Early Supported Discharge (in the context of Stroke Rehabilitation in the Community)

Transcription

1 Early Supported Discharge (in the context of Stroke Rehabilitation in the Community) Gold Standard Framework This document was produced with reference to national standards for best practice (e.g. NICE guidelines), a consensus document on stroke (Fisher et. al, 2011) and local expert opinion/benchmarking of ESD teams within Cheshire and Merseyside Early supported discharge (ESD) teams should be commissioned as part of a whole pathway commissioning approach (National Stroke Strategy, 2007) Stroke Rehabilitation PART 1 Models of Service Delivery People who have had strokes access high-quality rehabilitation and, with their carer, receive support from stroke-skilled services as soon as possible after they have a stroke, available in hospital, immediately after transfer from hospital and for as long as they need it Quality Marker 10, Stroke Strategy Aim of Early Supported Discharge (ESD) Team Different models of ESD An ESD team should, according to needs and preferences of individual patients: Facilitate earliest possible safe discharge from hospital, (wherever possible to the usual place of residence). Provide high quality, stroke specialist multi-disciplinary rehabilitation; the initial frequency and intensity of therapy intervention must be at least equivalent to what would be provided on a stroke unit and be reduced gradually based on need. It should not result in a delay in care. ESD is just one part of the patient pathway for a proportion (typically about 40%) of stroke patients. Locally, consideration should be given to how ESD fits within the entire pathway to ensure there is not a two tier system at the expense of non-esd patients and to ensure smooth transition into longer term rehabilitation and support services. An integrated approach with Social Care is essential and a joined up approach to commissioning may be needed to facilitate this. The models may vary depending on what is provided across the whole pathway within a locality but all should provide the same level of quality. In reach vs Outreach Consideration of the local context and a whole pathway approach is key to ensuring the highest quality of rehabilitation for all patients. Outreach teams will need to work closely with community rehabilitation teams to ensure there are no excessive gaps when referring on. In contrast, in reach/community based teams should have a presence on the ward and be a key part of the

2 discharge planning in order to facilitate the meeting of quality standards e.g. first contact within 24 hours of discharge, joint MDT care plan negotiated with patient/carers within 72 hours of referral to ESD team etc Referral Criteria 5 or 7 day service All ESD teams should offer at least a limited service at weekends to enable safe and timely discharge and respond to urgent needs. Therapy intervention at weekends should be available based on patient choice and if it is clinically appropriate. Analysis of capacity and demand should inform planning service delivery over 7 days that meets the required quality standards. ESD 18 years + Registered with a GP or residents (by postcode) within a defined area Clinical diagnosis of stroke (or subarachnoid haemorrhage if other suitable services are not available) Under the care of a Stroke Consultant Medically stable Continence and nutrition plans in place and needs can be met Risk assessment indicates patient is safe to be at home (taking into account home circumstances) The discharge destination is a suitable environment in which to carry out rehabilitation The patient is able to engage in rehabilitation and progress towards goals Can transfer independently or with one person/have a barthel score greater than 9 for pure ESD provision. There is increasing evidence within established ESD teams that more complex patients can also benefit from ESD, e.g. those that transfer with two. Where an ESD pathway is part of a broader community rehabilitation team or accepts more complex patients as part of a whole pathway approach (different referral criteria) this will have implications for team composition and skill mix. Length of time can access ESD pathway Non ESD Pathway for patients outside of ESD criteria There should be clear local guidance for pathways for non-esd patients. Recommended range= between 6 and 16 weeks depending on the longer term rehabilitation and support services available. The ESD pathway should be a core component of a stroke rehabilitation and support pathway with access to stroke skilled staff for up to six months post stroke depending on need. Patients eligible for an ESD pathway will typically require the high intensity of input for up to 6 weeks. For patients that require further stroke specialist rehabilitation at a reduced intensity (including non-esd patients) there should be appropriate pathways in place. e.g. ESD and non-esd pathways provided by the same team (often community based) Managed transition from an ESD team (often outreach) to a community stroke or neuro team To ensure flow through these pathways it is important to for stroke

3 rehabilitation teams to have clarity on other support services post the stroke specialist rehabilitation period (e.g. emotional support, life after stroke programmes, cardiac rehab etc.) including those provided by CCG funded voluntary sector providers. Opportunities to work in collaboration with these services and the voluntary workforce (e.g. carers, expert patients, volunteers) should be explored locally to ensure an integrated whole pathway approach A gold standard ESD team will work closely with acute staff and community teams and support services to ensure flow of patients along the entire pathway. Commissioners may need to consider how to address any blocks in the pathway or consider options for continued rehabilitation post ESD when required, potentially through a whole pathway approach. Part 2 Workforce and Skill Mix Early supported discharge teams should: Be multi-disciplinary As a minimum should include dedicated physiotherapy, occupational therapy, speech and language therapy and access to psychological support in line with the sentinel stroke national audit programme/nice guidelines Have specialist knowledge in stroke care and rehabilitation Be organised by a team coordinator a Band 7 AHP with at least 5 years experience in neuro/stroke. Additional sessions should be allocated for this to ensure there is no negative impact on face to face time within one therapy discipline. For a 100 patient per year caseload (note these figures were based on providing a 5 day service and would need adjusting to provide a 7 day service): 1.0 Physiotherapist (dedicated) 1.0 Occupational Therapist (dedicated) 0.5 Speech and Language Therapist (dedicated) Social Worker (consideration will need to be given to how to achieve an integrated model if there is not dedicated social worker time into the team) Nurse (more nursing input will be required for teams where increasingly complex patients are discharged earlier and supported by the team) 0.1 Physician (teams that have this typically use the time to contribute to an MDT meeting) 0.25 assistant (though many teams make greater use of assistant roles) Access to Psychological support Access to dietetics Based on a consensus (Fisher et. al., 2011) Improvements in access to psychological support by ESD patients need to be demonstrated over time in line with the national drive to improve access to psychological support.

4 Skill Mix: Services can be flexible and use judgement in the use of skill mix to ensure a high level of specialist knowledge and skills and adequate support for the range of grades within the team, e.g. assistant practitioners taking on extended roles where there is support available from qualified staff with specialist skills and experience, band 5 staff working jointly with a senior clinician until a level of competency is attained. There are opportunities with the possibility of collaboration between stroke services and whole pathway, outcome based commissioning to think innovatively about these workforce issues, e.g. having an expert/consultant therapist across a larger geographical patch to focus on quality and improvement, ensuring a range of posts at different bands across the team, flexing staff across integrated pathways, coordinated approaches to recruiting and developing new graduates, e.g. rotational posts, maximising the skills of assistant practitioners. Managers and commissioners should consider local geography and travelling distances and costs when agreeing staffing levels. Part 3 Measuring quality, performance and outcomes A gold standard ESD team should: Measurement Have agreed local processes for collection of performance data and Improvement Will be registered with the Sentinel Stroke National Audit Programme (SSNAP) and input all required fields to SSNAP on a regular basis Will own their own performance data and will work with senior managers and commissioners locally to drive improvements Have a service improvement plan in place which addresses workforce, recruitment and retention issues; staff training and development; improvements in data collection and reporting, and quality of clinical care against NICE guidelines. Audits itself against the NICE stroke rehabilitation guidelines and incorporates into service improvement plan to be shared with commissioners as required Evidence that the service has contributed to work with all stakeholders to look at financial sustainability of all services across the whole stroke pathway, including consideration of unbundling of the stroke tariff Quality of care and patient experience Quality Indicator Measures collected through SSNAP can be looked at by Trust and CCG Local arrangements should be in place to ensure seamless transfer of care, e.g. joint discharge visits, joint discharge planning meetings Joint health and social care plan Measure Submit data on all relevant measures and receive quarterly reports Agreed process developed jointly (ESD team(s) and acute team), 100% of transfers of care in line with local process 100% of patients with a personal copy

5 developed jointly with families that supports seamless transfer from hospital (need a clear and regionally agreed and understood definition of this to ensure relevance to patients with different needs) Ensure patients are safe for discharge, e.g. equipment in place, training of carers completed, appropriate nutrition/continence plans in place Local arrangements in place to ensure integration with social care for those that need it All patients eligible for ESD are able to access it (typically around 40% depending on case mix) of a joint health and social care plan developed in collaboration with patients, carers and families Exception reporting of readmissions or incidents relating to unsafe discharge Potential measures: reduction in total number of visits from ESD and social care due to shared planning, exception reporting of delayed discharge due to delays in social care packages Report % and exception reporting of where patients are unable to access ESD Visit at home within 24 hours of discharge by a relevant member of the specialist stroke rehabilitation team for assessment of patientidentified needs and the development of shared management plans Shared responsibility with the acute service to reduce or (for established ESD teams) maintain a low level of length of stay Report on % achieved Exception reporting of delayed discharge due to capacity of ESD team 100% patients have rehabilitation goals jointly agreed with patient/carer within 72hours of discharge - the patient and their family/carers should receive a copy of the goals which is appropriately formatted for their individual needs. Provide 45 minutes of therapy from each relevant stroke rehabilitation therapy (physiotherapy, occupational therapy and speech and language therapy) for a minimum of 5 days per Report on % achieved Measured by % of patients receiving 45 mins of each therapy, 5 days a week for first 2 weeks post discharge

6 week to people who have the ability to participate, and where functional goals can be achieved. Intensity to be reduced gradually with a planned transition to longer term rehabilitation and support services. Mood screen completed within 6 weeks if not completed as an inpatient Increasing levels of access to psychological support when needed Report on % achieved Referral rates and/or waiting times Patient experience measures agreed with local commissioners via a survey of all patients 100% patients receive a survey. To include questions about: level of satisfaction with their involvement in the development of the joint health and social care plan % of patients that report receiving a copy of this plan Carer satisfaction with support and training prior to and during discharge Outcomes Collect the nationally agreed outcome measures and submit these via the SSNAP audit (where possible this should the primary method for measuring outcomes used by commissioners) 100% of patients should have a record of outcome measures within one week of arrival to the team that can be reviewed within an agreed timeframe. Changes over time to be reported. Will have own local processes for measuring and reporting on outcomes agreed with commissioners as appropriate that include - Patient centred scale - Functional outcome measure - Patient satisfaction - Mood screen Key markers of quality longer term rehabilitation (ESD or broader community stroke/community neuro rehab teams) - % increases from baseline targets to be defined Reduce dependency and enable patients to self-manage, e.g. by working in collaboration with third sector organisations Increasing number of patients able to access psychological support Increasing number of patients able to access return to work support if appropriate A joined up whole pathway approach to reviews at 6weeks, 6 months and 12 months post stroke There should be the flexibility for re-referral into stroke specialist rehabilitation services where it is clinically appropriate e.g. botox therapy for spasticity re-referral rates to be reported to commissioners to identify gaps

7 Contributors A task and finish group produced the document at an initial meeting which was reviewed at a follow up meeting. The document was shared for wider consultation via a stroke therapist network meeting along with a group of patients/carers, a representative from the Stroke Association and a commissioner. Name Role Involvement Jenny Ryan ESD, Wirral University Teaching Hospital NHS Trust Chair, C&M Stroke Therapist group 2 meetings and comments Ruth Witham Jane Hogan Denise Coughlin Tony Probbing Michelle Keay Jennifer Currie Stella Dynes Marie Florian Clinical specialist physiotherapist in Stroke, ESD, Warrington & Halton Hospitals NHS Trust ESD, Aintree University Hospitals Trust ESD, St Helens and Knowsley NHS Teaching Hospital NHS Trust Therapy Manager, Wirral University Teaching Hospital NHS Trust Senior Dietitian, Gerontology and Stroke, Royal Liverpool and Broadgreen University Teaching Hospital NHS Trust Physiotherapy Team Lead (ESD), Royal Liverpool and Broadgreen University Teaching Hospital NHS Trust Liverpool Heart and Chest Hospital 2 meetings and comments 2 meetings 2 meetings Claire Hammill Quality Improvement Lead, CMSCN 2 meetings References Department of Health (2007) National Stroke Strategy. CQC. Fisher, J. et. al. (2011) A Consensus on Stroke: Early Supported Discharge. Stroke (p ) National Institute for Health and Care Excellence (2013) Stroke Rehabilitation: Long term Rehabilitation after Stroke. NICE.