intention to investigate procurement of the stroke pathway has been raised under commissioning intentions HCT have been asked to identify current spend on stroke from the block contract The CCG have been advised by to test the market to ascertain potential provider interest Identification of potential capacity and demand in each stage of pathway, with associated staffing Delineation of required investment to address gaps in service (see below) The model of delivery is an extended version of blended model of stroke service provision operated in services such as Blackburn and Darwen, Northampton and North East Essex. Advantages 100% discharged patients followed up by a specialist service, a single point of contact and potential for seamless service. Meets Midlands and East Specification and performance standards No conflicting caseload demands and high levels of 6 Disadvantages Investment required. If a full 7 day service included further costs may be incurred Potential to destabilise existing services. Lack of

13 skills and competency. Workforce flexibility across the stroke pathway Maximises the patient s ability to live independently, reducing the long term cost of disability 10 ability to use staff flexibly in periods of high and low demand across other services. Access to neurorehabilitation services would still be required for some elements of service. Limited establishment of stroke skills in the wider workforce, potential for elitist service. This pathway excludes patients whose community rehabilitation needs are generic or not stroke specific and those requiring specialist commissioning or individual funding requests and longer term services. STROKE Hyper- Acute Stroke Unit Acute Stroke Unit Home Rehabilitation ESD/Community Specialist Rehabilitation Stroke Rehabilitation Unit LONG-TERM CARE (non-specialist) 6 Month Review TIA 6 week Review Home Lower Functioning Support KEY WORKING/INFORMATION,ADVICE AND SUPPORT/STEPPED MODEL OF PSYCHOLOGICAL CARE for patient and carer The option for procurement of the stroke pathway is to undertake a phased approach, ensuring the opportunity for integration of community health, social and other services. This will ensure a fully integrated pathway within an agreed timeframe, once HASU arrangements are confirmed. 2. Elements within Pathway Appendix 6: Proposed Pathway Summary of Services to be Delivered through re-deployment of existing service through procurement a) Hyper-acute & Acute Stroke Services b) Community Stroke Rehabilitation (excluding ESD), including self-management programme Summary of Services Requiring Additional Investment a) Uplift of community beds to meet stroke specification staffing standards b) Early Supported Discharge to provide intensive community specialist rehabilitation c) Increase Clinical Psychology d) 6 month reviews Based on the estimated number of stroke survivors 579 the typical proportion and number of patients that would require each service is estimated as when discharged from the acute setting: Hyper-Acute Bed Table1. Summary of predicted volumes Acute Bed 602 Number 692 stroke+ --mimics Proportion Return home with up to 3 week programmes % Moderate to High Functioning at home with intensive package % Community beds followed by rehabilitation at home % Residential or Nursing Care 58 10% 10 Langhorne P, for the Early Supported Discharge Trialists. Services fo reducing duration of hospital care for acute stroke patients (review).cochrane database of systematic reviews 2005, issue 2 7

14 2.3 Stroke In-patient Care Proposals Table: Predicted Required Bed Capacity (see Appendix7) HASU Beds (3 days) ASU Beds (40% 8, 60% 14 days) E&NHCCG only 10 18/20 15 (if levels of mimic not 25 (at 14 day ALOS) decreased) + out of area admissions to Lister 29 (all at 14 day ALOS) + potential HASU 2 reconfiguration Rehabilitation Beds (35 days) 15 Predicted reduction in rehabilitation beds over time with robust community services Cap Gemini scoping for the Midlands and East Stroke Review January 2013: Lister, with no HASU at PAH/Bedford: 8 HASU:32 ASU (complete in-patient rehabilitation). This scoping appears to exclude mimic admissions 2.1a. Hyper Acute Beds/Acute Beds Hyper acute and acute beds to meet Midlands and East Service Specification standards, suggests with proposed uplift and robust community services sufficient in system 2.1b. On-going Stroke Rehabilitation Beds Evidence base and guideline is that the provision of stroke rehabilitation in community beds which meet acute unit standards will maximize outcomes % of patients are estimated to have severe disability 12. This is broadly in line with the current bed base admission rates of approximately 20%. Therefore, there is no requirement to increase the total bed base but to improve the numbers which meet stroke standards and reduce length of stay. Investment required to support ICT beds to reach stroke standards: 10 existing community ICT beds would become stroke specific community rehabilitation beds in addition to the current 5/6 neuro-rehabilitation beds. Beds will be required in both East and North Herts The availability of these beds will ensure that there is capacity for patients to be effectively discharged from the acute hospitals. There will be no increase in bed stock but some investment is required to uplift therapies to provide 5/7 x 45 mins therapy per week and access to psychology 2.2 Community Services 2.2a. Early Supported Discharge: Predicted volume New Investment ESD services are not currently commissioned and would require investment in intensive intervention, minimum volume 40% of in-patient discharges of patients with mild to moderate disability (Barthel index >9/20) with interventions comparable to in-patient care for up to 6 weeks Discharge within 24hrs providing continuity of health and social care from the hospital into the community, supporting both the patient and the family during the transitional period. 7 day assessment service If Community Specialist services are to be delivered this is not attainable within current resource 2.2b. Stroke Specialist Community Rehabilitation Team Follow up all not accessing and post ESD, supporting and signposting stroke survivors and carers to adapt to living with stroke, specific rehabilitation therapy and management of patients up to maximum 6 months post stroke admission. Therapy at intensity to meet need up to 3x per week Short term education and training for care home staff to support newly admitted stroke survivor 6 month reviews New Investment All services to include stepped model of psychological intervention, including access to psychologist access to appropriate equipment and information and advice services Access to existing neuro rehabilitation services for specialist spasticity, pain management etc Access to splinting and specialist equipment 11 NICE guidelines National Sentinel Stroke Clinical Audit 2010 Public Report. Published

15 2.4 Staffing (Appendix 8: Midlands and East Staffing Specification Staffing Recommendations) All teams are multi-disciplinary and will work with an integrated approach, and will consist of the following clinical roles: Consultant Stroke physician Physiotherapy Occupational Therapy (OT) Speech and Language Therapy (SaLT) Generic rehabilitation assistants Nursing Psychology Dietetics Social work Administration Access to orthoptist, orthotics, voluntary sector It is projected that Hyper-acute-acute staffing provided within tariff (psychology needs agreement) no additional costs In-patient rehabilitation nursing staff in place for 15 beds. Uplift in therapies and psychology for 10 beds, staffing for 5 beds in place Staff currently delivering stroke care, from existing resources, will be allocated to new services Investment in staff to undertake ESD and 6 month review Equipment projected to be in the system Implementation: Time Line to be agreed on approval Timeline Activity - Commissioning intentions raised with providers - Outcomes of SCN reviewed - West Essex CCG engaged to investigate potential for joint working - Market Testing for procurement - Request to HCT for confirmation of financial stroke spend - Detailed pathway development complete -? temporary uplift in beds to meet winter pressures - Procurement process commenced - Notice to HCT - ESD service become available - 10 generic community beds become stroke specific beds - Community stroke rehab services reconfigured HCT notice period on contract: 6 months Procurement timeline: 9 months Process predicted to have 18 month timeline Impact assessment Financial Income/costs recurrent, non-recurrent Option 1: Specialist Integrated Service Pathway Utilising Current Resources Need to add in TIA costs and relook at CSR Cost 000 Secondary Acute Care Acute Care Current Costs 3,319 Less preventable post 30 day readmissions (50) Less reduced excess bed days (60) Potential to unbundle tariff* Stroke Rehabilitation Beds 1,595 Community Stroke Rehabilitation team 578 Early Supported Discharge Service (staff costs) 511 Total 5,893 Total additional Investment 621 This costing includes increased psychology and establishment to deliver 6 month reviews. No equipment costs but not predicted to increase. 9

16 *regional modelling of HASU and ASU may result in splitting of the HASU/ASU tariff. Financial modelling undertaken in Essex indicates 42% of acute tariff attributable to HASU activity. Thus future potential to realise savings against patients discharged directly to the community. There should be no extra equipment costs, although a small set up of may be required for ESD. Option 2: Fully Established Service with additional investment for All beds at neuro-rehabilitation standards with 7 day rehabilitation More specialist workforce Full 7 day ESD service Increased intensity Specialist clinics Cost 000 Secondary Acute Care Acute Care Current Costs 3,319 Less preventable post 30 day readmissions (76) Less reduced excess bed days (78) Potential to unbundle tariff* Stroke Rehabilitation Beds at neuro-rehabilitation standard 1,905 Community Stroke Rehabilitation (staff costs) 733 Early Supported Discharge Service 733 Total 6,536 Total additional Investment 1,264 Nice Clinical Guideline C68(2008): Diagnosis and initial management of acute stroke and transient ischaemic attack The discounted lifetime costs for looking after stroke patient is: 49,884 for 3.6 years life expectancy dependant within 90 days and 7,214 for 5.4 years life expectancy independent within 90 days. If there were reduced adverse events associated with ESD cost costs associated with 14 dependent up to 100,996 cost savings could be made Midlands and East SHA (2013): Midlands and East SHA: NHS Midlands and East 2012/13: Review of Stroke Pathway Summary of Intelligence to Support Cost Effectiveness of Implementing Published case studies indicate that ESD reduces the cost of stroke care by 9-20% Suggests local savings of Evidence base indicates longer-term savings are realised within social care Quality QIA 2.docx Outcome and Activity: Expectation of attainment of performance indicators in Midlands and East Specification (Appendix 8) Key Indicators 10 Performance Indicator CCG Performance Key indicators how we will know we succeeded Stroke Metrics: 4 hr admission to acute stroke unit 90% Stay in Acute Stroke Unit Early Discharge Psychological Support within 6 months 6 month follow up assessment Improved Clinical Outcomes Direct discharge from HASU of patients with confirmed stroke Discharged by day 8 Waiting times for stroke neurorehabilitation bed 66.9% (YTD) 73.3% (YTD) 0% 90% (10% improvement within 12 months ) 80% (within 12 months) 90% within 2 yrs 40% (by end of Yr1 fully established service) 0% 40% (by end of Yr1 fully established service) 0% 95% >50% of patients requiring post ESD rehabilitation >10% 30 day readmission of patients accessing ESD Reduction in care packages Reduction in mortality and dependency tba patients reporting attainment of goals and improvement on the Modified Rankin Scale at 6 months tba 10% stretch in Year 1 14 days (June 13) 50% reduction in Year % reduction in excess bed days

17 Reduction in Community In-patient ALOS Patients treated in community by stroke specialist service Reduced post 30 day preventable readmissions High Levels of patient and carer satisfaction with service 44.8 days (12/13) 35 days by end of Year 1 with projected further reduction In-patient : 40% 80% Comm: 33% 50% reduction in associated bed days 10% stretch on current performance (to be measured under (14/15 KPI) Stakeholder Engagement Evidence from patient and carer : Midlands and East Stroke Review evidence, local patient stories, local patient assessment of key priorities for KPI Evidence collected from acute and community providers, HCC and voluntary sector Outcomes Measures and Evaluation Programme aims Increase patient safety by reducing the risk of in-hospital decompensation in stroke survivors Establish close collaborative working across the system Enabling early discharge of patients from stroke wards, thus maximising patient flows Increase person-centred care by engaging patients and carers in ongoing rehabilitation in the most appropriate location Key indicators how we will know we succeeded 10% absolute reduction in rates of in-hospital decompensation 10% improvement in other stroke audit / patient safety indicators 60% of stakeholders from the acute, primary care, social care and voluntary sector agree that there is collaborative working across the system One patient pathway funding model tested 20% increase in discharge within days specified in guidelines 5% increase in throughput on stroke wards 20% increase in rate of people receiving rehabilitation at home 60% of patients and carers agree that care meets their needs Assessment methods how we will measure success Comparison of case-matched before and after data Comparison of case-matched data from programme versus control area Online survey with health professionals and managers across the health and social care system, plus possible comparison in control area Interviews with stakeholders about barriers and facilitators Comparison of case-matched before and after data Comparison of case-matched data from programme versus control area Comparison of case-matched before and after community data Satisfaction and outcomes survey with patients and carers Follow up interviews with patients and carers Deliverability Potential providers have been identified, project may be impacted by outcome of a) Current clinical strategic network regional review of stroke services and regional decisions b) Outcome of West Essex CCG internal review of service Market testing of potential providers to be undertaken Procurement be required of a) Pathway b) ESD service North East Essex undertook procurement of ESD service Risks and mitigation Risk Risk Rating Mitigation Failure of CCG to successfully 6 Market testing prior to full procurement process procure a whole stroke pathway Failure to engage stakeholders in pathway 6 Discussions commenced with HCC and flagged in commissioning intentions Destabilisation of current provider services 6 11

18 Failure to have accurately assess budget required for delivery Failure to recruit suitable staff, failure to identify staff to transfer to new service Outcome of regional stroke review will be contrary to outcomes 6 Staffing levels have been estimated against national guidance where available and benchmark services where appropriate Tariff subject to variations 6 Pathway procurement and use of 2 Pathway based on national guidelines, pathway unlikely to differ but numbers may show some variation Formal Sign off process Date of Programme Board Approval: Date of Executive/Governing Body Approval: i Providers reporting significantly lower ALOS based on all unit activity including mimics and admitted high risk TIAs who will have significantly shorter stays. Appendix: Appendix 1: Copy of ENCCG Summary by HRG: Appendix 8: Appendix 8 Midlands and East FINAL-SPEC-19-Sept-2012.pdf Appendix 1 CCG HRG Summary.xlsx Appendix 2: Summary of Current Stroke Services: Appendix 2 Summary of Current Stroke Pathway Performance.docx Appendix 3: Current Scoped Stroke Pathway Appendix 3 Current Community Pathway.2.docx Appendix 4: Strategic Fit Appendix 4. Strategic Fit to CCG Commissioning Intentions and Outcome Framework.docx Appendix 5: Evidence Base Appendix 5 Summary of Evidence Base.docx Appendix 6: Potential Pathway Appendix 6 Potential Pathway.2 docx.docx Appendix 7: Bed Calculations Appendix 7 beds calculations.docx 12

19 Service Specification Service Specification No. Service Early Supported Discharge (ESD) including 6 Month Stroke Reviews. Commissioner Lead Provider Lead Period Date of Review TBC 1. Population Needs National/local context and evidence base National Context The National Stroke Strategy (DOH 2007) identified major stages in the stroke pathway and recognized the potential benefits of effective early treatment with rapid access to stroke specialist services. Quality Marker 10 High Quality Specialist Rehabilitation states people who have had strokes should have access to high-quality rehabilitation and with their carer. This should be available in hospital, immediately after transfer from hospital, should include ESD and should be available for as long as they need it. The evidence base for this specification is provided in Appendix 1 Early Supported Discharge ESD is defined as pathways of care for people transferred from an inpatient environment to a primary care setting to continue a period of rehabilitation, reablement and recuperation at a similar level of intensity and delivered by staff with the same level of expertise as they would have received in the inpatient setting. Service provision is focused around time specific patient goals and embraces the needs and ability of their carers. Early discharge services for stroke allow stroke patients to return home early and improve their long-term recovery. Transferring patients to their homes to complete their rehabilitation achieves outcomes that are at least as good or better than those achieved in inpatient settings, may reduce patient institutionalization, contextualizes the rehabilitation and is no more costly than in-patient rehabilitation. It achieves the objectives of High Quality Care for All by providing accessible high quality care in the patient s home and will contribute to a reduction in healthcare acquired infections. A Cochrane review has shown that Early supported discharge services helps patients to return home sooner and maximizes independence in daily activities. The best results were seen with wellorganized discharge teams and patients with less severe strokes 1 6 Month Reviews 1 Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD DOI: / CD pub3 1

20 The NHS Outcomes Framework 13/14 requires a proportion of patients reporting improvement on a Modified Rankin scale at 6 months People with stroke need access to medical and social support as their needs change. The National Stroke Strategy (2007) recommends under quality marker 14: They and their carer should be: Offered a review from primary care services of their health and social care status and secondary prevention needs, typically within six weeks of discharge home or to care home and again before six months after leaving hospital. Specialist reviews can help ensure patients and carers receive appropriate support and access services based on need. The 6 month review is a holistic health and social care assessment including secondary prevention, identifying un-met rehabilitation and participation needs, needs of carers, and the development of individualized care plans. Outcomes Measures of success of ESD and 6 month Review services include reduced hospital stays, readmissions and long term dependency rates. Comprehensive ESD services, that include processes for delivering reviews, will also act as a catalyst for access to and development of the wider local community based services for stroke survivors and their carers. This specification sets out the proposed model of local care proposed, which ensures all stroke patients receive coordinated, seamless transfers of care from acute to community care all ESD eligible stroke patients are identified in the acute stroke /community in-patient unit, and receive rehabilitation in the individuals place of discharge (e.g. own home, relatives home or residential care) to an agreed single set of joint health and social care goals and rehabilitation plan. all stroke survivors and carers are offered a specialist review at 6 months post admission Local Context The estimated number of survivors of new stroke events in East and North Herts are approximately 579 per year. East and North Herts CCG and the Local Authority is committed to jointly commission an ESD services that ensures total coordination of care between health, social, voluntary or third sector providers and that all stoke providers have a multi-faceted 6 month review. A minimum of 40% of patients (this equates to 232 patients using model predictions) will be provided with an intensive package of Early Supported Discharge interventions in the home. 90% of stroke survivors who consent will be reviewed between 4and 8 months after their stroke. Given the geographical spread and flows to various acute providers both within and outside of Hertfordshire, it is important to ensure that a standardised multi-faceted, equitable, approach is taken to stroke service provision for all East and North Herts CCG stroke survivors irrespective of acute provider. A central stroke register for East and North Herts CCG is required to ensure service delivery and reviews are carried out in a coordinated manner to ensure all stroke survivors receive the same standard of care. 2

21 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators Domain 1 Preventing people from dying prematurely X Domain 2 Enhancing quality of life for people with long-term X conditions Domain 3 Helping people to recover from episodes of ill-health or X following injury Domain 4 Ensuring people have a positive experience of care X Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm X Social Care Indicators 2.2 Local defined outcomes The implementation of the ESD service, will ensure the effective use of statutory and voluntary care resources. ESD service General Improved outcomes from stroke rehabilitation in terms of reduced level of disability and impairment, improved level of social participation, reduced dependency on social care packages and long term care. It is proposed this will be measured using locally agreed tools,. EDQ5, or Goal Attainment Scaling, entry into care packages. Reduced number of days spent in hospital (acute and community), from baseline metric Quality improvements demonstrated by achievement of National Stroke Strategy Quality Markers, targets and local Standards for stroke rehabilitation Stroke survivors/carers will report Increased choice and control over their lives Attaining their agreed goals with involvement of their family carer or paid carer as appropriate through the application of clinical expertise in stroke rehabilitation and physical and emotional support. Achieving increased independence living at home, measured by improved functional outcomes on discharge, as measured by agreed tool and reduced entry into longer term care services Being able to participate in/manage activities of daily living Being able to confidently self-manage disability and risk factors Being signposted to appropriate support services in a timely manner High levels of satisfaction with the care they received Achieving high service quality provision 40% of new stroke survivors will receive care from the Early Supported Discharge team ensuring on-going interventions are provided with seamless transfers of care to community teams. Improved stroke morbidity rates, less incidence of preventable secondary complications (including pressure sores, chest infections and contractures) Reduction of readmissions within 30 days and first year post stroke by avoiding escalation of problems and proactive identification of issues Identification and proactive management of secondary prevention needs (e.g. atrial fibrillation, hypertension, medications management) and the optimal modification of risk factors 3

22 Increased proportion of patients confirmed with a stoke accessing a stroke unit within 4 hrs of arrival at hospital and spending 90% of time on a stroke unit Improved access and uptake of voluntary sector support services (by highlighting areas where voluntary services can meet needs) Achieving equity of access Greater equity of out of hospital service provision for stroke survivors across East and North Herts CCG Improved management of capacity and demand across entire stoke pathway. 3. Scope 3.1 Aims and Objective of Service Aims To provide an Early Supported Discharge Service to all stroke survivors and their carers, in E&NHCCG regardless of which acute trust the patient received emergency care.. To enable recovery of stroke survivors to reach their potential for independence. To ensure stroke patients receive rehabilitation in their own home at the same level of intensity as inpatient care (ESD) To ensure that all services are fully integrated across health and social care. To ensure a whole system approach that raises standards across the whole stroke pathway by establishing a recommended model of early and intensive intervention and specialist reviews. To facilitate coordinated community stroke care, this includes timely, appropriate access to wider in-patient, out-patient and community enablement/neuro rehabilitation and intermediate care pathways. To establish care pathways with other local health, social care and voluntary sector services, including in-patient services, Homefirst, Carer Friendly Schemes and Integrated Discharge teams, to improve service outcomes for stroke survivors. To help the patient and their family to adjust to life after stroke To identify and proactively manage un-met health and social care needs and risks through ESD services and 6 month reviews Objectives To provide a 7 day person centred Early Supported Discharge (ESD) service to stroke survivors in ENHCCG, enabling them to achieve mutually agreed rehabilitation goals. To provide specialist ESD assessment, stroke rehabilitation and care from an integrated health and social care team, which includes appropriately qualified and trained staff, rehabilitation assistants and/or enablement workers., and sufficient staff and resources for a 7 day service. For eligible stroke patients, the service will meet standards of a specialist stroke team as defined by the Royal College of Physician and include capacity for 6 month reviews. To provide an ESD/Review service compliant with best evidence and national quality markers. To support a coordinated approach to community stroke care, with each stroke survivor receiving a community follow-up from an appropriate service and being given a single point of contact and named key worker, as appropriate to need To ensure stroke survivors, carers and families are at the centre and fully involved in the process of rehabilitation, ensuring a range of specialist care programmes are available and tailored to the individual, taking into account the persons dignity, respect, cultural and religious needs To provide access to psychological assessment, support and intervention To ensure stroke reviews for all stroke survivors and their carers, 4-8 months post-admission to acute hospital services, regardless of whether they have entered early supported discharge services To provide a second opinion and specialist stroke advice to providers of community services in NHS East and North Herts CCG. 4

23 To develop strong relationships with relevant agencies (statutory and non statutory) along the wider stroke pathway to support in-reach/outreach models of working and smooth transitions of care. 3.2 Scope of Service Providers are expected to work in a collaborative manner to maximize clinical outcomes across the whole pathway and ensure that collective resources are used effectively. This document scopes the Community Out-of Hospital Early Supported Discharge Specialist Stroke Pathway which addresses coordination, early and intensive intervention and 6 month reviews. In common with the entire stroke pathway these services must be underpinned by: a) Service User and Carer Experience Timely, effective, accessible and regular communication and information with service users and carers, in a range of formats to meet the population need Regular and on-going audit of service user and carer experience b) Engagement and Communications Awareness raising activities with regard to both identification and impact of stroke Links to stroke networks and local governance arrangements Relevant guidelines, policies and procedures in place which include access to - Equipment - Psychological services to manage mood and cognition - Spasticity, Orthotics and Pain management - Vocational management Formal links with patient and carer organisations and the voluntary sector A programme of clinical audit Adherence to the requirements of the Care Quality Commission. c) Data Transfer and Information Sharing Information sharing agreements between health, social care and the voluntary sector and where possible shared IT systems Accurate and explicit service user records and data collection systems which are shared using agreed protocols in a timely way, are validated and reliable Participation in local, regional and national audit, including the Stroke Sentinel National Audit Programme Providing the commissioner with data and information as required. Information Sharing Share information with service users and carers about a broad range of local services across health, social care, and community sectors. Ensure service user and carer consent is obtained to share outcomes with relevant parties, at minimum with the patient s registered GP Have systems in place to make seamless onward referrals. Have systems in place to collect and share relevant information Have systems in-place to up-load information on to the Stroke Sentinel National Audit Programme, with appropriate consent Have systems in place to review and collate information which identifies trends in unmet need 3.3 Service Description The service will provide: work collaboratively with existing acute/ community and discharge services to coordinate and manage transfers of care to the community, ensuring all patients have access to a key worker and follow-up (follow-up may be via Stroke Association Life after Stroke Services, as appropriate) a managed stroke register with a single point of integrated access provide early and intensive packages of community care (ESD), which include a 6 week 5

24 review by a stroke physician short term individualized training and support for carers of patients transferred into long-term care services 6 month reviews to all stroke patients support and work alongside existing acute and community health, social and voluntary sector services 3.31 Early Supported Discharge The ESD service will progress patient through goals and onto self-management/appropriate long-term services. Core features of an ESD service will include: A single point of referral/entry, a rapid same-day response and facilitation of timely discharge A 7 day service delivery A single set of health and social care goals, orientated to a rehabilitation approach to all activities, with clear care/rehabilitation plan reviewed at regular periods during intervention Provision of intense rehabilitation, primarily in the stroke survivors own home including assessment, intervention, education and information to the stroke survivor and carers Be time-limited for up to 6 weeks following discharge from inpatient care CHECK Care elements to be free of charge to the service user for up to 4 weeks; Key workers who support communication between stroke survivor, the MDT and local services, implement and review the rehabilitation/care programme Strong links with acute and community stroke providers to enable ESD services to identify those eligible for ESD as soon as possible post stroke and support discharge planning Strong links with community stroke rehabilitation and care providers to enable smooth transition to ongoing community rehabilitation/care if required Provide support for stroke survivors and carers and strategies for longer term selfmanagement including Personal Health Planning Stroke patients meeting the ESD eligibility criteria (see below), will be discharged early from acute stroke units and community in-patient rehabilitation units. Patients may be referred/discharged directly from Hyper-Acute Stroke Units. ESD will provide specialist multidisciplinary stroke rehabilitation and care, according to patient s needs, in the home setting. Patient specific goals should be set for no more than 6 weeks. Some patients may achieve their goals faster and should be discharged at that point. Any patient still benefitting from intensive support to maximise their goal attainment should be discussed and agreed with commissioners prior to breaching the 6 week period of intervention. Patients will be seamlessly transferred to other community rehab, or health and social care services for ongoing care/intervention as appropriate, following a period of Early Supported Discharge. The service will aim to reduce multiple assessments, within the team and across providers by working closely together and with an inter-disciplinary approach. A stroke survivor and their family/ carers will have access to a named key worker who will support the individual s during their ESD care pathway and provide a point of contact for up to 6 months. Key workers will ensure patients/carers are contacted during their inpatient rehabilitation, as appropriate and that on transfer from the ESD service have an allocated named key worker from within any receiving team or a point of contact, as appropriate to the needs of the individual. Key workers will be focused on facilitating a seamless transfer from one care setting to another; providing continuity of contact The ESD service will ensure assessment of, treatment for and advice on issues relating to stroke including: Mobility and movement 6

25 Communication Everyday activities washing and dressing, meal preparation Emotional and psychological issues Swallowing Nutrition Impaired cognition Visual disturbance Continence Secondary Prevention Relationships and sex Pain Returning to work Life after stroke An ESD service will provide access to 7 day services, with intensive access to each of the required therapies 5 x per week, as appropriate to need and provision of psychological support. Stroke ESD is just one part of the overall stroke care pathway. Approximately 40% of stroke patients will be eligible for ESD. The coordination of care for those patients not accessing ESD will be supported by the ESD working in partnership with other community services. This will require the service to maintain patients on a stroke register and virtual ward for up to 6 months post stroke and act as a single point of contact The Service will coordinate, offer and provide a 6 month stroke survivor and carer review to all East and North Herts CCG between 4-8 months after a new stroke, in a location most appropriate to their need, regardless of whether they have accessed ESD services. All those accepting review will be provided with a holistic health and social care assessment of both service user and carer need, using a recognised tool, and ensuring it has appropriate carers assessments. Regular reviews provide an opportunity to assess care packages already in place, and as such it is important for the process to be integrated across health and social care. A 6 month review will not preclude reviews at other times as clinically indicated. 6 month follow up reviews will encompass: Medicines/general health and secondary prevention needs; Mood, memory cognitive and psychological status and need; Information, education and training needs On-going rehabilitation needs ( these may be met by a range of services beyond healthcare); Return to work issues Social care needs, carer wellbeing, finances/benefits, driving, travel and transport situation. A Modified Rankin Scale and Modified Barthel Index score. A management plan for any unmet needs. A copy of which will be given to the service user in an appropriate format to meet any communication, cognitive or language needs. The lead reviewer will be responsible for ensuring the implementation of any action plan based on unmet need and sign-posting to information, education and training as required by the service user/carer. The service will be required to up-load all required data and submit to the Stroke Sentinel National Audit Programme (SSNAP) Service Model The service model must be compliant with guidance from the Royal College of Physicians, NICE Quality Standards and Clinical Guidelines for Stroke, quality measures from the National Stroke Strategy and NHS and Social Care Outcomes Framework The primary role of the service will be to Support the coordination of community care Provide intensive, multi-faceted stroke-specialised rehabilitation and support to eligible stroke 7

26 survivors within their homes, enabling earlier supported discharge (ESD) from In-patient care, for a minimum of 40% of stroke survivors, which include 6 week stroke consultant reviews Provide specialist 6 month reviews. A secondary purpose of the service will be to increase the local capacity to provide intensive strokespecialist rehabilitation to stroke patients already in the community supporting existing teams with delivery of specialist, intensive programmes. Whilst all staff in ESD service may not be qualified AHPs/Nurses/Social Workers they will all have received appropriate additional training in stroke rehabilitation. Initial assessment and treatment planning must be undertaken by qualified professionals. Effective delivery requires the following elements to be in place: A live Stroke Register within community services which is updated regularly with stroke patient admissions to acute trusts. A lead to oversee the implementation and delivery Processes in place to identify patients who have Out of Area Strokes and patients for ESD The service model will be as follows: 3.41 Early Supported Discharge (Appendix 2 and 3) The early supported discharge service should provide a comprehensive stroke skilled interdisciplinary team to manage patients at their place of residence and who are able to provide care and rehabilitation of similar intensity to that of a stroke unit. ESD must be led by a clinical lead for stroke working together with the various in-patient stroke units and rehabilitation facilities in both the acute and community sector. The team will be specialist in stroke and is expected to meet quality and performance standards for ESD services. Each patient will be assigned a key worker and their role is to monitor the implementation of the care plan, progress of onward referrals to other services and review of needs. The team will additionally support coordinated transfers of care of all stroke survivors from in-patient to community care provide all stroke survivors with an holistic 6 month review community and primary care teams in the management of all new stroke Effective delivery requires the following elements to be in place: A live Stroke Register within community services which is updated within 5 working days with stroke patient admissions to acute trusts. A lead to oversee the implementation and delivery Processes in place to identify patients who have Out of Area Strokes and patients for ESD A secondary purpose of the service will be to increase the local capacity to provide intensive strokespecialist rehabilitation to stroke patients already in the community supporting existing teams with delivery of specialist, intensive programmes Referral Pathways The ESD team will work with all stroke stakeholders and providers to agree and publish referral protocol. The team will work to established referral methods for a seamless transfer of care to relevant community rehabilitation services. The service will only accept a patient to the service following discussion and agreement that the patient has a confirmed diagnosis of stroke and consents to transfer. ESD services will work with in patient units to identify any individual eligible to participate in the ESD. The ESD team will proactively be involved in this process; visiting/contacting the primary stroke wards on a daily basis to identify eligible individuals, and to plan and coordinate their discharge 8

27 Referrals from the community stroke in-patient units will be accepted if they have not completed a full 42day programme. Their length of stay in ESD will be for a period up to 42 days that includes their community in-patient stay Referrals for ESD and 6 month reviews will be made via a single point of access Assessment Assessment and goal setting will take place as outlined below. Every effort should be made to use trusted assessment procedures and reduce repetition The stroke survivor s needs are assessed with family and carers involvement, if consent is provided. Assessment and goal setting is designed according to specific needs and priorities of the individual. Potentially eligible patients will be screened by the ESD team. There are three possible outcome from this screen: ACCEPTED the patient meets all of the criteria and is ready for discharge PENDING the patient does not yet meet the full criteria, but is likely to be eligible in the future. These individuals will be monitored on a daily basis and assessment will be repeated only as and if appropriate NOT ACCEPTED the patient does not meet the criteria for ESD, in which case they will be sign-posted to an appropriate service Prior to discharge inpatient services will complete at minimum the following in-patient activity will be completed, an assessment of : All inpatient medical assessment Initial therapy assessment including a visual and cognitive screen Dysphagia screen Communication screen Continence assessment Falls assessment Social work initial assessment Any required equipment must be ordered and in-place prior to discharge Feedback from assessment is provided to the referrer and GP within 1 working day as to acceptance with the intended management plan and predicted timelines. Feedback will also be provided to the GP if a service user s condition changes or deteriorates such that further medical assessment is required 3.44 Intervention Once an individual has been accepted by ESD, they will be allocated an ESD key worker/coordinator. ESD is responsible for: Meeting/contacting the patient and their family within in 1 day to discuss the role of ESD, explain the nature of the service, and to answer and queries of concerns that may arise. Alternative options to ESD will be discussed, and consent to transfer should be obtained. Written literature about the service is provided which includes information about the team, contact details, and a timetable for initial input Planning and coordinating the individuals discharge, in collaboration with the ward MDT/IDT and the patient/family and liaising with relevant community health/social care service through existing referral pathways to support delivery. Accepted ESD patients will receive Up to 5 x 45 minute rehabilitation sessions i per week per of any of the required therapies or as appropriate and determined by individual patient clinical need and goals for up to 6 weeks and commencing on day of discharge, this may be included as part of the enabling package Psychological support, A named point of contact for stroke information, written information about the patients diagnosis and management plan, this may be through Life After Stroke Information Advice and Support Services Sufficient practical training for carers to enable them to deliver/support care provision by discharge 9

28 Patients who have nursing or other needs are beyond the capacity/skills of the ESD services and where there has been an agreed care plan will be visited at home by rapid response/community nursing team by an agreed period post discharge. Patients may receive individual or group OT, PT & SALT intervention in a community setting other than home, as indicated by the assessment, need and goal setting. Some interventions may be carried out by trained rehabilitation/enablement support workers or carers under direct or indirect supervision of qualified therapists. The outcomes of interventions will be assessed against agreed outcome measures and goal setting programmes. Monitoring systems are a core part of rehabilitation services during intervention period in order to determine progress towards goals. This will include regular multidisciplinary team meetings, patient and family meetings. Intervention packages will include personalised comprehensive planning for transfer from ESD. This will include assessment of social situation/support mechanisms, equipment provision and review, provision of relevant training for informal carers, utilisation of psychological decisions support tools, leisure and occupational needs and referral to other agencies. A stroke survivor will be provided with personalised joint health and social care assessment results, goals and a rehabilitation programme/care plan. The care plan should include any social care needs and liaison with any generic community team as appropriate. Where a patient has an informal carer, the carer must be offered a Carers Needs assessment. The team must ensure the patient (where possible family and/ or informal carers) understand what has happened to them, what they can expect from recovery and services and what is expected from them Month Stroke Reviews Stroke Reviews will be offered to all Stroke Survivors. The 6 month review will encompass health and social care and is designed to enable the stroke survivor and carer to be signposted to sources of support and the need for further clinical review. The ESD services will provide Holistic Health and Social Care reviews at 6 months post-stroke offering ongoing assessment of clinical, emotional and social needs of stroke survivors and carers, and stroke navigation to plan of ongoing interventions to support patients and carers. Patients will be identified for a 6 month stroke review via a stroke register. Call and re-call processes need to be robustly organised The review should be led by an individual with the knowledge and skills of stroke to undertake a holistic assessment. This includes the ability to provide information and sign-post to relevant services The Stroke reviews should be designed to Reduce risk of secondary stroke and acute admission from secondary complications Prevent and advise on other health issues Ensure that any change, positive or negative and its impact on the individual and/or carer is reviewed, documented and an action plan initiated, as appropriate Promote independence and reduce the need for formal care or the need for residential placement Enable informal carers to continue in their caring role Improve patient health and quality of life as measured by patient reported and clinical outcome measures Ensure high level of patient engagement and experience Be provided by people with stroke specific knowledge 3.5 The ESD Team 10

29 Services will be provided by teams of health, social care and third sector professionals with stroke competencies, appropriate to their role and will include both qualified, assistant staff and where appropriate volunteers. This will include specialist stroke teams as defined by the RCP (2012). While initial assessment of the stroke patient is carried out by a qualified professional, some of the care may be delivered by assistants under adequate supervision of a qualified staff. A stroke skilled physician/medical practitioner will provide medical oversight related to the service user s stroke and cerebrovascular health and 6 week reviews The ESD team will consist of multi-disciplinary staff with specialist knowledge and experience of stroke and neurological rehabilitation, capable of providing timely transfers of care and the 45min rehabilitation targets plus the 6 month reviews Features of the Team: Coordinated with clear management structures Stroke specialist and interdisciplinary, with appropriately trained and experienced staff Comprise as a minimum for 100 patients per year caseload: o Occupational Therapy (1.0); o Physiotherapy (1.0); o Speech And Language Therapy (0.4); o Physician (0.1); o Nurse (1.2); o Social worker (0.5); Plus Neuro/clinical psychology sufficient support staff to deliver 45mins of daily intervention of each required therapy for up to 6 weeks sufficient staff to deliver 6 month reviews sufficient administration to ensure maximized clinical engagement sufficient time and commitment to on-going training and education access to dietetics access to equipment access to specialist clinics such as orthotics, spinting, spasticity management The Clinical Neuropsychologist (or equivalent) will be responsible for delivery psychological support within the ESD Service to patients and carers assessed and identified as beyond the scope of the MDT. They will also be responsible for supporting supervision and training within the ESD and acute teams. A Co-ordinator/Lead will be the link between specialist acute stroke expertise and the ESD Service. They will co-ordinate and facilitate the ESD discharge along with Hospital Based Stroke Coordinators and Discharge Planning Teams. They will also co-ordinate follow up care and further targeted rehabilitation; operate and maintain an acute-community interfacing stroke register; be involved in pathway development and signposting, prevention and training The Stroke Physician in the ESD will provide the Stroke Survivors GP with the level of specialist advice and support facilitate early discharge back to the stroke survivors own home. The ESD team will review all referrals within 1 day of receipt meet weekly as a minimum set a single set of patient centred goals ensure at least 1 family meeting at 2 weeks,or as appropriate for ESD patients ensure timely provision of all required equipment, information and training deliver prevention and self-management advice to maximize independence, minimize the risk and maximize the management of complications undertake continual monitoring, re-assessment and rehabilitation to address continued impairments and disability, taking into account the patients psychological, emotional and cognitive needs. 11

30 3.5.2 Training Mandatory Training All staff must be up to date with Mandatory training as outlined in local policies including CPR, Manual Handling, Conflict Resolution, Information Governance, Infection Control etc. Underpinning all core skills and competencies should be a willingness to engage with patients from a person centred perspective and to ensure that patients and carers views are taken into account in tailoring core therapies and interventions within the overall context of the person s needs. Core Skills and Competencies All staff will have a competency profile in line with the Stroke Specific Education Framework/East of England Stroke Competencies All staff will receive a robust programme of induction All staff will receive sufficient training to remain competent within their professional areas/roles Clinical Supervision o Robust clinical supervision structures must be in place: o All staff to receive regular clinical supervision o Newly appointed staff to receive support and mentorship from a colleague for 1-year post appointment. o All staff must have an annual appraisal with their line managers and personal development plans agreed to enable individual development to meet stroke competence, professional registration and to support service development. 3.6 Equipment and Resources The service provider will ensure they have robust IT systems in place to manage a stroke register The service provider will ensure that smart working policies are in place to minimise unnecessary administrative costs and that staff have access to suitable systems to support mobile working The service will have suitable office premises. There will be a dedicated phone line, safe fax machine and printer. When carrying out home or community visits, each member of staff will carry infection control equipment to ensure compliance with hand washing and infection control policy and basic manual handling equipment. It is expected that the provider will provide a base for all health, social care and voluntary sector staff working in the service to facilitate team cohesion and clear, holistic case management across the services (therapeutic rehabilitation, support team and stroke review). The provider is also responsible for adequate clinic space and space for reviews and group work if required in suitable locations. The environment must meet Health and Safety requirements in accordance with legal and NHS standards. The Provider is responsible for the provision and maintenance of stroke rehabilitation equipment, given the high incidence of communication and cognitive disability this should include information and equipment that supports their needs The prompt provision of appropriate equipment for patients is vital if they are to be maintained safely in their own homes. The ESD must be able to access equipment for patients in their homes within the existing local policy arrangements. More expensive or specialised items may require authorisation by the seniors/team leaders. The service should provide interpreters where required to support the patient and documents should be available in easy-read and translated into other languages 3.7 Business Contingency Planning 12

31 Cover arrangements for services during periods of absence, annual leave, ill health and staff training must be in place. In extreme circumstances e.g. severe weather conditions, when services may not be at optimum staffing levels, care will be prioritised and patients notified of cancelled or re-scheduled visits. The service will use the workforce flexibly to support community teams, including in-patient services where there is capacity available and demand within those teams Systems will be in place with existing providers to meet increased demand where beyond the capacity of the ESD service 3.8 Additional Roles within the ESD Service Health Care The team will develop and maintain strong links with secondary and primary care, specifically in relation to follow-up appointments 6 weeks, 6 months and annually after discharge align and interface with the Home-First, neuro- rehabilitation and Intermediate Care Services. link to local initiatives relating to long-term conditions, including self-management programmes, exercise and communication groups. link with local support groups and third sector providers. facilitate, as appropriate, positive lifestyle changes. facilitate referrals to the End of Life Care pathway where appropriate. work in partnership with Commissioner as appropriate and will provide data / information as agreed. The team will input as appropriate, into both SSNAP and local databases timely and accurate data. Social Care The team will work in partnership with social care to: Provide enabling rehabilitation and care Undertake regular reviews of social care needs, at least 6 monthly, in line with statutory guidance. Investigate and monitor all safeguarding concerns and issues identified to the service. Promote self-directed support to eligible stroke patients and carers Ensure that all carers have access to a formal Carer s Assessment. Ensure patients are assessed and have access to a need based home care package Support patients with access to residential social and/or nursing care. Support access to appropriate information and advice Support access to voluntary sector services, including Herts Help, Life After Stroke Services and Carers in Herts Deliver structured education programmes across the whole stroke pathway. Voluntary Sector The team will work in partnership with the voluntary sector to: Support the psychological wellbeing of stroke survivors and carers. Support patients and carers in accessing appropriate self help and support groups. Provide carer information/education. Signpost patients and carers to appropriate local stroke support organisations 3.9 Referral Acceptance and Exclusion Criteria 3.91 Geographic coverage/boundaries The team will provide the service to patients registered with an E&NHCCG GP Location(s) of Service Delivery a) ESD Patients will be identified early in their hospital/ inpatient rehabilitation stay via the multidisciplinary team meetings attended by at least one of the team members identified to work with the patient and 13

32 their family/ carers. Discharge will be planned with the patient and carer and may involve either a home visit with the patient or an environmental visit (not attended) by the patient. The services will be delivered in the patient s home and local environment as appropriate. b) Reviews Reviews will be undertaken in a location most appropriate to service user need, this may include:- Community Clinics Domiciliary Visits Care Homes Service users at low risk of secondary complication who are unable to attend clinic may be reviewed by:- Telephone Questionnaire Non-face to face review should only be undertaken if a full assessment can be facilitated through this process 3.93 Days/Hours of operation ESD team rehabilitation should commence from the day of transfer from hospital, or within 24hrs, and is expected to continue as appropriate for up to six weeks. The frequency of visits is dependent on patient need. In stroke guidelines this varies from daily to 5 times a week for ESD. Patients who meet the criteria for enablement will be supported over the weekend by skilled enablement workers for continuation of care plans and rehabilitation goals. For the up to the first four weeks, the patient should receive at least five sessions per week of any required therapy occupational therapy, physiotherapy and speech and language therapy (as would be received by patients in an inpatient rehabilitation unit). This will be offered in the first instance and provided in accordance with individual patient clinical need. Therapy may be stepped down in weeks 4-6 to prepare the patient for discharge Support to stroke survivors and families/carers via the Life After Stroke Service will be provided based on need, during the first year after stroke and will be available Monday to Friday 3.94 Referral criteria & sources Patients should only be discharged early if able to continue rehabilitation on the same day and the patient is able to transfer safely from bed to chair independently, or safely with one if living with an able carer, and all other problems can be safely managed at home. Criteria to be assessed when considering a patient for ESD Diagnosis of stroke Over 18 years old Able to actively engage in a stroke rehab programme Able to consent to transfer and participate in rehabilitation Medically stable, with appropriate medical investigations completed and risks which are manageable in the community(must be agreed with their Consultant prior to discharge) Medication management system in place to safely manage medication and for those patients who still require changes that systems are in place to safely support this i.e. OP appointment Adequate oral nutrition modified diet acceptable (includes PEG feeding) providing risks can be managed. No patients with NG tubes. Able to transfer safely from bed to chair i.e. can transfer with one, able carer, or independently if living alone. Adequate level of cognition to maintain their own safety when at home alone Support networks- carers, ability and motivation Home environment conducive to patient goals 14

33 Potential goals to be achieved Carers needs can be met in the home For patients discharged alone to a private address they must be able to maintain their own safety independently. All necessary care, equipment and transportation are in place Where the skills or equipment required to support the condition are beyond the scope of the ESD team, this should be recognised and a joint plan formulated with the relevant team, e.g. Homefirst, Mental Health Services, Diabetes Services. Every effort should be made to liaise and access support from local teams to enable coordinated care and a solution-focussed approach. ESD Referrals will be expected via clinicians and therapists from: Acute Stroke Units Hyper-acute Stroke Units Community In-patient Services Other specialist neuro rehab services An open referral system will be used for the 6 Month Review and Life After Stroke support services All patients discharged from acute care will be eligible for a 6 month review. Referrals in to the service will be made via the last inpatient setting for acute care or rehabilitation. The review should be offered to all stroke survivors, even those who may not appear to have a residual impairment or effect on activity and/or participation ESD Exclusion criteria Unstable medical condition which cannot be safely supported in the community High dependency, requiring in-patient rehabilitation Patients with no functional deficit ( phone review via life after stroke services) Unsuitable home environment based on relevant clinical and/or social care assessment. Risks that cannot be managed in the home Rehabilitation needs that are not stroke related or a pre-morbid condition which will impact on their ability to participate in ESD rehabilitation. There would be no exclusion for support services Failure to consent to transfer Patients without the capacity to retain sufficient information and participate safely Patients not meeting the criteria of the service will be signposted to other appropriate services 3.95 Response time and prioritization a) ESD Members of the ESD Service will liaise closely with all acute and community in-patient stroke units and identify potential patient transfers (in collaboration with MDT) to the service. All qualified staff members within the ESD team will be able to complete a standard ESD screen, that enables them to assess the patient The ESD team will assess the patient s suitability within 24 hours of receipt of referral/1 working day and agree with in-patient staff, the patient and carer A suitable discharge date A home care treatment plan Equipment/transport to be ordered to facilitate discharge A key worker will be identified and make contact with the patient and carer with 1 day of referral 15

34 acceptance Outcome measures will be identified and recorded within 1 day of admission Goals will be agreed and set within 3 days of admission Ongoing care and treatment will typically be commenced within 24hours of hospital discharge. All stroke patients/carers identified as requiring further assessment or intervention to meet cognitive, adjustment, behavioural or psychological needs will be seen within 72 hours of admission. Where needs are greater than those which can be provided by the team onward referral will be made. All patients will receive an updated copy of their short and long term goals, negotiated with them and their family/carers that meet their individual needs and forms part of their care plan within 5 days of admission to the service Once discharged from in-patient care, into ESD services, the patient will be returned to the clinical care of their registered GP, with support of the stroke physician on the team. Assessment is required as to the safety of the home environment/situation. If following a risk assessment it is unsafe for either the service user or the ESD staff to carry out interventions, efforts should be made to arrange for therapy to take place in a suitable alternative b) 6 Month Reviews Calculation of the date of the six months should be from the date of stroke. The review can take place within 4-8 months of this date. The 6 month review service will make timely/appropriate onward referrals/signposting to alternative health/social care/voluntary/mainstream services Provide timely secondary prevention education including information and referrals to GP 3.96 Days/Hours of Operation The ESD service will offer a 7 day a week service 8.00am to 8.00pm (365 days per year).tba ESD team rehabilitation should commence from the day of transfer from hospital, or within 24hours, on the agreement of the patient and carer, and is expected to continue as appropriate for up to 6 weeks Arrangements should be in place to provide an Out of Hours point of contact and meet any Out-of Hours needs The frequency of visits is dependent on patient need. Patients who meet the criteria for enablement will be supported over the weekend by skilled enablement workers for continuation of care plans and rehabilitation goals. These workers will have access to clinical support. Services will be in place to support a 7 day assessment and admission service The 6 month Review Service will offer a 5 day a week service Monday to Friday pm 3.97 Discharge processes All stroke patients discharged from in-patient setting will be entered into a stroke register/virtual ward. All patients, regardless of whether they have received an ESD package will be offered a 6 month review following which they will be discharged from the virtual ward to the sole management of primary and community social care as required As part of the coordination role all stroke survivors will receive sign-posting and assistance to access relevant community and voluntary organisations. This may include 16

35 Herts Help Carers in Herts Smoking Cessation Services Exercise class referral Self-management classes Local stroke and communication groups a) ESD Package When the ESD intervention is complete, the patient will be discharged from the ESD service and if appropriate referred into relevant community rehabilitation and/or care. Further community rehabilitation, at the usual intensity and time period for community patients can follow on where required. An ESD discharge summary will be sent to the GP, within 48 hours of discharge and will include details of onward referrals to other services. The patients care plan will be included within the discharge summary and a copy maintained within the patient s own joint care plan. All patients will be offered a Personal Health plan prior to discharge and when necessary be supported to complete it. If the service user requires ongoing care this will be provided in a seamless transfer from week 4 at which point the rehabilitation team will provide training to the on-going care provider Whole Systems Relationships The service will work closely with acute and community providers across the stroke pathway The service is to be provided as part of an integrated health and social care stroke service, with access to the third sector. It will work in partnership with service users, using approaches that empower people to effectively make choices and control in their health and wellbeing arrangements. To enhance this service, interdependency must be taken into account and there should be referral to, and close working with other agencies including: o o o o o o o o o o o o o o o o o o o o o o o o All trusts providing stroke services Hyper-acute and acute stroke services; Ambulance and transport services Community rehabilitation teams ( in-patient, out-patient and community health and social care) Equipment services Smoking Cessation Services etc. where relevant; Specialist clinics for management of spasticity, pain etc. Community Services; Social Care; Voluntary services, Independent Sector; Orthotics; Primary Care; Home care and Care Home services; Day care services; Community equipment; The Mobility Centre; Information Services Respite care; Night sitting service; Mental Health services; Psychology Services; Other rehabilitation services; Care Home Services; 17

36 Services need to work closely with Adult Social Care and other services provided for people following stroke and episodes of ill-health such as Homefirst Other voluntary sector services need to be encouraged to work closely with the service to ensure all aspects of care and well-being are met e.g. return to work support The ESD Out of Hospital team is expected to take ownership for facilitating effective inter-disciplinary working 4. Applicable Service Standards The service will ensure it is compliant with all guidelines and legal requirements with respect to equity of access, choice, disability discrimination and equality The staffing and delivery of the ESD will be in alignment with guidance from the Royal College of Physicians, NICE Quality Standards and Guidance for Stroke, quality measures from the National Stroke Strategy and NHS/Social Care Outcomes Frameworks National Stroke Strategy DOH 2007Quality Markers QM10 High-quality specialist rehabilitation QM12 Seamless transfer of care QM13 Long-term care and support QM15 Participation in community life QM18 Leadership and skills NICE Quality Standards for Stroke Standard 7 Patients with stroke are offered a minimum of 45 minutes of each active therapy that is required, for a minimum of 5 days per week, at a level that enables the patient to meet their rehabilitation goals for as long as they are continuing to benefit from the therapy and are able to tolerate it - Standard 8 - Patients with stroke who have continued loss of bladder control 2 weeks after diagnosis are reassessed to identify the cause of incontinence, and have an ongoing treatment plan involving both patients and carers. - Standard 9 - All patients after stroke are screened within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment. - Standard 10 All patients discharged from hospital who have residual stroke related problems are followed up within 72 hours by specialist stroke rehabilitation services for assessment and ongoing management - Standard 11 - Carers of patients with stroke are provided with a named point of contact for stroke information, written information about the patient s diagnosis and management plan, and sufficient practical training to enable them to provide care. Reporting will initially be required on a monthly basis, with quarterly performance reviews. 5. Applicable quality requirements Performance Indicator Indicator Threshold Method of Measuring A reduction in ALOS 2013/14 ALOS Monthly HRG acute hospital in hospital for LOS from people with new current annual stroke baseline Percentage of eligible patients discharged into ESD services Eligible stroke survivors discharged into ESD service. Details of number of patients not accepted for ESD service and reasons why need to be recorded 40% of total stroke survivors Approx. 232 per Frequency of Monitoring Monthly 18

37 ESD caseload Caseload per annum annum Patients discharged to ESD services with 1 working day of acceptance ESD Commenced within 24hrs of discharge Percentage of delayed transfers into ESD 90% <10% Patients receive therapy at an intensity equivalent to inpatient care Supporting psychological needs of patients and carers Clinical Outcomes Single set of Health and Social Care Goals Improved Clinical Outcomes from Intervention Percentage of appropriate patients receiving 45 minutes of each active therapy a minimum of 5 days per week % of patients/carers identified with changes in mood and require psychology who are assessed within 3 days Pts with outcome measures recorded at one week and at discharge, to include Modified Rankin and Barthel Pts with single set of short and long term goals negotiated within 5 days Percentage of patients showing improvement on at least one defined clinical outcome scores by discharge from ESD 80% Physio 80% OT 80% SLT 80% 95% 2 90% 90% 3 Percentage of goals achieved on discharge from ESD 70-80% 4 Requirement for Social Care Preventable admissions to acute care Percentage of appropriate patients, facilitated seamlessly into on-going social care following ESD Patients with reduced care packages following ESD % of patients readmitted to acute or community services within 30 days of discharge 95% -- <10% (preventable) There will be a requirement to measure level of package on entry to service and level of package on discharge from ESD Service Number of ESD patients readmitted to hospital for 2 Chelsea and Westminster 3 4 UCL 19

38 Patient and Carer Support Reduction in post 30 day admissions for avoidable complications comparable to current baseline Percentage of patients and carers of ESD patients provided with a. a named point of contact for stroke information 95% avoidable complication, including reason and number of days in /post ESD service b. written information about diagnosis and management plan, 95% c. Percentage of carers with identified need signposted/provided with a carers assessments 95% PHP Percentage of ESD patients provided with a JCP/Personal Health Plans 95% Percentage of patients reporting information in JCP/PHP as relevant and useful 70% Selfmanagement Percentage of patients referred to and taking up a self-management course year 1 baseline Percentage of patients referred to and taking up healthy lifestyle advice services 6 month reviews % of patients accepting a 6 month review % of patients with action plan to address un met needs following 6 month review 90% of people discharged from hospital with a confirmed stroke, who are alive six months following discharge from hospital. Service User Experience % of patients satisfied with service Between % satisfied or very satisfied with the support 20

39 they received Adequately trained ESD Workforce - Planning meeting MDT meetings GP Discharge Summaries Evidence of competency profiles for staff members and stroke training Evidence that each patient has at least one family meeting during an admission to ESD Evidence of weekly (as a minimum) MDT/Review Percentage of discharge summaries sent to GP within 48hrs of discharge from ESD service 90% Quarterly Report 100% Local standard 5.1 Further Quality Requirements Audit Annual Audit against relevant NICE clinical guidelines Number of complaints including reasons and subsequent actions Number of compliments and reasons Evaluation of health outcomes for the population via Stroke Impact Scale/EQ5D or equivalent Evaluation of unmet-needs identified on 6 month review Percentage of discharge summaries sent to GP within 48 hours of discharge from ESD Service Audit of which services patients are referred to/continue with following ESD intervention Workforce Team Configuration and vacancy rates Results of annual staff satisfaction service Comprehensive straining programme and CPD ( internal and external) Clinical Effectiveness (as reflected in KPI above) Measureable improvements should relate to functional activity and identified disability mobility. The recognised measures include: Modified Barthel & Modfied Rankin Score; GAS; Nottingham extended ADL score (N-eADL); Stroke Impact scale; BCoS. Discs/Distress Thermometer Satisfaction with Service Family and Friends Assessment Analysis of Service User/Carer surveys; Evidence of stroke forum/focus group across the health system Staffing The staffing structure will be modelled in two ways: 21

40 1. Cochrane recommendations for staffing a stroke rehabilitation ESD service; where standards change a discussion between commissioner and provider will take place. 2. Delivering the recommended number of daily inputs (1) for all 3 therapy disciplines. (1)Input = Single visit from individual therapist (PT / OT / SLT or TA) Where a session is delivered by 2 different professionals and the activity addresses tasks associated with each, this will count as a single input by each discipline, where the profession is the same or the activity is uni professional this will count as one input only The duration and intensity of input is subject to individual Service User need and can radically differ across the Service User cohort. It is recognised that the need for flexibility is necessary across the disciplines. RCP 2012: Specialist Practitioner A specialist is defined as a healthcare professional with the necessary knowledge and skills in managing people with the problem concerned, usually by having a relevant further qualification and keeping up to date through continuing professional development.. It does not require the person exclusively to see people with stroke, but does require them to have specific knowledge and experience of stroke. RCP 2012: Specialist Team A specialist team or service is defined as a group of specialists who work together regularly managing people with a particular group of problems (for this guideline, stroke) and who between them have the knowledge and skills to assess and resolve the majority of problems. At a minimum, any specialist unit (team, service) must be able to fulfil all the relevant recommendations made in this guideline. As above, the team does not have to manage stroke exclusively, but the team should have specific experience of and knowledge about people with stroke. GM-SAT_proforma.p df South Central Stroke strategy - full 6_Month_Review_-_colour[1].pdf version.pdf NICe stroke rehab guidance - June 13.pdf Stroke Pathway ndi STROKE COMMUNITY A Primary Prevention Ambulance GP Referral A&E Self- Presenter HASU ACUTE ASU Discharge Coordination ESD/ACUTE MDT/IDT ESD 6 Month Review Community Rehab Primary Care Discharge to Primary Care Long Term Services In-Hospital Stroke Care SECONDARY PREVENTION 22