10 mousumi basu doyle esd camden.ppt

• 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. 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. National Strategy for Stroke: What is expected?

• National Strategy for Stroke(DoH, Dec 2007)

• 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.

• 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.

• Seamless transfer of care:A workable, clear discharge plan that has fully involved the individual (and their family where appropriate) and responded to the individuals particular circumstances and aspirations is developed by health and social care services, together with other services such as transport and housing.

• Long-term care and support:Arange 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. Camden Stroke Achievements

• Expansion of stroke support groups .

• Expanded provision ofStroke Association Communication Support Service .

• Gold standardstroke early supported discharge service

• Stroke Patient Handbook .

• Camden StrokeWebpag e http://www.camden.gov.uk/ccm/content/social-care-and-health/health-in-camden/stroke.en?page=1

• Use ofmulti-media to enable stroke survivors to share

• their experiences

• http://www.acting-up.org.uk/camdenstroke.htm

• Supportingyounger peoplewho have had a stroke.

• Carers Voices DVD.

• Family and Carers(Stroke) Hospital and Community Support Service

• Social activities give carers abreak

• Community StrokePsychologistrecruited

• Pathway toshort term home based rehabilitation Camden REACH

• Pathway tolonger term care management, psychological

• AdultSocial Care Annual Review

• CommissioningStroke Reviews and Navigator Service

• Close and multi-agency working

• CQC Stroke Auditpreliminary findings.

. . 5. How did we get there?

• Seizing the future

Setting the direction Delivering the service 6.

• 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

Camden Stroke REDS 7. Stroke REDS Pathway

• Receipt of referral and Assessment

• Neurological, Functional, Social Needs Assessment

• Social Worker starts integrated care plan formulation

• Facilitation of Discharge

• Access Visit

• Home visit

• Social Needs:

• night sitting

• day sitting

• daily visits + domestic support

• Day of Discharge

• Own transport

• Discharge home visit

• Start of enabling care

• Integrated Rehabilitation at Home

• A period of 6-8 weeks

• Discharge from team

• Onward referrals if needed

• Social work 4 week follow up post discharge

• Review at 6 months

• Focus on life after stroke, significant changes, quality of life, social needs

• Referral to new Stroke Coordination and Navigation Service

8.

• Week 1 settling in at home, therapy and assessments, enabling care, outcome measures

• Week 2 goal setting, therapy and assessments, enabling care

• Week 3 therapy + weaning off in enabling care

• Week 4- therapy + weaning off in enabling care + specialised Social Work review from Stroke REDS

• Week 5- therapy + weaning off in enabling care or end + liaison with post discharge teams

• Week 6- therapy + end of enabling care + goal review + outcome measures + discharge

• Potential to extend to8 weeksfor therapy only if appropriate

• Social Worker involved for a further 4 weeks post discharge

• This includes weekly interdisciplinary team meetings and also weekly meetings with enabling carers

Integrated Rehabilitation with Stroke REDS 9. Outcome Measures 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 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. Client perceptions

• 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 heartand I didnt 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.

11. Camden Stroke Groups 12.

• 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 being.

Camden Community Stroke Groups

• 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 theKilburn 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. 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 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 Visit Assess Needs Introduction Refer or signpost to other services Review Receive Referral 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. Case Study Mrs PP

• Referral from REACH team

• Wanted ongoing support after stroke

• Meet other stroke survivors

• Get out and about

16.

• 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 PPs Journey

• 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

17. Outcome Measurements

• Individual Targets

• Outcomes Star

Physical Dexterity Balance Coordination Mobility Strength Cognition VisualSpatial Language Emotional Memory Executive Cerebral Wellbeing Interaction Expression Assertiveness Keeping In Touch Self Esteem 18. Output Measures Outcome Star Measures

• 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 reportedimprovement 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 ofkeeping 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 survivorsimproved positive feelings like hope . 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 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.

20. Contact details [email protected][email_address] [email_address] [email_address]