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Model for Stroke Rehabilitation
in Scotland
SSCA National MeetingSSCA National Meeting30 August 2018
Mark Smith
AHP Consultant in Stroke
NHS Lothian
Rehabilitation: a biopsychosocial
approach
….interventions designed to optimize functioning and reduce
disability in individuals with health conditions in interaction
with their environment.
The benefits of rehabilitation are realised beyond the health The benefits of rehabilitation are realised beyond the health
sector. Rehabilitation can reduce care costs and enable
participation in education and gainful employment.
World Health Organisation 2017
Stroke Rehabilitation Evidence
Intervention Benefits Ref
Physiotherapywalking, mobility, balance, fitness, arm
function1-9
Occupational
Therapyarm function and activities of daily living 6-10
Speech and
Language Therapy
everyday communication, reading, writing,
speaking11
Language Therapy speaking
Psychotherapy mood, prevents depression 12
Music Therapy walking (? quality of life) 13
Visual Training (?reading) 14
Supported Self-
Managementquality of life (? confidence) 15
Early Supported
Discharge
(resourced)
reduces long-term dependency, length of
hospital stay, institutional care admissions16
Rehabilitation Sprint Audit 2015 – 2016 Criteria
1. Patients admitted to hospital due to an acute stroke should be
assessed by more than one Allied Health Professional by the
fourth day of their hospital admission (Day of admission = Day 0).
2. Multidisciplinary discussion about the patient’s rehabilitation
needs should have occurred by the fourth day of their hospital needs should have occurred by the fourth day of their hospital
admission.
3. The multidisciplinary discussion should be recorded in a paper or
electronic format which is accessible to all health professionals
involved in the patient’s care.
4. There should be documented evidence that the rehabilitation plan
has been agreed in discussion with the patient and/or their next
of kin.
SG Secondment through NACS/SSCA
• Purpose
• This project will scope how the key rehabilitation priority areas within the Stroke Improvement Plan are being delivered across Scotland and benchmark these against available evidence and best practice with a view to evolving optimal pathways for future provision.
• This will involve Mark Smith, working as part of the stroke improvement team, from 1st August 2018 for 6 months for 1 day per week. He will work with and report to the SSIP/Clinical Priorities Team at Scottish Government.report to the SSIP/Clinical Priorities Team at Scottish Government.
• Aims
• Produce outcome measures and data sources on stroke rehabilitation in Scotland to inform improvement.
• Objectives
• 1. Identify and analyse evidence on stroke rehabilitation for inpatient and in the community
• 2. Produce draft standards for stroke rehabilitation.
• 3. Establish how interventions and impact could be recorded and reported, in line with the SSIP.
• Outputs and timescale
• Phase 1 - Evidence review and initial analysis – update for NACS 19/11/18
• Phase 2 – Report of evidence review, standards and recommendations for data
and collection
• Project Outcomes:• Project Outcomes:
• Utilising data to focus on service outcome measures for our patients. This will
involve two main components, firstly inpatient rehabilitation and how we record
and measure intervention and secondly the scope of community rehabilitation for
this patient group.
• Utilising the Manchester Rehabilitation template to reflect the Scottish
performance with a patient centred outcome focus.
A way forward – better data?
• Clearer means of describing performance
• 45 min per treatment in hospital – discharge processes
• Community provision: ESD, D2A, Third Sector
• Data collection hospital and H&SC
• H&SC Integration – IJBs/Localities• H&SC Integration – IJBs/Localities
• Develop more defined pathway models beyond hospital
• Clinical Knowledge Publisher (NES)
• Better metrics ISD % compliance
• Greater Manchester Model
• Correlating SIP with SSNAP
• Patient experience measures
Measurement based on GMSODN
• ISD developing
• Model compliance overall grading key:
• A Blue >80.1%
• B Green >70.1%
• C Amber >60.1%• C Amber >60.1%
• D Red >50.1%
• E Black </= 50%
• Percentage of adults having stroke rehabilitation in hospital offered at least 45 minutes of physiotherapy/OT/SLT for a minimum of 5 days a week for up to 6 weeks
Stroke ISU Rehab Casemix
The six categories are:
1. Patients with TIA/minor stroke discharged within 48 hours who may not need to come into ISU from the front door
2. Actively unwell and unfit for rehab (some of whom will be likely to die within 4 weeks)die within 4 weeks)
3. Rehab – “fast-track” patients (to community rehab on an accelerated pathway, in-reach/D2A)
4. Rehab – stroke specific (need to be on ISU, may become Cat 3)
5. Rehab – non-stroke specific (could go to alternative rehab settings, eg. MOE)
6. Finished and delayed (could move off the ISU to wait with appropriate support/guidance)
Stroke ISU Rehab Casemix
The six categories are:
1. Patients with TIA/minor stroke discharged within 48 hours who may not need to come into ISU from the front door
2. Actively unwell and unfit for rehab (some of whom will be likely to die within 4 weeks)die within 4 weeks)
3. Rehab – “fast-track” patients (to community rehab on an accelerated pathway, in-reach/D2A)
4. Rehab – stroke specific (need to be on ISU, may become Cat 3)
5. Rehab – non-stroke specific (could go to alternative rehab settings, eg. MOE)
6. Finished and delayed (could move off the ISU to wait with appropriate support/guidance)
Specialty teams:
e.g. ECSS/AAH/Neuro OP
Only what no-one but “we” can do?
Core case load?
But how can we influence others?
Stroke Community Service
Delivery Pyramid – Skills Mix
Specialist teams
Generic high volume deep
generalist teams: e.g. ICS/REACT
Generic high volume community service
e.g. care/reablement teams
What we can do to expedite discharge
and deliver rehab in a home setting?
Availability of care?
How can we continue
rehabilitation interventions
in the context of
care/reablement?
Families?
Stroke Unit Staffing• Chief Health Professions Office SG scoping ideal Stroke Unit
Staffing using the UK Stroke Forum Education and Training –Stroke Specific Education Framework Stroke Staffing Calculator:
https://www.stroke-education.org.uk/staffing/
• SSCA Organisational Audit annually looks at actual staffing • SSCA Organisational Audit annually looks at actual staffing
• BASP Standards (2014) 1.0 wte OT/PT per 5 beds, 1.0 wte SLT per 10 beds
• Access to neuropsychology
• Comparison?
Edinburgh ICS “Fast-Track” (Cat 3)
Referral CriteriaResident in Edinburgh
No ongoing acute medical issues
Therapy requirements can be met
Care requirements can be metCare requirements can be met
Risks identified and management plan in place
Suitable home environment
Family prepared to support discharge
Continence management plan in place
Nutrition plan in place
Front door AHP
assessment for D/C
needs <24 hrs
ISU – MDT
Assessment
OT/PT/SLT
SSCA By Day 3
ISU Stroke Rehab Process
Chart
Admit ISU
Prioritisation
High
Medium
MDT Meeting
– set patient
centred goals
, EDD, Cat 3/4
Ongoing
treatment 45’
daily as
appropriate
(RCP)
Preparation of
discharge
environment/pro
vision of
aids/adaptations
Discharge
NHS
LTC/Nursing
Home/
Discontinue
Rx
Under 65/rehab
potential Cat 4
AAH
Downstream
Rehab
Home – referral to
community services –
Stroke MCN
Community referral
algorithm Cat 1
Home
Home – referral to
community services –
Stroke MCN
Community referral
algorithm
Home +/- ESD
Low
, EDD, Cat 3/4aids/adaptations
Liaison with
family/community
services
Monitor/maintain
Cat 2/5/6
Home +/- ESD
Detailed process map for ISU rehabilitation discharge pathway
Patient admitted
to ISU
Discharge home with
Monitor/maintenance
Regular reassessment
on ward
Initial assessment,
ID and Prioritisation process
Unconscious/severe
stroke/TACS (Cat 2)
Mild stroke with short
LOS < 2 days (Cat 1)
Significant stroke requiring
Intensive rehabilitation (Cat 3/4)
Detailed MDT
assessment
Discussion in huddle on following day
“fast track” criteria met
Telephone inform ICS of admission and
likely accelerated pathway - EDD
Send detail in TRAK/by email
Prioritised intensive IP rehabDischarge home with
appropriate referralAgree EDD with ICS
Deliver in-patient therapy as intensively
as patient and service can sustain
Share goals and therapy treatment
plans with ICS prior to discharge
Discuss patient centred goals in MDT with ICS
representation in person or on telephone
Patient can go with
in-reach or with outreach supportHome
Prioritised intensive IP rehab
45 mins/day/discipline
http://www.lothianstrokemcn.scot.nhs.uk/journey/Pages/default.aspx
Edinburgh Stroke Immediate Discharge and Rehabilitation Algorithm
To be discharged home from hospital?
Medical Day Hospital
(example; click this will open
directory at “OPRA”)
Yes
Intermediate Care ServicesYes
Ongoing Medical/Nursing needs and >65 years of age?
No
Personal Care and Rehabilitation needs?
No
Home Care/Reablement
serviceYesPersonal Care needs only and not rehabilitation?
YES
Nursing Home placement or
Long Term NHS CareNO
Specialist Stroke rehabilitation needs any age >16 years of age?
No
YES
Multidisciplinary? Uniprofessional?
• e.g. Domiciliary SLT/PT
• Sector OT
• Domiciliary Physiotherapy
• Community SLT
• Carer Support
• Orthotics
• Dietetics
• Fitness Pathway
• Clinical Neuropsychology
• Advocacy
AAH OP Service(Hospital based)
ECSS (Community based)
Consult
• NACS
• SSCA – Steering Group/Rehabilitation Subgroup
• MCN Subgroup of NACS• MCN Subgroup of NACS
• SSAHPF
• SSNF
Summary
• We plan to audit intensity of rehabilitation delivered in hospital as dose is critical to achieving best outcomes which will also have health economic benefits – staff capacity
• We need to determine that stroke patients can access appropriately specialist ESD/D2A and access appropriately specialist ESD/D2A and community rehabilitation pathways – within the context of H&SC Integration
• Future SSCA initiatives to more specifically address performance around ongoing issues within the SIP such as vocational rehabilitation, vision, driving, neuropsychology, self management, exercise, spasticity
Acknowledgements
• Prof Frederike van Wijck GCU
• Prof Marian Brady NMAHPRU/GCU
• Thérèse Lebedis NHS Grampian/NACS
• Katrina Brennan NHS Lanarkshire/NACS• Katrina Brennan NHS Lanarkshire/NACS
• Neil Muir NHSNSS ISD
• Connie Smith Scottish Government
Cochrane Database References• 1. English C, Hillier SL, Lynch EA. Circuit class therapy for improving mobility after stroke. Cochrane Database of Systematic Reviews 2017,
Issue 6. Art. No.: CD007513. DOI: 10.1002/14651858.CD007513.pub3.
• 2. Saunders DH, Sanderson M, Hayes S, Kilrane M, Greig CA, Brazzelli M, Mead GE.Physical fitness training for stroke patients.CochraneDatabase of Systematic Reviews 2016, Issue 3. Art. No.: CD003316.DOI: 10.1002/14651858.CD003316.pub6.
• 3. Mehrholz J, Thomas S, Werner C, Kugler J, Pohl M, Elsner B. Electromechanical-assisted training for walking after stroke. Cochrane Database of Systematic Reviews 2017, Issue 5. Art. No.: CD006185. DOI: 10.1002/14651858.CD006185.pub4.
• 4. Mehrholz J, Thomas S, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD002840. DOI: 10.1002/14651858.CD002840.pub4
• 5. Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, Pomeroy VM, Langhorne P. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD001920.DOI: 10.1002/14651858.CD001920.pub3.
• 6. Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F.Interventions for improving upper limb function after stroke.Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010820.DOI: 10.1002/14651858.CD010820.pub2.
• 7. French B, Thomas LH, Coupe J, McMahon NE, Connell L, Harrison J, Sutton CJ, Tishkovskaya S, Watkins CL.Repetitive task training for improving functional ability after stroke.Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD006073.DOI: 10.1002/14651858.CD006073.pub3.
• 8. Mehrholz J, Pohl M, Platz T, Kugler J, Elsner B. Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke.Cochrane Database of Systematic Reviews 2015, Issue 11. Art. No.: CD006876.DOI: arm function, and arm muscle strength after stroke.Cochrane Database of Systematic Reviews 2015, Issue 11. Art. No.: CD006876.DOI: 10.1002/14651858.CD006876.pub4
• 9. Corbetta D, Sirtori V, Castellini G, Moja L, Gatti R. Constraint-induced movement therapy for upper extremities in people with stroke. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD004433. DOI: 10.1002/14651858.CD004433.pub3.
• 10.Legg LA, Lewis SR, Schofield-Robinson OJ, Drummond A, Langhorne P. Occupational therapy for adults with problems in activities of daily living after stroke. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003585. DOI: 10.1002/14651858.CD003585.pub3.
• 11.Brady MC, Kelly H, Godwin J, Enderby P, Campbell P. Speech and language therapy for aphasia following stroke. Cochrane Database of Systematic Reviews 2016, Issue 6. Art. No.: CD000425. DOI: 10.1002/14651858.CD000425.pub4.
• 12. Hackett ML, Anderson CS, House A, Xia J.Interventions for treating depression after stroke.Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD003437.DOI: 10.1002/14651858.CD003437.pub3
• 13. Magee WL, Clark I, Tamplin J, Bradt J.Music interventions for acquired brain injury.Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD006787.DOI: 10.1002/14651858.CD006787.pub3.
• 14. Pollock A, Hazelton C, Henderson CA, Angilley J, Dhillon B, Langhorne P, Livingstone K, Munro FA, Orr H, Rowe FJ, ShahaniU.Interventions for visual field defects in patients with stroke.Cochrane Database of Systematic Reviews 2011, Issue 10. Art. No.: CD008388.DOI: 10.1002/14651858.CD008388.pub2.
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