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Commissioning stroke rehabilitation - Making London's healthcare

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					Healthcare for London’s stroke
rehabilitation commissioning
guidance: an introduction
 Dr Tony Rudd
 London Stroke Clinical Director

Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business support to London’s NHS.
Lecture outline

• Background
• Brief review of evidence
• Key elements for a comprehensive stroke
  service
National Stroke Strategy, DH, 2007


 “For those who have had a stroke and
 their relatives and carers, whether at home
 or in care homes, to achieve a good
 quality of life and maximise independence,
 well-being and choices”.
Everyday in London…
Approximately 54 people will have a stroke.
6000 per year with lasting disability.
Stroke pathway
                                                                   Access to leisure,
                             Stroke   Tailored      Self care/
 Primary    Rapid     Thromb                                            employment,
                              Unit     Community    Peer support
Prevention detection -olysis                                              other
                              care     rehab       Sign posting
                                                                    opportunities

                      Quality information for users and carers

                        Quality information for professionals

               A workforce skilled in working with people with stroke

                         Preventing a further stroke or TIA




 Acute phase recovery                                    Living with a disability
                           Learning to live with a
                                  disability
Chapters in rehabilitation commissioning
guide
•   Inpatient rehabilitation
•   Community rehabilitation
•   Early supported discharge
•   Support structures
•   Regular review
Stroke Unit care

• Every PCT commissions inpatient
  rehabilitation that is available for all stroke
  patients. This should start as soon as
  possible and continue for as long as
  required. This service must meet all of the
  performance standards.
                   100




                   80




                   60




                   40
Percent Survival




                                                                          Stroke unit

                   20                                                     SU-censored

                                                                          Conventional w ards

                    0                                                     CW-censored
                         0   1   2   3    4      5   6   7   8   9   10


                         Survival time (years)
              160


              140                                                                            Belgium

              120                                                                            England

              100                                                                            Switzerland
time (min.)




               80                                                                            Germany

               60


               40


               20


                0
                    total therapy   physio-therapy   occupational therapy   speech therapy   other therapies
Effects of augmented exercise therapy time after
stroke
Kwakkel et al, 2004



 • 20 trials, n=2686
 • Significant effect on activities of daily living in
   first 6 months after stroke
 • No ceiling effect for therapeutic intensity

 • 16 additional hours
Community rehabilitation

• Every PCT should commission a
  community rehabilitation service for stroke
  patients, delivered by staff with stroke
  specialist skills. Service configuration
  should be locally determined and the
  service must meet all of the performance
  standards.
Outpatient Service Trialists
Personal ADL
Outpatient Service Trialists
Extended ADL
Equipment and environmental
adaptations
– 47% of equipment never used
  (Gitlin et al, 1996)

– Lack of information on
  availability
  (Mann et al, 1995)

– Stroke patients using more
  equipment / environmental
  adaptations and significantly
  more independent at one year
  after stroke
  (Logan et al, 1995)
Simple, inexpensive AND effective
Community rehabilitation

• Key gap: A lack of timely access to a
  community rehabilitation team can lead to
  delays within rehabilitation causing a loss
  of improvements gained during
  rehabilitation.
• Priority for development: Every PCT
  should ensure access to a responsive
  stroke specialist community rehabilitation
  service.
Early supported discharge (ESD)

• Every PCT should commission an early
  supported discharge service for people
  who would benefit. This service should
  include staff with specialist stroke skills
  and must meet all of the performance
  standards.
Early supported discharge services

• Eight trials (data from seven) from UK,
  Norway, Sweden, Australia, Canada, USA
• Heterogeneity of services
• Average reduction in hospital length of
  stay by 9 days (95% CI 5-15; P<0.0001)
• Apparent reductions (P<0.01) in death/
  institutional care and death/dependency
• Modest reduction in costs?
                              ESD trialists (2001)
Early supported discharge services

•   Not applicable to all stroke patients
•   Can accelerate discharge home
•   Appear to improve subsequent recovery
•   Best results with ESD services
    coordinated and provided by a
    multidisciplinary rehabilitation team


                            ESD trialists (2001)
Early supported discharge

• Key gap: Many London hospitals do not have access to
  ESD; ESD services that do exist may operate in isolation
  without a fully developed community stroke rehabilitation
  service, resulting in poor exit strategies from the
  rehabilitation pathway.
• Priority for development: An ESD service must be seen
  as an addition to a community stroke rehabilitation
  service. An ESD service should be appropriately
  resourced to offer the same intensity of rehabilitation as
  an inpatient stroke service.
Support services

•    Everyone who has had a stroke, and their carers,
     should have:
1.   A key support worker such as a family support
     worker or community matron to provide:
     navigation and advocacy; a link with the inpatient
     and community rehabilitation teams and other care
     providers.
2.   A designated person from health or social care
     who is the key contact for the patient and carer
     whilst in each setting, such as a therapist, social
     worker, or healthcare assistant.
Support services

• Key gap: There is a lack of collaboration
  between health and social care provided
  services leading to confusion for patients,
  families, carers and staff regarding access to
  services and support.
• Priority for development: Every PCT should work
  collaboratively to develop support roles that
  cover the whole stroke pathway in order for
  patients, families, carers and staff to have
  access to services and support.
Regular review

• For the first 12 months following stroke, all
  people who have had a stroke and their
  carers should have a regular review and
  assessment of ongoing medical, social
  and emotional needs as both an inpatient
  and in the community.
Regular review

• Key gap: There is no specific follow up
  programme in place for stroke patients.
• Priority for development: Every PCT
  should ensure participation of all services
  along the pathway, including GPs and
  social care, with respect to ongoing
  management.

				
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