VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
Early Supported Discharge & Long Term Stroke Support
1. 1
Early Supported Discharge
& Long Term Support Services
Camden case study
Mousumi Basu-Doyle, Strategic Commissioner, NHS Camden and LB Camden
Ashley Jones, Stroke Groups Project Officer, LB Camden
Mirek Skrypak, Stroke REDS Co-ordinator, NHS Camden Provider Services
Building Partnerships
2. 2
New Stroke Care Pathway
Stroke happens
Stroke identified quickly
Emergency response and treatment
HASU
Community rehabilitation Hospital rehabilitation
Long term community rehabilitation, care and support
Post-stroke review
Annual reviews by health and social care teams
Stroke Early Supported Discharge
3. 3
National Strategy for Stroke:
What is expected?
National Strategy for Stroke (DoH, Dec 2007)
1. Information, advice and support: People who have had a stroke, and their relatives and carers, have
access to practical advice, emotional support, advocacy and information throughout the care pathway and
lifelong.
2. High-quality specialist rehabilitation: 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.
3. Seamless transfer of care: A workable, clear discharge plan that has fully involved the individual (and their
family where appropriate) and responded to the individual’s particular circumstances and aspirations is
developed by health and social care services, together with other services such as transport and housing.
4. Long-term care and support: A range of services are in place and easily accessible to support the individual
long-term needs of individuals and their carers.
5. Assessment and review: People who have had strokes and their carers, either living at home or in care
homes, are offered a review from primary care services of their health and social care status and secondary
prevention needs, typically within six weeks of discharge home or to care home and again before six months
after leaving hospital.
This is followed by an annual health and social care check, which facilitates a clear pathway back to further
specialist review, advice, information, support and rehabilitation where required.
4. 4
Camden Stroke Achievements
Expansion of stroke support groups.
Expanded provision of Stroke Association Communication Support Service.
Gold standard stroke early supported discharge service
Stroke Patient Handbook.
Camden Stroke Webpage
http://www.camden.gov.uk/ccm/content/social-care-and-health/health-in-camden/stroke.en?page=1
Use of multi-media to enable stroke survivors to share
their experiences
http://www.acting-up.org.uk/camdenstroke.htm
Supporting younger people who have had a stroke.
Carers Voices’ DVD.
Family and Carers (Stroke) Hospital and Community Support Service
Social activities give carers a break
Community Stroke Psychologist recruited
Pathway to short term home based rehabilitation– Camden REACH
Pathway to longer term care management, psychological
Adult Social Care Annual Review
Commissioning Stroke Reviews and Navigator Service
Close and multi-agency working
CQC Stroke Audit preliminary findings.
.
.
5. 5
How did we get there?
Seizing the future
Setting the direction
Delivering the service
6. 6
Camden Stroke REDS
• We have 8.2 full time
equivalent staff including
the following professionals
who specialise in stroke
rehabilitation:
– Speech and Language
Therapy
– Occupational Therapy
– Physiotherapy
– Social Work
– Rehabilitation
Assistant
– Nursing
– Dietetics
– Psychology
– Team Coordinator
• Every patient in the
pathway has a keyworker
• The Stroke REDS team
was locally determined
to meet the needs of the
Camden stroke survivors
(ESD) and follow DH +
HfL recommendations.
• It was developed from
the Camden REACH
community rehabilitation
team and is seen as an
add on to an existing
stroke pathway.
• Stroke REDS team use
enabling carers (10
staff)
• Access to medical input
from REACH
7. 7
Stroke REDS Pathway
Receipt of referral andReceipt of referral and
AssessmentAssessment
•Neurological, Functional,
Social Needs Assessment
•Social Worker starts
integrated care plan
formulation
Facilitation ofFacilitation of
DischargeDischarge
• Access Visit
• Home visit
• Social Needs:
1. night sitting
2. day sitting
3. daily visits + domestic support
Day of DischargeDay of Discharge
•Own transport
•Discharge home visit
•Start of enabling care
IntegratedIntegrated
Rehabilitation atRehabilitation at
HomeHome
•A period of 6-8 weeks
Discharge fromDischarge from
teamteam
•Onward referrals if
needed
•Social work 4 week
follow up post
discharge
Review at 6 monthsReview at 6 months
•Focus on life after
stroke, significant
changes, quality of life,
social needs
•Referral to new Stroke
Coordination and
Navigation Service
8. 8
• Week 1Week 1 – settling in at home, therapy and
assessments, enabling care, outcome measures
• Week 2Week 2 – goal setting, therapy and assessments,
enabling care
• Week 3Week 3 – therapy + weaning off in enabling care
• Week 4Week 4 - therapy + weaning off in enabling care +
specialised Social Work review from Stroke REDS
• Week 5Week 5 - therapy + weaning off in enabling care
or end + liaison with post discharge teams
• Week 6Week 6 - therapy + end of enabling care + goal
review + outcome measures + discharge
• Potential to extend to 8 weeks8 weeks for therapy only if
appropriate
• Social Worker involved for a further 4 weeks post
discharge
• This includes weekly interdisciplinary teamThis includes weekly interdisciplinary team
meetings and also weekly meetings with enablingmeetings and also weekly meetings with enabling
carerscarers
Integrated Rehabilitation with Stroke REDS
9. 9
Barthel 100% of clients maintained or improved their score
Performance COPM 100% of clients maintained or improved their score
Satisfaction COPM 96.6% of clients maintained or improved their score
SAQOL-39 70% of clients maintained or improved their score
N eADL 87% of clients maintained or improved their score
Outcome Measures
Approximately 179 Stroke survivors in Camden 2009, 57 discharged with Stroke
REDS – this equates to 32% of all stroke survivors discharged early.
The average age of a Stroke REDS client is about 71 years.
The youngest Stroke REDS client being 36 years, and the oldest 94 years.
On average reduced length of stay in acute units by 10 days (total of 550 acute bed
days had been saved / 1853 trim days saved: potentially an acute bed day saving of
£307,161)
Achieved 80% of all goals set with clients (using GAS – Goal Attainment Scale).
Reduced packages of care on average by 15 hours per week, resulting in on
average 2 hours per week of care needs following rehabilitation with Stroke REDS.
10. 10
•They made me feel quite confident and I felt that they were very thorough,
caring and professional.
•The at home treatment was beneficial. I am sure it contributed to my recovery.
•The Stroke Reds Team helped with getting my confidence back with
movement, speech and general health.
•It is actually quite daunting leaving hospital where everyone is on hand to go
home and deal with things ‘in the real world’. The team were very supportive
and very professional. I always felt they had my best interests at heart…and I
didn’t feel like I was just a number. Obviously I will have some ongoing issues
but I can proceed with more confidence after having such great support to start
with.
•Very helpful, kind and understanding in such a difficult situation, of which we
had no knowledge of dealing with.
•I did feel that REDS made a difference because they helped me make the
transition from hospital to home.
Client perceptions
12. 12
Camden Community Stroke Groups
Programme
• The Community Stroke groups
were set up to provide long
term support to stroke survivors
and their carers.
• There are three community
groups set up in Resource
Centres offering a service to
approximately 60 stroke
survivors
• We offer a range of activities
which enable service users to
engage in their planned
programme of rehabilitation
• Groups are held weekly and are
structured to include an after
stroke exercise session before
providing a nutritious lunch and
then an afternoon session of
activities
• Both the exercise sessions and
the activity sessions aim to
maintain and improve physical
and mental health and well
Networking
• The formation of the Camden
Stroke Local Implementation
Team has meant that
communication has improved
throughout the borough and
stroke survivors have been
referred to us from several
agencies.
• We have strong links with the
Kilburn Older Voices
Exchange, a forum that looks
at older peoples issues and
who network with over 40
community groups.
• Our Stroke Project Officer
presents to Care
Management team meetings
to keep social workers
informed of developments
and ongoing programmes
• Local surgeries and health
centres are frequently visited
and given current information
Partnerships
•Camden Active Health team
-structured exercise and
swimming
•Creative Health Lab –
Mosaics for therapy
•Art Therapists – work with
small groups and individuals
•YMCA – exercise and
outings
•Pet Therapy – visits
fortnightly
•Speech Therapy students –
work with aphasic stroke
survivors
•Camden Carers
organisations to ensure that
carers of stroke survivors are
identified and supported
13. 13
Pathway
The first home visit includes an assessment of
how the person has been affected by their stroke
to find out what difficulties they have.
We would also aim to discuss a strategy for
rehabilitation and or enablement
If it was established at the visit that the stroke
survivor did not want to attend a community group
we would signpost to any other relevant service
and keep contact by phone or e mail
Visit –
Assess Needs
Introduction
Refer or signpost
to other services
Review
Receive Referral
During the first visit to the centre, a key worker
would be assigned and an Individual Service Plan
would outline the agreed strategy and the
intended time frame.
The plan would be reviewed at six monthly
intervals
14. 14
Key-Working
Purpose
An individual works with a member of staff to ensure they receive a
personalised and optimal service
Tools
• Individual Service Plan – the core document that outlines the
support the person needs to fully engage in the service
• Targets form – identifies effects of the stroke that the person wishes
to use the service to improve or recover
• Reviews –evaluates progress towards targets and changes in
support needs
• Multi-media – used to document the review process and also to
enhance communication
• Star outcomes – monitors general health and wellbeing
15. 15
Case Study Mrs PP
• Referral from REACH
team
• Wanted ongoing
support after stroke
• Meet other stroke
survivors
• Get out and about
16. 16
Ongoing Service
• Re-examine goals and aims
• Appraise progress and
enjoyment
Continuing support
• Referrals to physiotherapist
for new leg brace and arm
support
• Inclusion in specialised
exercise at the YMCA
Outcomes
• In all areas of wellbeing Mrs
PP showed great
improvement particularly in
keeping in touch and
expression
• There were also universal
improvements physically
with the greatest being in
mobility and dexterity
• Greater incentive to get out
and about generally
• Feels she has greater
access to support and
services
First Visit To Centre
• Introduced to exercise tutor
who goes through exercises
that may benefit her
• Establishes abilities and
identifies risks for exercises
• Targets areas for
improvement
In Group
• Is introduced to other stroke
survivors
• Discussion facilitated to
support PP to be fully
involved
In Centre
• Is introduced to staff and
facilities
• Establish what support PP
needs while attending
Home Visit
History
• Had a valve replacement
• Has high blood pressure
• Had a single stroke in
late 2008
Direct effects of stroke
• Hemiplegia on Left side
• Loss of balance and
strength results in falls
• Has to use wheelchair for
much of her mobilising
• Loss of Dexterity in hand
• Complete change of role
in family
Targets set
• Needs transport to attend
• Wants to strengthen leg
to improve walking
• Wants to share
experiences with other
stroke survivors
Mrs PP’s Journey
18. 18
•Pilot shows a study of people
attending the groups.
•There is a broad cross section
of individuals including people
that have attended the groups
for many years as well as new
comers. The views of a wide
variety of people with differing
abilities is present.
100% showed that they benefitted from attending the groups and
reported improvement in their well-being - Staying as well as they
could, feeling positive and keeping in touch with their community.
Generally, the biggest impact on people was in the area of keeping
in touch with their community. A popular reason given was that
attending the centre meant seeing friends regularly.
Feeling positive had the next biggest impact. The general
consensus being that sharing experiences with other stroke
survivors improved positive feelings like hope.
Output Measures
Service users who have attended community stroke groups 82
Service users receiving outreach service but not attending a group 24
Current Aphasic service users receiving communication support 11
Service users referred to and for other services 13
Also use other resource centre services 78
Average quarterly new referral fig 6
Outcome Star Measures
19. 19
Key Messages
Commissioning and delivery success factors
• Clear leadership
• Single commissioner across the whole community pathway (joint
commissioning)
• Ambitious and tenacious
• Well trained and motivated workforce, working within an integrated
model of care delivery
• Personalised approach to planning and delivery
Current and future challenges
• Financial pressures
• New policy direction: re-enablement, public health, personalisation
• Re-focus from outputs alone towards outcomes
• Innovation
• Harnessing existing and new partnerships.
Running groups in RC’s gives stroke survivors access to a Keyworking model already in place, and a team of staff that uses this system.
These are the tools we use to ensure a completely person centred service.
I’ll go through some of these tools in more detail when looking at the case study.
Mrs PP was referred from the Reach team for long term support to follow on from her treatment and rehabilitation
The main needs identified was emotional support and preventing Isolation.
This is an example of her Pathway from getting back home to now.
The purpose of the initial assessment is to determine what areas the stroke survivor wants to improve using the targets form. Mrs PP identifies wellbeing targets such as socialising and expression to be most important to her. She also identifies Physical targets she wants to achieve.
We also make a support strategy using the Individual Service Plan to identify what help she would need to attend the centre.
Ideally, we try to keep the waiting time between referral and attending the group to a minimum. and so Mrs PP starts attending within a month.
As Mrs PP continues to attend the groups she has access to ongoing support for any changes in her daily living situation. Her family is also in touch with our carer support service and regular contact is maintained with them.
Mrs PP has been attending the stroke groups for 2 years.
In the initial assessment when the SU outlines specific targets they'd like to achieve, these are the criteria we use to monitor them.
We use these criteria to ensure that our activity programme fulfils all the needs a stroke survivor would have.
This is the wellbeing star that we’re piloting in camden for older persons.
Numbers throughout the two years that the stroke groups have been running.
Of the people that attend the groups there is a large proportion that have aphasia resulting from their stroke.
Other resource centre services include lunch, care support and transport.
Referral rates peak and dip drastically from summer to winter. A great many more referrals are made in the summer.
These are some findings from the output star results. The biggest impacts we’re in the social areas. Notable improvements were also found in staying as well as you can which covers physical exercise, maintaining ongoing medical conditions and diet.
