Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects

NHS
CANCER NHS Improvement

DIAGNOSTICS

HEART

LUNG

STROKE

Stroke Improvement Programme
Improving post hospital and long term care:
case studies from the Stroke Improvement
Programme projects

Contents

Introduction 3 Rehabilitation 23

Transfer of care 4 Aintree University Hospitals 24
NHS Foundation Trust
Dudley PCT 5
NHS Hampshire 26
NHS Lewisham and South East 7
London Cardiac and Stroke Network NHS Medway 27

Lincolnshire Community Health 9 Norfolk and Norwich University 30
Services Hospitals NHS Foundation Trust and
NHS Norfolk
NHS Milton Keynes and Milton 11
Keynes Council Northampton General Hospital, 32
Kettering General Hospital and NHS
Nottinghamshire County Council and 13 Northamptonshire
Nottinghamshire Community Health
Portsmouth Hospitals NHS Trust 34
Poole Hospital NHS Foundation Trust 15
and Bournemouth and Poole NHS West Sussex, West Sussex Health 36
Community Health Services and West Sussex County Council

Royal Bournemouth and Christchurch 17 York Hospitals NHS Foundation Trust 38
Hospitals NHS Foundation Trust
Stroke resources 40
South West London Cardiac 18
and Stroke Network Further information 42

Stoke on Trent City Council 20

Key learning from the transfer 22
of care national projects

Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 3

Introduction

Since March 2009, the Stroke
Improvement Programme has been
running projects looking at the key
areas of transfer of care and
rehabilitation. This publication gives
the detail of each project.

The suggestions, experiences and
examples provided in this document
are intended to generate ideas, to
show what is possible when teams
work constructively together and to
guide planning for improvement
activities.

The Stroke Improvement Programme
continuously publishes materials to
help those striving to improve stroke
and TIA services. All materials are
available on the Stroke Improvement
Programme web site at:
www.improvement.nhs.uk/stroke.

Contacts for each of the projects are
included at the end of the
publication. Full case studies of the
service improvements can be found
at www.improvement.nhs.uk/stroke

www.improvement.nhs.uk/stroke

4 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects

Transfer of care

Quality marker 12 of the National TOP TIPS
Stroke Strategy set a standard that
individuals should have a clear • Manage the health and social
discharge plan, covering all their care interface
needs, across both health and social • Involve patients in improving
care. Nine sites across England transfer of care
analysed their systems for transfer of • Provide emotional support for
stroke survivors and carers
care for people with stroke and
• Ensure access to appropriate
focused their improvements on
services, including rehabilitation,
processes influencing this stage of
social care and community
the stroke pathway and impacting on opportunities
several of the National Stroke
Strategy quality markers, notably
quality marker 12 (transfer of care),
10 (rehabilitation), 3 (information
advice and support) and 13 (long
term care and support).

This section contains information
about the improvements made to
transfer of care by the nine project
teams across England. The case
studies provided here are a summary
of the improvements and how they
were achieved.

National Stroke Strategy, Department of Health, 2007.
1



Seamless care
Dudley PCT, Dudley Social Services, Dudley Group
of Hospitals and Dudley Stroke Association

Aims discharge but few referrals included a These have impacted positively on
This joint team established that their comprehensive patient centred workload and consequently improved
key aims were to: programme with individualised waiting times.
• improve communication between patient goals. There was no
primary and secondary care dedicated social worker for stroke. All A social worker dedicated to stroke
rehabilitation teams of these factors contributed to delays now works full-time in the Dudley
• improve staffing levels within the in discharge, with an average length hospitals and a family and carer
community rehabilitation team, of stay of 18 days. support worker, employed by Dudley
provide more intensive Stroke Association, now goes into the
rehabilitation and set up an early Actions hospital three days a week to provide
supported discharge service A system of short monthly meetings support as needed.
• enable earlier discharges and was established between key staff
reduce delayed discharges from Dudley Social Services, Dudley A community stroke coordinator was
• increase the involvement of social Group of Hospitals, the Stroke employed. As well as leading the
services Association and the PCT to improve Community Support Rehabilitation
• improve social and emotional and optimise communication, and Team, she visits the hospital once a
support for patients, their families identify and work through the week and works with the hospital
and carers improvements needed. Smaller task stroke coordinator to improve
groups met separately to tackle communication between the teams
Issues specific problems quickly, as and and identify patients suitable for early
The service was very fragmented. when needed. A joint investigation supported discharge.
Patients would be brought to A&E, committee was formed to improve
seen and assessed when their turn communication and target Outcomes
came, admitted to the emergency achievements. A comprehensive stroke service
admissions unit, and transferred to specification is in place, with a
the stroke ward if there was a bed. Stroke and TIA pathways for primary complete stroke service pathway
Stroke beds were regularly used by and secondary care were developed across acute and community services.
medical outliers. CT scans were not and agreed. As well as the improvements made
routinely performed within 24 hours for the project, changes were made
of presentation, with a wait of A comprehensive community service in acute care including the alerting of
sometimes up to three days. The specification that engaged the Dudley hospitals by the ambulance
Community Support Rehabilitation existing community team was crew for imminent stroke admissions
Team waiting times could be up to six developed, resulting in clear and immediate assessment on arrival
weeks post-discharge. Patients were entrance, exit and exclusion criteria. by the stroke team.
referred to the community team on



TOP TIPS

‘Communication, communication,
communication.’
The Dudley Team

This has positively impacted on A psychologist is now available and Contacts
meeting acute stroke clinical assesses patients referred by the Dr Liz Pope
guidelines and admission to the medical team. All patients receive GP, Dudley PCT
stroke ward. patient centred, individualised care liz.pope@dudley.nhs.uk
plans and goals on discharge.
The PCT invested £75,000 to support Derek Hunter
early supported discharge to appoint These improvements have made an Commissioning Lead -
health care assistants, releasing impact on delayed discharges, Urgent Care
therapists and other clinicians to reducing average length of stay from Dudley PCT
focus on appropriate specialist 18 to 15 days, saving £750 per derek.hunter@dudley.nhs.uk
activities. The Community Support patient.
Rehabilitation Team contact the
patient soon after admission to assess Patients are satisfied with the service
for early supported discharge and they receive from the stroke team:
now utilise entry and exit criteria and
plan patient contact according to “I cannot speak too highly of
geography and job roles within the the services I have received …
team, to improve productivity and
efficiency. Waiting times have
Each and everyone involved
reduced to an average of 3.4 days for have given a high standard of
the first contact with the team. treatment and care, for this I
am deeply grateful. It has
The family and carer support worker boosted my self-esteem and
and social worker are now involved
soon after admission to provide
made me feel that life is worth
support and plan care on discharge. living. I cannot see any area
The team demonstrated the post where things could be
saved the trust around £94,500 in its improved”
first year on crisis admissions and
emergency room visits by patients
recently discharged from hospital,
providing patients and families with a
point of contact for any worries and
concerns.1 This has avoided patients
unnecessarily going to A&E or calling
an ambulance or their GP for
straightforward issues or concerns.

The business case for the Dudley Family and Carers Stroke Support
1

Worker can be found on the Stroke Improvement website:
www.improvement.nhs.uk/stroke/SocialCareforStroke/SocialCareforStrokeResources.aspx



Lewisham integrated stroke project
NHS Lewisham and the South East London
Cardiac and Stroke Network

Aims Only 23% of patients went onto have A pilot neuro-rehabilitation team was
The project team from NHS Lewisham rehabilitation from either Lewisham formed as part of the integrated care
was jointly led by the PCT and the Intermediate Care team (LINC) or the team to address the lack of stroke
South East London Cardiac and Lewisham Adult Therapies Team specific community rehabilitation.
Stroke Network, and had close links (LATT). Neither team was stroke
with social care through joint specific and had long waits, in some At ward level a number of key
commissioning. It aimed to redesign cases up to 12 weeks. improvements were made:
the post acute phase to create an • reconfiguration and simplification
integrated pathway between acute Delays also occurred in securing of the discharge process
and community stroke services, placements for specialist neurological • systems for coding patients were
through both stroke service teams. It rehabilitation for younger people and reviewed and improved after a case
also aimed to improve discharge for complex care packages. There notes review found that 17% of
planning and communication across was an average length of stay of 40 patients were erroneously coded
the pathway, facilitate earlier transfer days for these patients, and the • implementation of a key worker
of care and ensure high quality longest wait was 188 days. system
rehabilitation and enablement. • a single point of referral to social
Actions care in hospital, ward based social
Issues The team gained wide stakeholder care workers, location of the social
A typical Lewisham stroke patient engagement and board level support care office close to the stroke ward
passed through five to seven different for the project. Staff, patients and and location of social care
teams, leading to a number of quality carers were involved in a process computers in the same room as the
problems relating to patient mapping event to identify bottlenecks multidisciplinary team meetings for
experience. The systems and as well as existing good practice to ease of access to records
processes in place were complex. adopt more widely. • a discharge planning group was
Not all patients were cared for on a established to improve patient
dedicated stroke ward and the A project initiation document, project information and ward
average length of stay for all patients plan, communication plan and risk documentation
in 2007/8 was 22.5 days. log were written and a baseline of
existing services was established.
Current cost and demand analysis
was carried out and agreement on
measures was gained.



Table 1: Key outcomes in Lewisham

Jan 2009 Apr-Jun 2009 Oct 2009 - Mar 2010

Stroke vital sign <40% >80% >80%
Proportion of patients spending
90% of time on a stroke unit

Average length of stay (days) 22.5 18 19 (Oct-Dec swine flu and norovirus)

Waiting time for community Intermediate care SALT - 48 days SALT - 38 days
therapy team 4-6 weeks

Adult therapies OT - 65 days OT - 44 days
team 12 weeks
Physio - 96 days Physio - 74 days

Number of new patients per month LINC 1-2 - New pilot LINC team 5-6 days

Duration of therapy LINC 35 days - New pilot LINC team 28 days

The workforce was reconfigured to Co-ordination of care is improved and Contact
include some new posts and new a more personalised holistic service Sara Nelson
ways of working: with community enablement offers Associate Director and Interim Project
• Stroke Association family more personalised care planning and Lead, South East London Cardiac and
support worker and communication goal setting. This will be assisted by Stroke Network and NHS Lewisham
support worker posts were performing joint single assessments, sara.nelson@lewishampct.nhs.uk
re-specified and agreed sharing information and joint
• the social care grant used for a new documentation, as well as effective
‘back to life’ senior social care post communication.
• community health and social care
staff attended hospital The length of stay has decreased
multidisciplinary team meetings from 22.5 days in 2007/08 to 19 days
• rotation of therapy posts between in March 2010.
the acute hospital and community
teams The improvements made a significant
• appointment of a senior therapist impact on access to community
to lead the new community neuro waiting times for therapy even before
team the planned early supported
• Connect and the Stroke Association discharge team was in place.
training for care home and social
care staff Better patient outcomes and value for
money will be realised in the
Outcomes integrated team through shared
There is now a reconfigured, more resources such as administration,
efficient, simplified stroke pathway in shared assessments and reduction in
place and enhanced joint working handoffs and duplication.
with social care.



Assisted discharge service for stroke
Lincolnshire Community Health Services

Aims The extended length of stay was • timely assessment as soon as a
The team set out to establish identified as a factor that limited patient is identified by the ward as
affordable, value for money care and availability of beds on the stroke suitable
rehabilitation for stroke patients units, leading to an above average • attendance by the assisted
across the pathway, in collaboration number of patients who were not discharge team at ward team
with service providers in secondary accessing stroke units in the three meetings, at referring stroke units
care, social services and the third main sites in the county. and, in some areas in order to
sector. improve rapport and referral
Actions numbers, attendance at daily
Objectives to be achieved to meet The service was designed as part of handover sessions with stroke unit
this aim were: a tendering process, including an staff
• to develop quality information for in depth and fully costed • setting up systems to ensure the
patients and carers to support implementation plan. An team met the performance
informed choices and self implementation lead was identified indicators
management to drive the project. A core team was
• to increase active participation of recruited and a lead for the service Outcomes
patient and carers in the planning, identified at an early stage. A patient Average length of stay reduced from
development, delivery and and public involvement lead was 29 days to 20 days (see figure 1), and
monitoring of the service identified to capture patient waiting times for community therapy
• to provide a highly skilled experience from an early stage. reduced from three weeks to around
workforce, across the two days (see figure 2). Patient
organisational boundaries The new team were clear from the satisfaction with the new service is
outset that the service would be high (see figures 3 and 4). Patient
Issues performance monitored and outcomes have improved, as
At the start of the project there was managed. Data collection was measured by Barthel scoring from an
no community stroke rehabilitation embedded within clinical activity and average of 15 on discharge from
available in the county and limited regular meetings with commissioners hospital to 17.5 on discharge from
generic community rehabilitation. kept the team focused on outcomes. the assisted discharge service,
This was identified as a major reason demonstrating that the team are
why length of stay in the acute stroke The new assisted discharge service impacting on functional
units or secondary care was above team was established, informed by improvements.
average. patient and carer views, to provide
access to a seven day community
service across the county, including:



Contact
Figure 1: Average number of days from stroke to hospital discharge Joan Lawton
Clinical Team Lead
40 AHP/Implementation lead ADSS
Average number of days Lincolnshire Community
from stroke to home
30 Health Service
joan.lawton@lpct.nhs.uk
Days

20

20

0
December January February March April May
Months

Figure 2: Average number of days from hospital discharge to first face
to face contact with the Assisted Discharge Service

8
Average number of days
6
Days

4

2

0
December January February March April May
Months

Figure 3: The handover of my care from Figure 4: My carer was involved in agreeing the care
hospital to home went smoothly plan and their needs were taken into consideration

25 25

20 20
Number of Patients

Number of Patients

15 15

10 10

5 5

0 0
Strongly Agree Neither Disagree Strongly Not No Strongly Agree Neither Disagree Strongly Not No
Agree agree or disagree applicable comment Agree agree or disagree applicable comment
disagree disagree
Choice Answers Choice Answers



Stroke transfer of care and supported
rehabilitation in the community project
NHS Milton Keynes and Milton Keynes Council

Aims Issues Patients reported a lack of
The joint commissioner and provider The baseline position for transfer of information and confusion about
led team from Milton Keynes planned care did not meet National Stroke what services they could access, but
a service redesign in anticipation of Strategy standards, with no stroke when they were referred to the
funding for a new early supported specialist rehabilitation staff in the community stroke team this was
discharge service, due to start in community at the point of discharge highly praised.
January 2010. Preparatory work and only a third of patients known to
aimed to improve person centred care follow-up services. There was no Actions
planning, involve the person and their stroke pathway and patient A Local Implementation Team met
carers in decisions and goal setting. It information was poor. every other month and set up a small
was also intended to improve project group, including user
collaboration between the hospital Length of hospital stay was around representatives, to develop the
and community staff, information 25 days and prolonged past the point patient information portfolio. A
during hospital stay and on where patients were medically fit for project manager in commissioning
discharge, access to professionals discharge due to a lack of confidence was assigned to work closely with the
specialised in stroke care and in community support. An average of hospital project team to ensure that
outcomes for patients. 45% of patients were never admitted the stroke pathway became as
to the stroke unit with most not seamless as possible.
Milton Keynes Hospital NHS known to the stroke team. The stroke
Foundation Trust was also vital sign was estimated and based on The team developed a vision for the
participating in the Stroke trajectory, not actual figures. service and a service specification for
Improvement Programme acute an early supported discharge service,
stroke project, so the teams aligned The hospital multidisciplinary team with widespread user and
their aims for reduced length of stay, had regular staff changes and lacked stakeholder involvement.
increased occupancy rates and direct consistent links with the community
access to the acute stroke unit. stroke specialist, so the rehabilitation
team missed many patients. Decisions
were made by hospital staff about
best options for continuing
rehabilitation in the community but
with little knowledge of the options.



In preparation for the new service, Despite not being fully established,
some improvements were made to the early supported discharge team
the process of transfer of care: saw eight patients in the first month,
• a new patient pathway reducing the length of stay
• a new patient information pack dramatically to below 10 days. The
• a new record of patient care, which stroke vital sign improved to 70% of
ensured patients’ aspirations were patients spending 90% of their time
central to their care and discharge on a stroke unit.
planning
• a staff competency audit, and A recent change in staffing on the
subsequent training programme ward has led to significant
• plans for collation of key hospital improvements in the notification of
and community data, analysed in a patients to the community stroke
robust way to determine the specialist.
baseline and points for
improvement Contact
• development of the role of the Dr Marianne Vinson
community stroke specialist, Consultant in Public Health
including the interface with the NHS Milton Keynes
stroke ward multidisciplinary team marianne.vinson@miltonkeynes.nhs.uk

Outcomes
The team experienced a significant
delay in funding of the early
supported discharge team, which has
delayed the benefits of the work
done so far, but due to the team’s
persistence the service began at the
beginning of April 2010.



Access to emotional support for
carers of stroke survivors
Nottinghamshire County Council Adult Social Care, Nottinghamshire
Community Health and The Stroke Association

Aims “Joint working between the three agencies has enabled a
The project team from
Nottinghamshire focused their shared language and understanding to be developed.
improvement on access to emotional Barriers have been discussed and overcome between
support for carers of stroke survivors,
organisations and a much improved understanding of the
by funding and defining a specific
role for a family and carer support world faced by a stroke survivor and their carer is
worker on the acute stroke ward to understood by all”
provide support to carers into the
south of the county. The Nottinghamshire project team

Issues
At the start of the project there was Actions Outcomes
an inequitable service for stroke There was integral involvement from The service was evaluated by
survivors and families to access a stroke survivor and carer on the comparing results for carer strain
emotional support. 88% of patients steering group. This led to support index and general health
were not referred for further being offered to carers once the questionnaire with those of a study
rehabilitation, and received no follow stroke survivor was out of the acute of the community stroke team carried
up, advice or information (data phase, as carers themselves appeared out in 2002.2 The evaluation showed
collected January to June 2009). to be in crisis until this point. Support that carers experience higher levels of
Patients who went on for further by carers was sought after usual stress now than in 2002, but also
rehabilitation were signposted to office hours when they felt they had that the family and carer support
additional support from social care more time to talk. worker appears to have a positive
and voluntary agencies using a impact on perceived carer health and
significant amount of clinical time In addition, the new service was wellbeing.
and detracting from time available for promoted to the stroke wards to
other rehabilitation. increase referrals to the family and There was no difference between the
carer support worker. family support worker and the
community stroke team for all
measures, showing benefits were
consistent across all services.

2N B Lincoln ,M F Walker, A Dixon, P Knights (2004) Evaluation of a multiprofessional community

stroke team: a randomized controlled trial Clinical Rehabilitation 18:40-47).



The process of meeting regularly to
develop the service and establishing
joint objectives improved working
relations between the organisations
and the success of the support
worker role led to commissioning of
two further family and carer support
services in the county.

Contact
Christopher Greensmith
Team Leader – Community
Stroke Team
Nottinghamshire Community Health
christopher.greensmith@nottscommu
nityhealth.nhs.uk

Mandy Shiel
Interagency Planning and
Commissioning
Adult Social Care and Health
Department, Nottinghamshire
County Council
mandy.shiel@nottscc.gov.uk



Poole together for stroke
Poole Hospital NHS Foundation Trust, Bournemouth and Poole
Community Health Services and Dorset Cardiac and Stroke Network

Aims Actions Minimum standards for the quality of
The team aimed to develop and A patient and carer feedback forum handover of information to the
deliver an aspirational pathway for established the shortfalls in the community team were made and the
stroke, provide equity of access to transfer of care pathway and team committed to see patients
care in the community and, working described their aspirations for the within a week of hospital discharge.
with Borough of Poole social services, ideal stroke service. The conclusions
to define and integrate the role of were presented to staff from social Social care stroke co-coordinator
the social care stroke co-ordination care, health and the voluntary sector posts funded by the social care grant
team. who developed a pathway for the were appointed to support stroke
service based directly on those survivors in hospital and afterwards.
Issues to resolve visions. This pathway formed the
Four main problems were identified basis of the team’s action plan for Outcomes
at the start of the project: improvements. Measurable improvements include
• problems with the discharge improved patient satisfaction scores
process meant the hospital length A ‘meet the team’ meeting was for involvement in the transfer of care
of stay on the acute ward was established early in the first week of process, reduced waiting times for
higher than the national average at the hospital stay, to discuss prognosis community therapy and improved
21 days and plans for rehabilitation and quality of handover information
• a patient survey showed that only discharge with the patient and family. between hospital and community
18% of patients felt fully involved teams (see figures 5 and 6).
in the discharge process A key worker system was
• there was an average wait of 11 implemented on the acute stroke All of the changes made to the
days for the generic community ward. service were within existing resources
rehabilitation team and largely involved improvements to
• significant shortfalls were The content of patient information processes at ward level. The most
demonstrated in the quality of and the process for giving significant impact is the radical and
information shared between the information to patients and families demonstrable improvement in patient
acute trust and the community was reviewed and improved. experience.
rehabilitation team



This project benefited from the
Figure 5: Poole Hospital - How involved did you strong leadership of the consultant
feel in plans for leaving hospital? physicians who took a hands on
approach to both driving and
70
implementing the changes. The
60 cohesive multidisciplinary team
50
embraced and led further change to
% of Responses

influence all aspects of the transfer of
40 care process. The Dorset Cardiac and
30 Stroke Network were integral in
implementing the improvements.
20
Involvement in the Stroke
10 Improvement Programme project
0 improved joint working between the
May-Jul Aug-Sep Oct Nov Dec Jan acute trust and community stroke
Months teams with the resultant benefits to
Not at all Not involved Involved Very Involved patients.

Contacts
Dr Tracey Villar
Stroke Consultant, Poole Hospital
Figure 6: Poole Hospital and Woodland Community Rehabilitation Team: NHS Foundation Trust
Waiting times for community rehabilitation reduced from 10.7 to 6.8 days tracey.villar@poole.nhs.uk

12 Naomi Gibson
Senior Physiotherapist, NHS
Delay to first appointment

10 10.7
Bournemouth and Poole
8 Naomi.gibson@bp-pct.nhs.uk
6 6.8

4

2

0
January 2009 September 2009



Making sense of the muddle
Royal Bournemouth and Christchurch Hospitals NHS Foundation
Trust and Dorset Cardiac and Stroke Network

Aims satisfaction. Care review Outcomes
This team aimed to clarify the transfer documentation is given to the patient These improvements necessitated a
of care pathway from hospital to and carer to reinforce information change in culture by the acute and
home. given during the meeting. rehabilitation ward teams and have
taken time to embed. The work done
Issues Training for all registered health in the project between health and
The system for transfer of care was professionals on the new discharge social care teams supports the work
muddled and confused with no clear processes motivated staff and broke identified in Accelerating Stroke
pathway. Patients had differing down resistance to the new ways of Improvement to improve joint care
experiences of discharge planning working. All staff are now engaged planning. The project took time to
and transfer of care, depending on with discharge planning. get started, delayed by waiting for
which health and social care the funding of a community
professional was involved in the Development of written information rehabilitation team, but measurable
discharge process. The bid for a resources has supported verbal improvements to the process of care
stroke community rehabilitation team messages for patients and carers. and patient and carer experience are
was unsuccessful and waiting for a Patients are also informed of their anticipated after the lifetime of this
definitive answer from the PCT on first appointment with the national project.
funding took time. The team then community rehabilitation team prior
focused on making improvements to to discharge. Standardisation of Contact
the current system whilst waiting for paperwork between the acute and Clare Gordon
news of possible future funding for a rehabilitation units now includes a Consultant Stroke Nurse, The Royal
community stroke team. discharge checklist and Bournemouth and Christchurch
multidisciplinary handover Hospitals NHS Foundation Trust
Actions information for primary care. clare.gordon@rbch.nhs.uk
Patient and carer feedback has been
integral to this project, and has Closer working of health and social
informed the team at many levels as care teams is supported by the
to the effectiveness of their location of the social workers, an
improvements. information support officer and the
Stroke Association support staff in
Formalised care review meetings with the hospital near to the stroke ward,
patients and carers for enhanced rather than at the local authority.
communication and discharge A more consistent prediction of
planning have improved patient estimated discharge date helps this.



Stepping out
South West London Cardiac and Stroke Network

Aims
The project aimed to test the Figure 7: Patient self efficacy scores
applicability of a self management
programme in Croydon. 130
Pre Post
120
Issues 110
There was a lack of continuity in the 100
development and resolution of 90
treatment plans which were not 80
70
Score

incorporated into the whole care of
patients or transfer of overall plans. 60
Not all treatment plans were agreed 50
with patients and their carers. Staff 40
were not consistently working 30
towards patient centred goals and 20
outcomes to ensure that treatment 10
was patient led and individualised. 0
1 2 3 4 5 6 7 8 9 10 11 12
Patient
Actions
A self management approach called
the ‘Stepping Out Programme’ (now
known as ‘Bridges’) was piloted with which remained high throughout (see
24 staff across the stroke pathway in Outcomes figure 7). Improvements were also
Croydon. This approach focuses on 72% of staff participants changed made in patients’ perceptions of the
successes, decreases dependence their practice by the end of the impact of the stroke measured using
on therapists and facilitates programme towards a more patient the Stroke Impact Scale. No change
empowerment of stroke survivors centred, goal orientated approach was shown in hospital anxiety and
and carers to set, record and which promoted patients’ self depression scores, although none of
evaluate their own goals. efficacy. the participants had scores which
indicated the need for intervention
Improvements in self efficacy scores (see figure 8).
were shown in eight of the 12
patients and two others had scores



Figure 8: Patients perceptions of the impact of the stroke
measured using the Stroke Impact Scale

120
Before programme After programme
100

80

60

40

20

0
SIS SIS SIS SIS HAD HAD Self
(physical) (recovery) (participation) (emotion) (d) (a) efficacy

Staff feedback indicated that they
now use goals that are important to
patients and families and facilitate
discussions around living with stroke
for both the individual and the family

This project demonstrated that a self
management programme could be
successfully implemented in usual
clinical practice with positive benefits
on patients’ self efficacy and facilitate
the goal orientated approach
endorsed in national clinical
guidance.

Contact
Elaine Hayward
Senior Project Manager, South
London Cardiac and Stroke Networks
elaine.hayward@slcsn.nhs.uk



Redesign of stroke care pathway from
rehabilitation into the community
Stoke on Trent City Council

Aims Policies for discharge and for rapid
The team aimed to develop a person assessment by the community stroke
centred, integrated health and social discharge team were implemented.
care service for stroke and use a truly
joined up approach. An information database of
community services was established
Issues as a staff resource for signposting
Existing systems inhibited patients to further support after
communication between health and discharge.
social care, and excluded referral of a
range of individuals to social care All staff were encouraged to access
who would benefit from long term stroke specific accredited training
support. Social care referrals were programmes, facilitating the
limited and delayed. development of common skills and
knowledge.
Actions
Both the social care and early Outcomes
supported discharge teams adopted These were:
the same name, Community Stroke • improved partnership working
Discharge Team, to give a strong across health and social care with
message about joint working and a resulting development of shared
seamless service. A single point of objectives and goals
contact on one business card was • establishment of a dedicated social
used for patients and carers on care team for stroke
discharge. • a steady increase in Barthel index
scores demonstrating improved
The social care grant for stroke was levels of patient independence (see
used to increase social care time, figure 9)
enabling a daily visit to the • increased number of social care
rehabilitation ward and earlier referrals (see figure 10)
referral of patients.



Figure 9: Stroke rehabilitation unit average discharge Bartel score

16

12
Barthel Score

8

4

0
Nov 2009 Dec 2009 Jan 2010 Feb 2010 Mar 2010
Month

Average Barthel Score 2006/07 Average 2007/08 Average 2008/09 Average

Figure 10: Social care activity since all stroke wards have attached workers

350

300
Number of contacts/visits

250

200

150

100

50

0
Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10
Month

The success of the Stoke on Trent Contact
team’s improvements can be Lorraine Cobb
attributed to focused leadership by Social Care Team Manager and
the project lead in social care, Project Lead
genuine cross organisational working Stoke on Trent Social Services
through joint health and social care lorraine.cobb@stoke.gov.uk
objectives, and practical support from
the Shropshire and Staffordshire
Cardiac and Stroke Network. These
objectives were implemented at an
operational level by dynamic health
and social staff who worked regularly
and closely together.



Key learning from the transfer
of care national projects

Understanding the real state of the of stay and access to community and Key principles to accelerate
service is essential before long term support. Leaving hospital improvement in the transfer of care
improvements can be made. with a clear point of contact for help, can be summarised as follows:
Primarily this needs to be from the should it be required, was another • nominate a champion to drive
perspective of the stroke survivor and significant feature. improvement in each organisation
family, but also from the staff who • co-locate the stroke health and
work in the service and from the Strong leadership was another quality social care teams in the same
evidence seen from measuring the seen in these national projects. building, preferably in the same
service objectively. Measuring where Leaders emerged and developed from room
the service is at the start and regularly different members of the project • use a variety of tools to involve
reviewing progress towards objectives teams; from clinical staff, some with patients and carers to see where
is an essential component of protected time but several with none, the service is and what needs to
successful service improvement. and all with a clinical commitment, change
from commissioners of services, • actively include the patient and
The case studies described here all managers and network staff. With a family in decisions about leaving
accurately identified the shortfalls in leader to champion and drive the hospital at the earliest appropriate
the service, targeted improvements at project, the likelihood of successful opportunity
the points in the service where they outcomes is increased. • nominate a single point of contact
were needed, then monitored the as a resource for stroke survivors
improvement to ensure it was A consistent theme of the projects is after hospital discharge
effective and achieving the that effective communication and
intended outcome. genuine joined up working across
organisations supports rapid
Stroke survivors and their families improvement in transfer of care,
need to be central to the process of especially where this includes good
improving stroke services as well as working links between health trusts,
their early and active involvement in social care and voluntary agencies.
their own care and plans for leaving
hospital. Several of the projects
demonstrated that discussions about
transfer of care and early planning
was appreciated by patients and
families and impacted positively on
the measurable outcomes of length



Rehabilitation

Quality marker 10 of the National TOP TIPS
Stroke Strategy requires services to
ensure that people who have had • Proactively recruit patients to the
strokes have access to high-quality community service
rehabilitation and, with their carer, • Develop a flexible, stroke skilled
receive support from stroke-skilled workforce
services as soon as possible after they • Develop a team commitment to
measuring progress
have a stroke, available in hospital,
• Identify and use all services and
immediately after transfer from
delivery partners
hospital and for as long as they need
• Support effective leadership
it. Eight sites across England analysed
their rehabilitation services and made
improvements to them based on
what they found, establishing new
community and early supported
discharge services, improving the
skills of the multidisciplinary teams,
and developing plans to provide
weekend therapy.

This section contains information
about those improvements made by
the project teams. The case studies
provided here are a summary of the
improvements and how they were
achieved.



To improve the quality and quantity of
rehabilitation services for stroke survivors on a
combined unit, based on local and national
guidelines around quality marker 10
Aintree University Hospitals NHS Foundation Trust

Aims Actions Work has been undertaken to
To improve the quality and quantity The team undertook an observation improve the aesthetics of the day
of rehabilitation services for stroke study of a patient’s day across five room, and it is on the ward induction
survivors on a combined unit based domains – nursing, physiotherapy, check list for new patients.
on local and national guidelines occupational therapy, medical and
around quality marker 10. social. Time was divided into 15 More work is planned around skill
minute slots from 7am until 9pm, mix, additional staff, competencies,
Issues with observations taking place in the and further data collection, using the
Aintree Stroke Centre is a combined female rehabilitation bay. newly established rehabilitation
in-patient stroke unit. The hyper metrics as a basis.
acute and acute needs of the patients They also undertook feedback
have historically been the main focus questionnaires for patients and staff. Outcomes
for the multidisciplinary team, The staff questionnaires showed Relationships between the
resulting in significant changes in variability in confidence and multidisciplinary team have improved;
practice over many years. As a knowledge of handling and nutrition, therapy staff attend the daily nursing
consequence, staff identified the amongst all grades and professions. handover, use and update the
need to re-focus on the rehabilitation The patients indicated considerable nursing electronic handover and the
needs of stroke survivors. periods of boredom, especially in the discharge planning process is
afternoons, and lack of awareness of becoming more cohesive. The team is
Prior to the project the service had the existence of a day room. considering the re-introduction of
already identified several key factors communal eating on the ward, and
for further consideration, including a A successful bid for additional implementing a focus group looking
lack of true cohesive multidisciplinary handling equipment, with further at patient and carer information.
team working and absence of bids for more feeding aids/manual
relevant metrics. There were no handling equipment. They have shown that a 24 hour
mechanisms in place to collect approach and shared ownership of
patient and carer views, and a real A programme of joint training rehabilitation in partnership with the
lack of rehabilitation equipment on sessions between therapists and patients can support improvements in
the ward. nurses around handling and nutrition care, and enhance multidisciplinary
management has been implemented, team effectiveness and cohesion
including a process for evaluation. without huge investments of money.



Key learning was identified as
follows:
• undertaking a national project
always requires more time than is
anticipated. It is essential to gain
support within the organisation for
protected time to achieve this
• liaison with key stakeholders as
early on as possible makes a big
difference
• specific time bound objectives with
well-defined baseline metrics are
fundamental for project success.
Metrics for quality can be more
difficult to develop
• sort out a plan for data as soon as
possible, including how to collect,
store and analyse it, and ensure the
resources are there to support this
• tap into local resources (the stroke
research team, The Stroke
Association, the volunteers
department, the cardiac and stroke
network) to prevent duplication
and gain additional support
• small, bite sized improvements are
deliverable and lead to significant
changes over time
• ensure you have named individuals
at the correct grade who can take
responsibility for taking specific
issues forward (problems with
rotational staff, ownership and
commitment)

Contact
Helen Evans
Physiotherapy Manager
Aintree University Hospitals NHS
Foundation Trust
helen.evans@aintree.nhs.uk



Early stroke rehabilitation: development
of commissioning specification
NHS Hampshire

Aims Subsequently, they designed an Key learning was identified as
To develop a commissioning approach to pathway development follows:
specification for early stroke that accelerated service • establish a core project team and
rehabilitation (up to three months transformation. Regular develop them, e.g. through specific
post stroke) on behalf of a PCT communication with all key parties team building activities
collaborative of NHS Hampshire, NHS was achieved through a project • ensure that all key people are
Portsmouth, NHS Southampton and website, which was a repository of all involved at the very beginning so
NHS Isle of Wight. information relating to the project. that the project requirements are
fully scoped, e.g. it was useful to
Issues Outcomes have the contracting template for
Mapping of the rehabilitation services The specification was completed to the specification at the beginning
across Hampshire revealed wide time and within six months of • develop robust data collection
variation in the models of care, often launching the project. It is currently methodologies – establish early on
with poor co-ordination and a history being taken to each of the what data is available. This may be
of under-funding. The establishment organisations for a decision on particularly difficult for community
of community stroke services nearby, commissioning plans. rehabilitation services
via the Community Stroke
Rehabilitation Team in Portsmouth, Good communication was the key to Contact
demonstrated the positive outcomes steering the project through a variety Philippa Darnton
that might be achieved by changing of stages, and across many Programme Manager
the way in which these services are organisations. The team felt that NHS Hampshire
commissioned. coordination of engagement in the philippa.darnton@hampshire.nhs.uk
project resulted in the development
Actions of positive relationships with the local
The team obtained views of stroke authorities and commitment to work
survivors and carers from surveys together in future to address
conducted by The Stroke Association pathway issues as a whole system.
and Hampshire County Council, to Cross-functional relationships within
support design of the pathway. The the team have developed since the
team then tried to collect and start of the project, particularly with
interpret data, discovering that in teams such as contracting and
community settings it was not finance, which are so critical to the
possible to isolate stroke from success of the project.
general rehabilitation data.



To develop and agree a seven day therapy model
NHS Medway, Medway Community Healthcare

Aims Actions Those admitted on Saturday were not
Medway Community Healthcare, the They piloted an additional therapy always accessible for assessment, due
Acute Stroke Unit at Medway service on Saturdays from 9am to to the admission and investigation
Maritime Hospital and the Stroke 3pm on the acute unit over nine process or they were too tired for
Rehabilitation Unit St Bartholomew’s weeks and on the rehabilitation unit therapy assessment. The findings on
Hospital in Rochester aimed to work over 12 weeks. This was staffed by the rehabilitation unit were similar.
together to develop and agree a volunteers from the existing stroke From this, they concluded that six day
seven day therapy model. They services. working, with the sixth day being a
wanted to compare the impact of a Sunday, would have greater impact
six day therapy service, with the A variety of metrics were used to on the access to assessment time and
traditional five day service, across two capture a range of possible effects. prevent the backlog of assessments
sites, an acute stroke unit and stroke These included referral to treatment on a Monday more effectively.
rehabilitation unit. time, frequency of contact, length of Saturday service only captures those
stay, number of new referrals on the new patients admitted on Friday
Issues first day of the week, goals, mood afternoon or evening. A seven days
Stroke services in Medway did not assessments and treatment plans, service would have even more effect.
provide a seven day service across all discharges (weekday and weekend),
services. Consultation with stroke discharge destination and package of Admission to assessment time
survivors, carers and staff had already care. reduced. On the acute unit this
taken place to consider how this reduced from 42 hours running the
could be developed. Feedback There was no funding locally to service on five days, to 35 hours
indicated that patients and carers deliver this, so the team set about when running six days. This service
would value access to seven day running a pilot as preparation for a has adopted a model of more
therapy in a hospital setting, but not business case. multidisciplinary assessment, having
once they were home with their physiotherapists and occupational
families. Outcomes therapists assessing patients for both
Number of new referrals on first services, which has enabled this to be
day of the week stayed the same. measured across one metric, and,
On the acute stroke unit, the number with therapy services available for an
of patients to be assessed on a extra day, facilitated a reduction in
Monday morning reduced by 1.1 time to assessment.
when a six day service was available.



On the rehabilitation unit, there was Six day therapy service impact from 33.5 to 22.06, a reduction of
little impact on physiotherapy had minimal impact on weekend 11.4 days, which again if replicated
assessment, but significant impact on discharges. Possible reasons for this consistently, could lead to a saving
occupational therapy and speech and include the absence of the other for the trust of £746,000 per year. Six
language therapy during the six day necessary services at weekends to day therapy provision therefore can
service, as the referral to treatment make this viable, i.e. equipment have a very positive effect on length
time reduced by one day services and the willingness of of stay, in both acute and
(occupational therapy), and a 35 hour medical staff to support this. rehabilitation settings, but the greater
reduction for speech and language However, the data showed that the benefit is evident in rehabilitation,
therapy, lowering it to two days. The six day service did bring forward the possibly due to the more stable status
impact on physiotherapy, that was date of discharge to an earlier point of the patients, their availability for
already meeting the RCP guidelines, within the working week. On the treatment sessions and general
was less than on OT and SLT, whose rehabilitation unit, there was a 100% tolerance levels. There are also
admission to assessment times were increase in the number of Friday hidden benefits such as access to
well outside of the RCP guidelines. discharges during the six day period. family and carers for information
This can be improved further, if A change in culture and processes exchange and education, and to
therapy services can develop an within the pathway may also be nursing staff for mutual support and
integrated approach to assessment, necessary to ensure that both education, promoting more effective
for example on the acute stroke unit patients and the service may benefit team planning, goal setting and
in Medway Maritime Hospital, from the provision of weekend discharge planning.
patients can access even more timely, therapy through safe discharges at
holistic assessment. weekends. Six day therapy service provision
does not significantly affect
Total therapy contacts increased Bed occupancy in the discharge destination in the acute
on the rehabilitation unit where rehabilitation unit rose from phase, reflecting that this is
the six day service resulted in a 68.88% to 79.44%, even with an determined across a range of
significant increase in therapy time absence of additional discharges over parameters including medical status,
for patients across all professions. weekends. It is thought that so that additional sessions during the
This occurred against a background additional therapy staff on the ward comparatively early time after stroke
of depleted staffing, so the results at weekends may impact on decision does not influence this significantly.
could have been even better if the making by the ward staff and bed Very few patients transferred from
team had been fully staffed at this managers. Examples include the acute setting directly into care
time. On the acute unit it was not therapists guiding the bed managers’ homes during the five or six day
possible to audit this meaningfully, as decisions around selection of patients service, reflecting the
staff felt that intensity was based on to move off of the ward when this inappropriateness of making such a
what the patient was able to tolerate, has become suddenly necessary, decision within the first week of
rather than 45 minutes of therapy, facilitating unanticipated but safe admission before the patients have
because of their medical status. weekend discharges, preventing had a reasonable opportunity for
Contributing factors include the inappropriate transfers off of the rehabilitation. Most of the patients
‘fitness’ of patients to cope with ward, or when beds have suddenly who returned home quickly could
therapy, their availability, prioritisation become available, identifying an access the existing early supported
of their needs, and tolerance levels. appropriate stroke patient on another discharge, or had minimal package of
ward for transfer across. care needs. Transfers out from the
rehabilitation unit to care homes
Length of stay reduced in the acute were also unchanged. In the
unit from 8.2 to 5.1 days which, if rehabilitation stage, availability of
replicated for all patients over a good community services, including
year, would equate to a saving of those provided to care homes, may
£574,200. On the rehabilitation unit have more impact on discharge
the impact was significant, reducing destination.



Figure 11: Impact on length of stay in NHS Medway

Length of Stay, SRU, 5 Day Therapy
Undertaken using less than 25 points
100
92 90

80

60
Value

56 Target 56
46 47

40

Mean 33.5
31
28
20
19
15 4b
12 11 12
8 LCL 2
0
Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient
1 2 3 4 5 6 7 8 9 10 11 12 13 14

Interval

Length of Stay, SRU, 6 Day Therapy
Undertaken using less than 25 points
80

UCL 73.48
65
60 57
Target 56
Value

40
34
27
Mean 22.06
20 15
19 20 21
18 4b
15
12 10 9
3 5 LCL 0
0
Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Interval

Value Mean UCL LCL Target

A reduction in the number of Contact
people requiring care packages. Fiona Jenkins
There is a significant difference in the Stroke Services Manager
number requiring care packages and Medway Community Healthcare
the number of carers required. It is fiona.jenkins@medwaypct.nhs.uk
not possible to attribute this wholly
to the additional therapeutic input
these patients received during their
stay, but as this occurred on a
background of additional therapeutic
input, over 12 weeks, and a shorter
length of stay, it is likely that there is
some link.



Stroke rehabilitation: a seamless
journey from day one
Norfolk and Norwich University Hospitals
NHS Foundation Trust and NHS Norfolk

Aims Recruitment of Band 3 rehabilitation Outcomes
To provide specialist rehabilitation for assistants and Band 4 assistant On the acute stroke unit length of stay
patients following a stroke from practitioners was initially difficult, due has been reduced by one day and in
onset, through inpatient rehabilition to the lack of specialist skills in stroke the rehabilitation unit by eight days.
and/or stroke early supported and the need for the post holder to
discharge. be competent in skills from all No patients have waited longer than
professions. In response, the team 24 hours to be admitted to the early
To ensure that the service is unified developed their own set of core supported discharge service once
and that patients feel they are competencies reflecting the core they were considered fit for transfer.
moving along a pathway rather than professions and requirements, and This has been achieved through the
moved between different devised a strategy to deliver the team’s proactive assessment service.
organisations or services. training themselves. This is now
supported by a continuous education Caseload has steadily risen and
Actions programme and competency packs. stabilised to an average of 27-32
The early supported discharge pilot patients each month. In line with this,
team went live in August 2009, as This occurred against a background the early supported discharge team
part of the Central Norfolk Stroke of noro-virus, staff shortages, and the has seen a rise in direct patient
Services Stroke Care pathway to inevitable challenges associated with contact, reflecting in part the
provide rehabilitation to patients in transforming a building site into a increasing competence of staff, their
their own home. It was also a pilot fully operational stroke rehabilitation ability to work independently, and
scheme to look at the demand and unit. highlighting their value to the team.
the effect the team would have on
both the patient and existing stroke
services.
Figure 12: The impact on caseload

In January 2010, the new purpose 30
Actual Trajectory Target (15)
built stroke rehabilitation unit was
Number of admissions

25
opened on the same site as the early
20
supported discharge base, several
miles away from the acute stroke 15
unit. 10

5

0
Aug09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10
Month



Review of patients’ Barthel scores
shows a statistically significant Figure 13: Patient recovery
improvement (P=<0.05) in levels of
10
independence at discharge from early
supported discharge. 8

Number of patients
8
6 7
The team were successful in being
able to support 90% of patients at 4 5 5
4 4
home, 6% in nursing homes and 2%
2 3
in residential homes. Two were
rehabilitated in other places such as 0 0 0 0
0
0 10 20 30 40 50 60 70 80 90 100
social services planning beds. Six
Percentage
patients were readmitted, four due to
non stroke causes.

There was a positive effect on the
Figure 14: Patient experience
overall demand for packages of care
for stroke patients both in number 25
and intensity. The project team is 23
20
Number of patients

considering further work to look at
the longer term levels of packages of 15
care within the early supported
discharge service. Their throughput 10

costs have also reduced steadily, as 5 7
2
the team settles and improves its 0 0 0 0 0
1
0 4
efficiency. 0
0 10 20 30 40 50 60 70 80 90 100
Percentage
A patient satisfaction survey was
carried out and 62% patients rated
their experience as 100%, and 92%
rated it as over 80%. They have Contact
received encouraging feedback from John Mallett
service users such as: Stroke Care Team Leader, Community
Rehabilitation – Inpatients, Norwich
Community Hospital
‘I have no suggestions to john.mallett@norfolk-pct.nhs.uk
improve the service as I was
fully satisfied.’
Key learning was identified as
follows:
• good data is important for
preparing the basis of additional
business cases. Proactive in-reach
and developing a good rapport
with the other parts of the stroke
pathway is important. In addition,
building a good team from scratch
takes time, and recruitment may be
a slow process, so creativity helps


Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects

Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects

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