Developing a Community Stroke Rehabilitation Team by qov12652

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									                                                          I had a dream………..
   Developing a Community
  Stroke Rehabilitation Team


               Dr Jane Williams,
        Consultant Nurse in Stroke Care
        Portsmouth Hospitals NHS Trust




              The Proposal

• To develop a Community Stroke Rehabilitation                                     Waterlooville
  Team by closing an in-patient stroke
  rehabilitation ward (patients aged 65 years and
  over) and re-using the WHOLE resource to          Portsmouth
                                                                                   Hayling Island
  enable patients to return home much sooner
  than was currently possible.

                                                                               Population approx
                                                                               285,000




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               Evidence Base                                      Supporting Evidence
                                                         • NSF for Older People
 • Cochrane Stroke Group systematic review, Lancet,      • RCP National Clinical Guidelines for Stroke 2001 & 2004
   2004                                                  • Stroke Review : local document
 • RCP Stroke Guidelines 2000 & 2004                     • Goal setting audit: health authority funded March 2002
 • Legg L. Lancet, 2004                                  • Visits to other areas of good practice : Sheffield &
 • Lincoln N. et al. Clin Rehabilitation, 2004             Dartford.
 • Langhorne P. et al. Lancet, 2005                      • Evidence of individual teams publications/reports/cited
                                                           as good practice such as Worthing, Newcastle and
 • Fjaertoft et al. cerebrovasc’ Disease, 2005             Ulster.
                                                         • Patient/carer/clinician experience.




                                                                   The Business Case
          Conventional Care
                                                                            Background
• Acute stroke ward, in-patient rehabilitation
  according to home address and age
• Patients wait for in-patient rehabilitation            • June 2004 – 1st business case presented
• Patients discharged without in-patient                 • Requested further detail, plus evidence of
  rehabilitation                                           “cost neutrality”
• Long waiting times for community therapy – may
  delay discharge or lose progress made during
                                                         • SE seconded from SLT for 1 month to
  in-patient stay                                          complete
• Patient and their family not prepared for life after   • A challenging time
  stroke in the community




                                                                                                                     2
            The Business Case                                          Project Management
                       The reality                               Developed clearly defined streams of work


• No consensus from Coalition Board on                          1. Organisational
  format/detail required                                        2. HR
• Inconsistencies across PCTs                                   3. Finances
• Difficulties in engaging acute trust on vital                 4. Clinical
  financial decisions                                           5. Education and Training




           Project Management                                       Appointing team leader
      Communication and dissemination

•   A priority from the beginning
•   Monthly newsletter – even when there was no news          • A priority for dedicated time to lead the project
•   Held briefing sessions, workshops, stakeholder events       and team inception
•   Unions involved from the outset                           • Pivotal to the success
•   Entries in info’ exchange, Link, Primary Care bulletins   • Personal and professional challenges
•   Info’ leaflet for patients and relatives
•   Meetings for relatives                                    • Uncertainty
                                                              • Leap of faith




                                                                                                                    3
                       Coalition Board                                                                                         The Team
      Reaching and sustaining decisions
                                                                                                    •   Team leader (1 x 8a)
• Presented at meetings                                                                             •   Nursing team (1 x 7, 1 x 6, 4.5 x 5, 6 x 3)
• High challenge – little support at times
• Refocusing leadership threatened process                                                          •   Physiotherapy (1 x 7, 2 x 6)
• Decisions made were not carried through at operational                                            •   Occupational therapy (1 x 7, 2 x 6)
  level
• Frustration all round at times                                                                    •   Speech and Language Therapy (0.5 + assistant)
• Last meeting – “what a shame we didn’t do this two                                                •   Associate Practitioners ( 3 x 4)
  years ago”      arghhhhhh!
• Go ahead……..and do it in three months!                                                            •   Team Administrator




                         Referral Criteria
                                                                                                               What should we measure?
•   The patient is aged 65 or over.                •   The home environment is conducive to
•   Confirmed diagnosis of new stroke.                 community rehabilitation (this may
•   Agreement that the patient is sufficiently         require an access visit).
    medically fit to be managed at home.                                                            •   Demographic information
                                                   •   The patient and their family/carer is
•   The patient is currently an inpatient.             agreeable to rehabilitation at home,         •   Numbers and dates of referral to CSRT
•   Referral is from a healthcare                      including the installation of necessary      •   Number not accepted to CSRT and reason why; details when no CSRT
    professional, following completion of a                                                             intervention
    comprehensive assessment which                     equipment and care to support this
    follows Intercollegiate Stroke Guidelines.         process.                                     •   Date entry to CSRT
•   Continence needs can be managed                •   The patient/carer accept that the service    •   Length of stay as inpatient, plus details of any discharge delay
    within the home environment.                       is time limited to 16 weeks maximum.         •   Predicted length of stay saving
•   Patients nutrition and hydration can be
    met orally or by established PEG feeding       •   Achievable rehabilitation goals can be       •   Length of input from CSRT, with full details of health and social services
    (i.e. not NG feeding)                              identified.                                      involvement.
•   Following a moving and handling risk           •   There will be flexible and reciprocal        •   Health and social services required on discharge from CSRT
    assessment, the patient has functional             agreement between rehabilitation
    sitting balance and is able to transfer with                                                    •   Length of delay in accessing other services, if appropriate
    one or two, ± equipment.                           services/intermediate care, to determine
                                                       who best meets the needs of the patient      •   Barthel on entry
•   If the patient was previously wheelchair
    independent they should have the ability           for onward referral.                         •   Barthel on discharge from CSRT
    to transfer.                                   •   The patient is registered with a GP within   •   Carer stress levels
•   The patient is deemed to have adequate             Portsmouth City or South of East Hants       •   Any specific comments, readmission details or identified benefits to patient
    cognitive ability to cope at home with or
    without care.                                      PCT.                                         •   Qualitative information, eg patient and family satisfaction




                                                                                                                                                                                       4
    What the patients say…..                              What the relatives say…..
• “Lots of humour and fun. I’ve had a fantastic       • “You couldn’t have been better”
  time and that’s helped me as much as anything”      • “We think the way mum was included in deciding
• I was in my own home with the incentive to get        what her needs were and then to work with her
  better. So I relaxed and got on with it”              to achieve them went well. “You made sure her
• It released my daughter to go back to work with       dignity was respected at all times along with
  less stress”                                          adapting to her usual routine”
• “I was frightened as I was no longer in charge of   • “The community stroke rehab team is a credit to
  my life. They helped me not to be frightened”         the NHS. We hope that the dedication of the
                                                        staff will stay strong”




                Evaluation                                            Evaluation
        Knowledge & Confidence                                        Carer Stress
• Transfer of knowledge and skills through            • Concerns over impact on carers of early
  working closely with patient & families               discharge, plus team visiting was addressed at
• Leads to greater confidence                           all stages of team development
                                                      • Evidence shows respect of carer with reduction
• Leads to greater functional outcomes
                                                        in stress due to support, education and
• Confidence is quoted in over 80% of                   confidence building
  feedback interviews                                 • Continue to build links with Social Services




                                                                                                          5
                        End of Year One                                                      Comparison of length of stay pre and
                    April 2005 to March 2006                                                            post CSRT
• 83 patients discharged from CSRT
• Average LOS with team 60 days
• Average Social Service savings of £3,748 per
  annum per patient have been demonstrated in
  packages of care alone
• Based on 2004 activity for closed ward used in
  the business case demonstrates a saving of
  £2711 per patient
• So difficult to calculate – no clear reference
  costs + organisational changes = muddle!




Comparison of cost of Package of Care over 90
                                                                                           End of Year Two: April 2006 to March 2007
       day period pre and post CSRT
                                                                                                     Year         Exton 3       Guernsey +         CSRT
                                                                                                    2003/4            84             98
                                                                                                  Discharges
       £3,500.00                                                                                 Reference Cost
                                                                                                                  unavailable    unavailable
                                                                                                 Cost per case
       £ 3,000.00
                                                                                                    2004/5           111            119
                                                                                                  Discharges
       £2,500.0                                                                                  Estimated Cost   £851,118       £950,000
       0
                                                                                                 Cost per case    £7,667.73      £7,983.20
       £2,000.0                                                                                     2005/6                          134              83
       0
                                                                                                  Discharges
       £1,500.00                                                                                 Reference Cost                  £1,985,133       £422,190

                                                                                                    Activity                       9,712            12,648
       £1,000.00                                                                                   measured                     OBDs@£204.40   Contacts@£33.38

                                                                                                 Cost per case                     £9,844          £5,073
        £500.00                                                                                     2006/7
                                                                                                  Discharges                        150             127
          £0.0                                                                                   Reference Cost
          0         1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16
                                                                                                                                 unavailable     unavailable
                                                                                                 Cost per case




                                                                                                                                                                 6
            Length of Stay                                         Key Successes
                    2005/06      2006/07
                                                    •   Improved outcome for patients
                                                    •   Department activity improved
                                                    •   Financial balance achieved
         CSRT        59.55        57.44             •   Financial savings evident
                                                    •   Service redesign achieved
                                                    •   Evidence base for early supported discharge enhanced
                                                    •   Phase two development being supported
       Guernsey      49.41        28.85             •   National profile of stroke care in Portsmouth enhanced




        The road to success                         Reflections & Recommendations
• Ensuring the patient was central to the process   • Need time to undertake thorough exploration & analysis
  and involved where possible.                        of the proposal .
• The success of the project required passionate,   • Timely recruitment of the team leader was pivotal to the
                                                      success of team.
  determined, champions with vision.                • Risk taking: personal, professional and service.
• Remaining focused on the opportunities.           • Communication, communication, communication.
                                                      Patients, staff, relatives, PCT’s, adult services, HR,
• Joined up thinking and partnership working.         voluntary and private sector.
• To expect and welcome constructive challenges.    • Constructive challenge and timely support.
                                                    • Need to develop and empower staff to become clinical
• Peer support                                        leaders.
• Future proofing.                                  • Keep focused, have a clear vision,keep promises and
                                                      ensure the patient is central to the process.




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                     Contact Details

            jane.williams@porthosp.nhs.uk


                              Thank you

Acknowledgements
Sarah Easton – CSRT, Team Leader
Nicky Moran – Clinical Specialist Physiotherapist
AND – the fantastic team!




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