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

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• 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.

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