Psychological care after stroke: A national update

Dr Ian Kneebone

Associate, NHS Improvement – Stroke

http://www.improvement.nhs.uk/stroke/Psychologicalcareafterstroke/tabid/177/Default.aspx

ASI 6: Timely access to psychological support

Proportion of patients who have received psychological support for mood, behaviour or cognitive disturbance by six months after stroke.

Target: 40 % by April 2011

ASI 6 Psychological care within 6 months of stroke

National Update

Multiple examples of good practice on the SI website:

Evidence paper:

Kneebone & Lincoln (2010) Stroke Improvement programme. Psychological support: State of knowledge.

National Update

Specific guidance:

Screening for emotional disorder

Screening for cognitive deficits

Does the patient have a communication difficulty?

Yes No

Administer the HADS

Score 9 or more on D scale?

Yes No

Non-depressed range

Administer suicide question from BASDEC

Respond with true?

No Yes

Depressed range

Report to nurse in charge.

Administer the DISCs

Scored 2 or more?

Yes invalid No

Administer SADQ H10

6 or more? No

Non-depressed range

Yes

Suicide questionfrom BASDEC

Respond with true?

No YesReport to nurse

in charge

Flow chart for people under 65 years

Staff concerns?Yes

Weeks 1-3 (or before discharge if <3weeks) OT to administer MOCA or ACE-R + Star CancellationInforms team of results – rehab planning

Week 4 Does patient have communication problems?Yes No

OT to administer RCPM

Assess cognitive problems further using functional assessment. Interfering with rehab?

Scores less than 19?

Review further assessment/treatment options with SALT and psychologist.

Review further assessment/treatment options with psychologist

Interfering with rehab?

What cognitive domains are affected?

Informs team of results

OT to administer RBANS

Comprehensive neuropsychological assessment by clinical neuropsychologist

Monitored by GP, refer for Stroke Associationsupport etc

Week 6 onwards. Review. If impaired, discuss treatment

options with psychologist

6 month review.Any cognitive problems reported?

Is patient going back to work or do they have cognitively demanding lifestyle or responsibilities (e.g. childcare)

Yes

YesYes

No Yes

Yes

No

No

No

No

National Update

Screening for emotional disorder2006 55% (RCP 2007):

2012 88% (RCP 2013)

Screening for cognitive deficits2006 71% (RCP 2007) for whom it was applicable?

2012 81% (RCP 2013)

ASI 6 Psychological care within 6 months of stroke

From around the nation• Progress is better than that measured.

– Many teams not yet submitting data, have undergone major service reorganisation to improve psychological care

• Midlands and East stroke review– Clinical psychology posts being built into specs for

ESD and community rehab teams

• Widespread use of economic case to support bids for clinical psychology

From around the nation• Progress is better than that measured.

Dorset:

-Trained IAPT in communication skills after stroke (SALT led)

-IAPT trained stroke practitioners in recognising mental health problems

-Established a clear referral pathway (IAPT level 3)

Befriending: Connect

• Reassure – You are not alone – ‘normalising’• Listening ear• Give Time• Empathise – Shared experience• Encourage and Support• Tips and Ideas – Signposting

(McVicker & Eustice, underway)

Befriending: Connect

• Information – Link to ongoing support• A chance to discuss opportunities • ‘A role model’• ‘A inspiration for a positive future and what ‘me with aphasia’ could look like’

(McVicker & Eustice, underway)

Motivational Interviewing

• “to support and build a patient’s motivation to adjust and adapt”

• “working with patient’s dilemmas and ambivalence…supporting and reinforcing optimism and self-efficacy”

Motivational Interviewing

• Elicit person’s own solutions

• Elicit person’s usual coping style that was successfully used in the past

• Explore application in the present & the future

Motivational Interviewing

• An RCT, has shown Motivational Interviewing can improve mood after stroke (Watkins et al., 2007)

• Administered by nurses with specific training and supervision

SSNAP Organisational audit 2012

0

20

40

60

80

100

120

2006 2012 2034

Percentage

Percentage of stroke units with access to psychology services by year

Sentinel Stroke National Audit Programme (SSNAP)

RCP National Clinical guidelines for stroke 2012

• Stroke services should adopt a ‘stepped care’ approach to delivering psychological care.

• All patients after stroke should be screened within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment (NICE guidance)

• Recommendations for management of depression, anxiety, fatigue, cognition, emotionalism

CCG Outcomes Indicator Set People who have had a stroke who:

• are admitted to an acute stroke unit within four hours of arrival to hospital • receive thrombolysis following an acute stroke • are discharged from hospital with a joint health and social care plan • receive a follow-up assessment between 4-8 months after initial admission

Mortality within 30 days of hospital admission for stroke

CCG Outcomes Indicator SetEnsuring people feel supported to manage their condition

• People feel supported to manage their condition

Enhancing quality of life for people with mental illness

• Access to community mental health services by people from BME groups• Access to psychological therapy services by people from BME groups• Recovery following talking therapies (all ages and older than 65)

 

The economic case for a clinical psychology

led service

NHS savings from provision of psychological care over two years

Savings around

£59,000 year 1

Savings around

£98,000 year 1

• Potentially a renewed interest in compassionate care for patients and development of culture where this is possible

• Legal responsibility for staff to be open about incidences of harm (including neglect)

• Services which expose patients to risk prevented from continuing