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Developing Stroke ESD service

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Developing Stroke ESD service Powered By Docstoc
					Developing a Stroke Early
  Supported Discharge
         Team
                Emma Hall
              Stroke Co-ordinator
           Margurite O’Mara
                  Team Lead

    Stoke on Trent Community Health Services
   Early Supported Discharge
Local Picture:
 Pockets of clinicians with stroke skills
  in the community
 Did not have stroke specialist team
 Had Intermediate Care Teams and
  Reablement Services that supported
  stroke patients in their homes
 Opportunity to develop a stroke
  specific service
     Early Supported Discharge
February 2008 Pilot:
 Six month funding available for ESD
  service.
 Recruit a team of 4 WTE therapy staff plus
  an information officer:
                    Stroke Co-ordinator
          1 x WTE Band 6 Occupational Therapist
              1 x WTE Band 6 Physiotherapist
         2 x WTE Band 4 Rehabilitation Assistants
        Stroke Information Officer (18 hrs per week)

   Evaluation commissioned by Keele
    University
     Early Supported Discharge
Four Key Objectives for Pilot:
1.   To provide patients with a specialised and co-
     ordinated rehabilitation service at their place
     of residence
2.   To improve patients independence /
     functional ability and their quality of life
     following stroke
3.   To reduce bed based length of stay in both
     the acute and rehabilitation setting for those
     appropriate patients
4.   To ensure that timely information is provided
     to patients and their families at a time it is
     most required
   Early Supported Discharge
Current Team:
 Stroke Co-ordinator – Manager
 Team lead – Advanced OT
 Advanced Nurse Practitioner (currently
  being advertised)
 2 x Specialist Physiotherapists
 2 x Rehabilitation Practitioners
 1 x Rehabilitation Assistant (recently
  appointed)
 1 x Stroke Information Officer
  Early Supported Discharge
Current Service Provision
 Three Strands
 1.High functioning: Earlier discharge to
  home with ESD team only
 2.Lower functioning but manageable at
  home: Support by ESD and Domiciliary
  rehab team support
 3.Residential/Nursing care –ESD team
  visit on discharge to check correct pt
  management
   Early Supported Discharge
Criteria:
 To support earlier discharge from
  stroke beds for:
  – Patients with primary diagnosis of
    stroke
  – Can be managed safely at home (max
    assist of 2)
  – Clear patient / carer goals
        Early Supported Discharge
 Team Standards
 On Referral
    – Patients that have not been seen on the wards
      will be contacted the following working day to
      arrange a visit
   On Assessment
    –   Neurological assessment
    –   Social and environmental assessment
    –   Admission Outcome Measures
    –   Individual goals set with the patient
    –   Patient information pack provided
    –   Discuss discharge protocol
        Early Supported Discharge
   Team Standards
   Weekly
    – MDT review of progress and goals
    – LoS, Estimated Discharge Date and contacts reviewed
    – Referrals to other services discussed
   On Discharge
    – Review goals
    – Repeat Outcome Measures
    – Advise re referrals to other services
    – Complete discharge letters to GP, Consultant and others
      as required
    – Record any unmet needs
   Follow up
    – Six week telephone follow up call
    Early Supported Discharge
Challenges:
 How to ensure earlier discharges from bed based
  services
 Emphasising ESD focus within team / service
 Small team for large geographic and stroke
  population
 Small team with limited capacity
 Accelerating Stroke Improvement targets to
  achieve
 Time limited intervention
 Unmet need for longer term stroke specialist
  rehabilitation
               May 10           June 10           July 10            Aug 10            Sept 10            Oct 10

Number of
Patients
Referred            31                19                38                 26                37                32

% Against
the ASI
Target          45%               30%               51%                37%               46%               40%
Average
Contacts
per Patient          9                7                 5.5                4                 8                 4

Patient       Home       24hr   Home       24hr   Home        24hr   Home       24hr   Home       24hr   Home       24hr
Destinatio
               29         2      18         1      37          1      26         0      32         5      31         1
              May 10     June 10      July 10         Aug 10        Sept 10        Oct 10

          Adm    D/ch   Adm   D/ch   Adm   D/ch   Adm    D/ch   Adm     D/ch   Adm    D/ch



Acute
Barthel   16     17     17    19     16    17     15     17     13      14.5 17       17.5



Rehab
Barthel   6.5    8      12.5 15      10    12     7      14     8       10     6      14



Acute
NEADL     17     24     17    31     18    27     21     32     13      25     18     28



Rehab
NEADL     5      8      16    21     14    23     7      23     10      17     15     21
   Early Supported Discharge
 Future  Plans
 Further expansion

 Six month follow-up service
Early Supported Discharge

          you
     Thank

  Any questions

				
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posted:7/26/2011
language:English
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