Early Supported Discharge. Heather Campbell Neuro-Rehab Pathway Manager GSTT Community Health Services

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1 Early Supported Discharge Heather Campbell Neuro-Rehab Pathway Manager GSTT Community Health Services

2 Overview Evidence for ESD History in Southwark Economic modelling Continual service redesign How it works Why it works Possible futures

3 Evidence Can reduce long term dependency Reduces length of stay in hospital Needs to be well co-ordinated and staffed by specialist teams Cost savings to hospitals and social care but overall cost likely to remain the same

4 History of ESD in Southwark Stroke Modernisation Initiative Integrated Health & Social Care National Stroke Strategy

5 Stroke MI Economic Model Model designed on assumed costs of optimal service and 9 bed days saved per pt Southwark PCT and Southwark Social Care funding. Acutes to contribute when savings demonstrated Assumed 33 suitable patients, saving 109,000 Instead 62 patients, saving 184,000 ( patients..)

6 Social Care Outcomes % with previous cp where increased at end of RSW input % of cp decreased after input Stroke Rehab Social Care Costs % avoided placement % of cp decreased after input % avoided placement % returned to preadmission care package % needing no care package % returned to pre-admission care package % needing no care package % with previous cp where increased at end of RSW input

7 Person-centred Outcomes I have more confidence to let patients go home earlier, you know they are getting specialist rehab as soon as they get home. Staff - Acute sector It was great to see a therapist (community) in hospital and know that I would be seen immediately I got home - it really reduced my concerns about going home. Service User I feel we make more of a difference, we get to see them (patients) earlier and more intensively with less dependence on Social Care Packages. Staff - Community sector...with RSW input, Mrs T received more consistent therapy and her rate of improvement increased almost immediately... I feel the RSW input was the turning point in Mrs T s rehabilitation. Staff community sector The RSW s have made a big difference in what Mrs R can do with her hand. [Mrs R] has told me that they make sure she uses it during personal care every morning. And I know carers wouldn t have done that. Staff community sector The RSW s have been very helpful... and made a difference to getting back my independence... I m almost back to where I was before the stroke Service user

8 Service design and redesign doing more on less 7 day service, 10 RSWs, Therapists on call All Neuro Team do ESD Hospital Discharge SWs Community SWs Psychology RSW manager, SPOCs 7 days, reduced hrs,6 RSWs, care agency on call Stroke ESD specific Therapists Withdrawn. Principal Stroke Therapist co-ordinates Withdrawn. Duty system ASI pilot new leaflets, signposting, awareness New post- Principal Stroke Therapist (3 jobs in 1!)

9 Criteria All strokes come to us 12 weeks (average 7-8) Capacity = 18 GAS goals In reach - Acute MDMs, Hospital Discharge SW, Community MDMs, allocation meetings After 12 weeks may go to LTC pathway

10 Client Communication Agreed Pathway, revisited Governance KCH Stroke Governance Meeting Stroke Network Mark Ward Steering Group Lambeth & Southwark Stroke Steering Group

11 . The Future Pressures and priorities

12 GSTT,KHP and Social Care priorities Admission avoidance, prevention Services closer to home Smooth and integrated care pathways Supporting people with LTCs Personalisation

13 Any Questions?

14 Vote 1. Is Early Supported Discharge sometimes too early? 2. Does focus on acute stroke care and ESD draw resources away from support for those living with stroke? If your answer to either is yes, what are you going to do about it?

15 Contact Heather Campbell Neuro-Rehab Pathway Manager GSTT Community Services Dulwich Community Hospital East Dulwich Grove Se 22 8PT Tel: /3597 Or Karen Smith, Principal Stroke Therapist

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