Stroke ilitation And Community Care Damian Jenkinson ilitation After Stroke National Clinical Lead NHS Stroke Improvement Programme Consultant Stroke Physician Royal Bournemouth & Christchurch NHS Foundation Trust Stroke ilitation Services Person with Stroke Stroke unit Early supported discharge Continuing rehabilitation Specialist Community Stroke Team 1. Stroke Units 2. Early ed Discharge 3. Out Patient Stroke Services 4. Community Occupational Therapy Long term support and re-assessment of needs Stroke Interventions: Public Health Implications Intervention Absolute Risk Reduction for death and dependency Eligible proportion of stroke patients Death and dependency avoided in all stroke Stroke Unit 5.6% 0% 5.6% Early ed Discharge Aspirin <48h rt-pa <3h Hemicraniectomy <48h 5.5% 40% 2.2% 1.2% 85% 1.0% 13.1% % 1.3% 22.7% 0.5% 0.1% Adapted from Gilligan et al 2005 Characteristics of Acute Stroke Units Continuous physiological monitoring 81% Access to scanning <3h of admission 99% Direct admission from A&E 24% Specialist ward round 7/week 11% Acute stroke protocols/guidelines 99% Nurses swallow-screen trained 88% Nurses trained in stroke assessment 90% All 42% RCP NSA 20 1
Nine Key Indicators - Changes Over Time in ENGLAND(%) Stroke and TIA Vital Signs Trajectory to Target 80% 70% 60% 50% Stroke: Proportion of patients spending more than 90% inpatient stay on a stroke unit Stro ke desired positio n 90% stay on stroke unit STROKE TIA Patients (%) 0 90 80 70 60 50 40 30 51 59 62 85 74 67 71 57 43 93 92 85 85 71 72 85 86 73 68 57 50 81 66 54 95 87 76 60 73 83 2006 2008 20 40% 30% TIA: Proportion of high-risk TIA patients completely treated within 24h of referral TIA desired po sition High risk TIA treated <24h Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 STROKE 39% 40% 45% 47% 52% 58% 58% 61% 68% 73% 75% 75% TIA 36% 40% 44% 47% 49% 46% 51% 56% 56% 58% 64% 66% NB A definition change in Q1 08/09 means that direct comparisons with previous quarters may not necessarily be valid DH analysis of vital sign data 20 0 Patients spent Screened Brain scan within Aspirin <48 hours Physiotherapy Assessment by OT Weighed at least Mood assessed by goals Average for key 9 90% stay on swallowing <24 24 hours after stroke assessment <72 <4 working days once during discharge agreed by the indicators Stroke Unit hours hours admission multi-disciplinary team Key Indicator Amount of therapy received London: Productivity PHYSIOTHERAPY provided on applicable days National 45 min and above 32% Less than 20 min 33% 20 Average length of stay 60% HASU destination on discharge OCCUPATIONAL THERAPY provided on applicable days National 45 min and above 31% Less than 20 min 42% 18 16 14 12 8 50% 40% 30% SPEECH & LANGUAGE THERAPY provided on applicable days National 45 min and above 18% Less than 20 min 64% Key Message Therapy time should be spent delivering direct patient care and administrative work should be kept to a minimum 6 4 2 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 2009/ 20/11 Average total length of stay fallen from 15 days in 2009/ to 11.5 days in 20/11 YTD. 20% % 0% Home Other Stroke Unit RIP (blank) 35% of patients discharged home from HASUs. Estimate at beginning of project was 20%, and national mean is 15% at 3 days. Early ed Discharge Purpose: Improve outcomes, accelerate discharge home from hospital and provide rehabilitation and support in the home setting Only 18% PCTs report fullyspecified ESD Fear of costs of double running Requires shared, patientcentred vision and trust Main Areas of Accelerated Work Domains Key Areas of Focus Joining Up Prevention AF Detection and Treatment Timely and effective management of TIA Implementing i) Proportion of patients Improving Post Best supported Practice by a Hospital stroke and in Acute skilled Care Early ed Long Term Care. Discharge team (40% by Direct April 2011) Early ed Admission to Discharge a Stroke ii) Presence Unit of Joint a stroke Care Plans Timely skilled Brain Early ed using Single Scan Discharge team Assessment Process Review at 6/52, 6/12 and yearly Carers Assessment Psychological 2
Conventional Stroke Services Early ed Discharge (ESD) Admission Discharge Review Admission Discharge Review Hospital Acute ilitation Hospital Acute Home Home ESD team: PT, OT, SW, nursing etc Quality and Productivity of ESD Tariff Unbundling to ESD East Midlands Network Savings identified from change in pathway Reduced LoS before Trim Point unbundle tariff and PCT/other provider fund acute provider with vertical integration Reduction in excess bed-day costs beyond Trim Point Reduction of beds/re-use of beds for elective work income Residential/nursing home costs Price Unbundled Tariff for AA22Z Based Upon Length of Stay 5,000.00 4,500.00 4,000.00 3,500.00 3,000.00 2,500.00 2,000.00 1,500.00 1,000.00 500.00 0.00 1 4 7 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 Length of Stay To assess the effects of therapy based rehabilitation services targeted towards stroke patients resident in the community within one year of stroke onset. The exact form (e.g. domiciliary, day hospital, outpatient clinic) was recorded but not used as an exclusion criterion. Compared with conventional care (i.e. normal practice or no routine intervention). 14 trials Heterogeneous interventions Including 1617 patients Patients receiving rehabilitation at home within one year of stroke onset are more likely to have a better outcome, in terms of independence and achievement of maximum level of function in all aspects of daily life. Lancet 2004; 363: 352-356 3
Personal ADL Extended ADL Workforce: Key facts Only 25% stroke units have adequate staff levels Home-Based or Centre-Based ilitation for Community Dwellers? Barthel Index at 6-8 weeks post-intervention Patchy access to psychologists, dieticians and social care Only 20% recommended number of stroke physicians Barthel Index at 3-6 months post-intervention UKFST and SSEF addressing issues of: No nationally-recognised stroke-specialist courses or competences for nurses or AHPs Many staff in traditional unidisciplinary roles without training in leadership and effective teamworking Community Care Personalisation agenda still the key driver Emphasis by social care on prevention and early intervention Reablement is a key service to help delay demand on LA services Eligibility criteria for social care raised across most councils Target to increase the provision of Personal Budgets still in place More emphasis on supporting carers, again, to reduce demand on LA services Care home residents Provision 486,000 beds in UK, majority private sector (54% single home ownership) Projected demand 1.5million by 2050 Residents Typically female >80 years, previously living alone in rented accommodation >50 % dementia, other degenerative disease or vascular disease, ~25% stroke/tia. 76 % require assistance with mobility or are immobile 71 % are incontinent. 4
A Survey of Immobility Related Complications After Stroke Residents with stroke Contractures- 59 (48%) Pressure sores- 24 (20%) Shoulder pain-59 (48%) Falls- 80 (66%) Other pain- 59 (48%) Occupational Therapy in Care Homes (OTCH) trial Care Homes Webpage updated, covering: National policy Getting started Key issues Training Reviews & specialist input Making the case Case studies Skills for Care - QCF competencies for stroke Psychological Care After Stroke Specialist Community Stroke Services Producing Collaborative Guidance Reaching Consensus Modified Delphi technique Review existing literature Draft initial statements Consensus Panel Consensus document Stroke ilitation And Community Care Stick to the evidence base Emphasise intensive, taskorientated therapy Be Innovative! From: Developing the NHS Commissioning Board July 2011 5