Final Stroke Day Service Evaluation Report

EVALUATION OF A

REPORT, 17TH APRIL 2020Dr. Jackie Gallagher, Institute of Technology Tralee

S T R O K ED A Y S E R V I C E

BAILE MHUIREDAY CARE CENTRE FOR OLDER PERSONS

ContentsExecutive Summary ..........................................................................................2

1. Introduction ................................................................................................5

• 1.1 Life after Stroke 7

2. The Stroke Day Service ..............................................................................9

• 2.1 The Evolution of the Stroke Day Service 9

• 2.2 Implementation of the Stroke Day Service 10

• 2.3 The Stroke Day Service Programme 10

3. Research Aim and Objectives ..................................................................13

4. Methodology ............................................................................................14

• 4.1 Participants 15

• 4.2 Test Instruments 15

5. Results........................................................................................................18

• 5.1 Client Profile 18

• 5.3 Service Impact: Participants 21

• 5.3.1 Physical Measures 22

• 5.3.2 Psychological Measures 22

• 5.3.3 Participants Perceptions of the Stroke Day Service Programme 25

• 5.4 Service Impact: Carers 29

• 5.4.1 Psychological Wellbeing 29

• 5.4.2 Carers Perceptions of the Stroke Day Service 30

• 5.5 Case Studies 34

6. Conclusion and Recommendations ........................................................37

• 6.1 Conclusion 37

• 6.2 Recommendations 38

• 6.3 Summary 40

Bibliography ....................................................................................................41

Appendices......................................................................................................43

Appendix 1 ......................................................................................................44

Appendix 2 ......................................................................................................45

Steering Committee on Stroke Day Service Evaluation ..............................46


Executive SummaryStroke is a leading cause of death and disability worldwide and it is estimated that cerebrovasculardisease accounts for up to five percent of total health care expenditure in a number of countries(Rossanagel et al., 2005; Evers et al., 2004). The physical disability and morbidity resulting fromstroke pose a significant burden both at individual and societal level (Hickey et al. 2012).Rehabilitation can have an important impact on the overall clinical and economic burden of strokenot just for the stroke survivor but also for the family/caregiver and the healthcare system. Theimportance of rehabilitation for stroke has been acknowledged and addressed in nationalstrategies and these same strategies have also acknowledged the gaps in these servicesthroughout Ireland (National Policy and Strategy for the Provision of Neuro-RehabilitationServices in Ireland 2011- 2015 Department of Health and Health Service Executive 2011, IrishHeart Foundation 2008; Smith et al. 2010, National Community Stroke Services survey, 2011.).

The estimated annual incidence of stroke in Kerry is just under 300 per year and with an increasingageing population this number will continue to increase. Traditionally rehabilitation post dischargefrom the acute setting is limited and tends to reduce with time post stroke. However as stroke isa chronic condition secondary problems due to inactivity and limited social interaction continueto impact the person’s life long after their initial stroke. The Kerry Stroke Support Group havehighlighted the gap in services in the community for people post stroke and have advocated foran increase in this type of service on behalf of their members for the past number of years.

Having obtained funding in October 2018 from the National Office for Services for OlderPeople & Palliative Care Strategy the Stroke Day Service began the implementation of theprogramme in November 2018. Ard Chúram provides the service to North Kerry and BaileMhuire provides it to the remainder of the county. Table 1 below provides an overview of thenumbers of programmes provided and the number of participants who engaged with theprogramme in each centre in 2019.

Overview of Programme Provided

This report presents the outcomes of an evaluation undertaken, based on the first 7 StrokeDay Service programmes, to determine the impact of the pilot programme on participantsphysical and psychological well-being. The nature of the evaluation undertaken was formative, (rather than summative), in that the primary focus was on extracting learning.

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Baile Mhuire

Ard Chúram

Number of Stroke DayService Programmes

6

4*

Number of Participants

49 clients in total - 47 New

29 clients in total - 24 New

*Ard Chúram provided a Parkinsons and ‘Keeping Well’ Programme in addition to the four Stroke Day Service Programmes included in the above table.


The outcomes of the evaluation undertaken can be summarised in terms of finding and recommendations as follows;

Key FindingsIn exploring both the participants and carers perspectives on the Stroke Day Service, via thefacilitation of numerous focus groups, the consistent message was that the service isbeneficial, for both participants and their carers/families, and should continue with allparticipants requesting to repeat the programme. The availability of physiotherapy, supportfrom all the staff members, suitability of the venues and the benefits of socialisation weresome of the key successful components of the programme from the participants’ point ofview. The social aspect of the programme was a significant motivator for both the initial andcontinued engagement in the programme. The programme was directed primarily towards theparticipants however family members and carers also experienced significant benefits as aresult of the programme. The carers highlighted the respite received was as a direct result ofthe service and a feeling of support obtained particularly when they often felt isolated andforgotten about once their family member had left the acute setting post stroke.

The participants described how the physiotherapy, in the form of the provision of an exerciseprogramme, enabled progression in their physical capacity with many seeing improvements.Engagement with the service has led to significant improvements in participants balance (BergBalance Scale), gait speed (10m Walking test) and mobility (Elderly Mobility) scores (p<0.05).In addition, many participants indicated that engagement with the service led to theenhancement of their confidence and sense of independence, a benefit echoed by many familymembers and carers.

In utilising WHO-5 Wellbeing Index to determine the impact programme engagement mayhave had on the mental well-being of participants, an increase in well-being index scores wasevident however, the increase was not statistically significant (p >0.05). Scores obtained fromthe WHOQOL-BERF questionnaire evidenced a statistically significant increase (p=0.00) inparticipants perception of their quality of life and an increase in their satisfaction with theirhealth (p=.001) post their engagement with the Stroke Day Service. Similar tests were usedto assess the carers/family members and both the Well-Being Index scores and Carer Burdenscores were evidenced, indicating that engagement with the Stroke Day Service Programmehad a positive impact on carer’s wellbeing and sense of burden.

In essence, the support received and engagement from a multi-disciplinary team (therapists,nursing staff, care attendants, volunteers and the physical activity leader) was identified as a key element that led to the success of the programme.

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Engagement and participation with the Kerry Stroke Support Group has increased as a directresult of engagement with the Day Service. Additionally, many participants having completedthe Stroke Day Service are now willing to engage with routine day services, which they maynot have considered prior to engagement with the Stroke Day Service.

Main RecommendationsOne of the key recommendations, evidenced from feedback obtained from the participantstheir carers and family members and through the improvements in both physical andpsychological well-being assessments was the continuation of the Stroke Day Service.

The success of the Stroke Day Service may be attributed to a number of key factors. One ofthe key factors that enabled programme delivery was the model of partnership between theHSE and voluntary agencies, this partnership enabled an effective model for providing thisservice. It allowed flexibility to respond to the feedback received from the participants andfamily members in a timely fashion. This meant that each programme was adapted andprovided increased input in different areas as highlighted through the participants and familymember’s focus groups. For example, transport to the service was highlighted as a barrier toaccessing the service, which was unsurprising given the geography of the county and lack oftransport. Staff at Baile Mhuire were able to respond to this need and are now providingtransport for participants engaged in the programmes currently being delivered. Occupationaltherapy input and group counselling sessions were introduced in response to feedbackobtained from the participants and their carers. In addition two carer events have beenorganised in response to a support need identified by the carers.

The model utilised in the provision of the Stroke Day Service which combined physical, mentaland social elements is a key recommendation going forward in the provision of communitybased care for stroke survivors. In addition expansion of the service is recommended thusenabling participants to access programmes more frequently during the year, which wouldensure that participants maintain the gains achieved and have regular contact with the multi-disciplinary team to advise and support the client on their journey post stroke.

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1. IntroductionStroke is a leading cause of death and disability worldwide and it is estimated thatcerebrovascular disease accounts for up to five per cent of total health care expenditure in anumber of countries (Rossanagel et al., 2005; Evers et al., 2004). In Ireland, approximately7,000 people experience a stroke each year, with 75% of strokes occurring in over 65s(National Stroke Programme, 2017). While stroke often affects those aged 65yrs or aboveabout one third of stroke survivors are less than 65 years of age (Hartle et al., 2011). Thereare up to 50,000 stroke survivors living in Ireland, of which 30,000 are living with residualdeficits (Irish Heart Foundation 2017). The residual deficits include for example, changes inpersonality or behaviour, motor function (weakness, clumsiness, etc.), speech, word retrieval,reading, writing, memory, attention, spatial perception (neglect of one side), other cognitiveproblems, sensation (vision, numbness/tingling, pain, etc.), mood, walking, pain, fatigue, andsexual function (Hillis & Tippett, 2014).

Rehabilitation forms a significant element in recovery from stroke, rehabilitation helps strokesurvivors relearn skills that are lost when part of the brain is damaged. For example, theseskills can include coordinating leg movements in order to walk or carrying out the stepsinvolved in any complex activity. Rehabilitation also teaches survivors new ways of performingtasks to compensate for any residual disabilities, for example individuals may need to learnhow to bathe and dress using only one hand, or how to communicate effectively when theirability to use language has been compromised. There is a strong consensus amongrehabilitation experts that the most important element in any rehabilitation programme iscarefully directed, well-focused, repetitive practice (National Institute of NeurologicalDisorders and Stroke, 2019).

While it is notoriously difficult to predict who will recover from stroke, how much they willrecover, and when they will recover, it is widely recognized that there is a great deal ofindividual variability in stroke recovery. Even two individuals with very similar appearingischemic strokes may show very different outcomes one year later. In general, successfulstroke rehabilitation depends on:

• Physical factors, including the severity of your stroke in terms of both cognitive and physical effects• Emotional factors, such as your motivation and mood, and your ability to stick with rehabilitation activities outside of therapy sessions• Social factors, such as the support of friends and family• Therapeutic factors, including an early start to your rehabilitation and the skill of your stroke rehabilitation team (Mayo Clinic, 2019).

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The rate of recovery is generally greatest in the weeks and months after a stroke. However,there is evidence that performance can improve even 12 to 18 months after a stroke.

Rehabilitation begins as soon as a stroke patient is stable, sometimes within 24 to 48 hoursafter a stroke. This first stage of rehabilitation can occur within an acute-care hospital. Forsome stroke survivors recovery can continue for months and years after stroke – well beyondthe rehabilitation period. Thus, for many rehabilitation will be an ongoing process to maintainand refine skills and could involve working with specialists for months or years after the stroke(Langhorne, Bernhardt, Kwakkel, 2011). The need for long term follow up for participants poststroke has been highlighted in both the National Irish Stroke Audit and the UK National clinicalGuidelines for Stroke 2016- ‘Systems for follow-up between stroke specialists and primarycare need to be developed and resourced for long-term follow-up, given the complexity andinter-individual heterogeneity of post-stroke complications, risk of further stroke, and thepotential for continuing longer term recovery. These systems should give a high priority tosystematic secondary prevention, rehabilitation and support’. Hence how best to supportstroke survivors once they stop accessing formal services is of great importance.

The National Clinical Guidelines for Stroke 2016 UK recommend physical activity for peoplewho have sustained a stroke in order to counteract the physical deconditioning, lowcardiorespiratory fitness, muscle strength and muscle power reported (Smith et al, 2012,Saunders et al, 2013). The recommendations for people post stroke include:

• Participation in physical activity for fitness.• Exercise prescription should be individualised, and reflect treatment goals and activity recommendations. • People with stroke should aim to be active every day and minimise the amount of time spent sitting for long periods. • People with stroke should aim to achieve 150 minutes or more of moderate intensity physical activity per week in bouts of 10 minutes or more (e.g. 30 minutes on at least 5 days per week). They should also engage in muscle strengthening activities at least twice per week. • People with stroke who are at risk of falls should engage in additional physical activity which incorporates balance and co-ordination at least twice per week. • Physical activity programmes for people with stroke may be delivered by therapists, fitness instructors or other appropriately trained people, supported by interagency working where possible; regular monitoring and progression should occur to promote physical fitness.• Physical activity programmes for people with stroke or TIA should be tailored to the individual after appropriate assessment, starting with low-intensity physical activity and gradually increasing to moderate levels.


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In 2017, the Irish Heart Foundation published a Stroke Manifesto calling on the Governmentto commit to the implementation of measures, identified within the manifesto, which willreduce the incidence of death and disability from stroke and enhances the recovery and livesof those that have had a stroke. Thus in the context of community services and support forstroke survivors, Manifesto Point 7 has called on the Government to ensure that strokesurvivors are no longer abandoned after leaving hospital by developing communityrehabilitation services with equality of access nationally and a process to monitor delivery.

In addition, Manifesto Point 12 calls on the Government to ensure that stroke survivors receivethe supports they need to contribute to society matching their abilities, including throughemployment and all areas of active citizenship, thus supporting those that are returning towork, enabling them to move back to being productive members of society. For those whocannot work or who are past retirement age access to social and emotional supports isessential to enable them to make the most of life after stroke and ensure they can live fulfilledlives in their own communities for as long as possible (Irish Heart Foundation 2017).

1.1 Life after Stroke

The key issues identified for people post stroke can be summarised as follows:

Lack of on-going access to rehabilitation. This has been evidenced in all reports on strokeservice in Ireland both from the clinicians and stroke survivor’s perspective (National Policyand Strategy for the Provision of Neuro Rehabilitation Services in Ireland (HSE, 2019), theNational Audit of Stroke Services ( Irish Heart Foundation 2008) and the National CommunityStroke Services survey, (Hickey et al 2012). The pockets of good practice throughout thecountry are often focused on the immediate period post discharge through Early SupportedDischarge Teams (as advocated in the HSE Stroke Clinical care programme) or are solelyprovided in an outpatient setting with limited day services available particularly for the under65’s.More recent studies by the ESRI (Wren at al 2014) and the Irish Heart Foundationrecommend that for rural areas where ESD teams are not available centre-based rehabilitationprogrammes should be maintained or developed and resourced. The Stroke Day Service aimsto provide access to a post stroke programme in an environment which promotes physicalactivity both for the duration of the programme and also after completion of the programmeirrespective of age and time since stroke.


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Lack of support after discharge from hospital. The return to the community has beendocumented as a difficult period for both the person with the stroke and their family/carers(Bhogal et al 2003). The UK Stroke guidelines, 2016 refer to the fact that ‘Life after strokeresearch has tended to concentrate on the acute and early phases of recovery yet for abouthalf of those who survive, life after stroke involves some permanent impairment and restrictionof their activities. As well as coping with the physical consequences, many people with strokeand their family/carers have long-term psychological and emotional needs’( p 112). In a UKsurvey ( McKevitt et al 2011) of people between 1 and 5 years after stroke, the great majorityfelt they did not receive the support they needed. The study also indicated that these needsare persistent and long-term. The Stroke Day service attempted to address the emotionalneeds of both the participants and their carers/families in the programme through the socialand supportive nature of the programme and also through sourcing external counsellingexpertise.

Lack of Opportunities to Reintegrate into Community. This is particularly relevant for theover 65’s where voluntary agencies who customarily work with people post stroke in thecommunity often have an age cut off. Helping people with stroke to integrate back into thecommunity in the way that they want is a key goal of healthcare and engagement incommunity activity is associated with improved quality of life. The Stroke day service aimedto encourage participants to re-engage with their communities through participation in theStroke Support Group and working with local gyms and Tralee Institute of Technology toreduce the barriers to continuing with a physically active lifestyle in their communities.


2. The Stroke Day Service

2.1 The Evolution of the Stroke Day Service

Kerry Stroke Support Group was set up in 2009 as an initiative of the Tralee Primary CareTeam to support stroke survivors in Co Kerry. Over a period of 18 months, a number of publicinformation events were held. The information sessions were facilitated by HSE Primary CareStaff in Tralee, these included Occupational and Speech and Language Therapists,contributions from The Irish Heart Foundation, other peer support groups and staff fromKerry University Hospital. This original group was initially facilitated by the multi-disciplinaryHSE primary care team. The group then progressed to a peer led group for stroke survivors;this group has since been established as a voluntary group in its own right with a constitutionand management committee charitable status. The group, supported by the HSE CommunityWork Department, hold monthly meetings, in Baile Mhuire Day Centre in Tralee, where peoplewho have had a Stroke have an opportunity to meet with fellow peers and have an opportunityto take part in meaningful activities such as light exercise, yoga and information talks. A coregroup of between 15 and 20 attend monthly. This group also provides some support to Carersand some element of respite.

Kerry Stroke Support Group was the driving force behind the development of the Stroke DayServices. The Stroke Support Group and in particular the chairperson of the Kerry StrokeSupport Group worked closely with the HSE Community Worker in identifying the need forthe provision of a Stroke Day Service. This led to collaboration with Baile Mhuire Day CareCentre to make a submission to the HSE and National Office for Older Persons & PalliativeCare Strategy to secure funding to develop the Stroke Day Service.

Funding was granted to both Baile Mhuire Day Centre in Tralee and to Ard Chúram Day CareCentre in Listowel to develop a Stroke Day Service. Following the allocation of funding aSteering Group was established comprising of representatives from Baile Mhuire, Ard Chúram,HSE Community Work, Physiotherapy and the National Office of Older People & PalliativeCare Strategy. This led to the development of a model of service provision in the form of TheStroke Day Service, a one day service in Tralee (Baile Mhuire) and a one Day Service in ArdChúram (Listowel).

A strong history of partnership with these two voluntary groups (Baile Mhuire and Ard Chúram Day Care Centre) has enabled the services to be developed.

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2.2 Implementation of the Stroke Day Service

The collaboration between the HSE, Kerry Stroke Support Group and both Ard Chúram andBaile Mhuire Day Centres provides a unique model for Stroke Day Service illustrated in thediagram below:

Figure 1

2.3 The Stroke Day Service Programme

Referral Process & Pre AssessmentThe Stroke Day Service is provided by a multidisciplinary team in each of the two centresconsisting of a Physiotherapist, Nurse Manager, Exercise Facilitator, Health Care Attendantsand Volunteers. Referrals are accepted from community and acute services including self-referral. Ard Chúram accepts referrals from North Kerry and West Limerick and Baile Mhuireaccepts referrals from the remainder of the county. The programme accepts participants whohave had a previous diagnosis of a stroke regardless of length of time since stroke. Allparticipants referred to the programme complete a pre-assessment in advance of theirengagement with the programme, which consists of an assessment of their baseline level ofmobility, functional levels and facilitates goal setting. Eight participants are then assigned toeach programme, this number allows for adequate supervision and assistance throughout the programme.

Ard Chúram Day Centre Baile Mhuire Day Centre

Joint Steering Group in Collaboration with HSE and Kerry Stroke supportGroup and the Board of both Day Centres.

Local Implementation Group Ard ChúramMDT team members, CW, reps from Board

of Management

Local Implementation Group Baile MhuireMDT team members, CW, reps from Board

of Management


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Programme ContentThe Stroke Day Service Programme provides a group exercise class, individual physiotherapysessions and a mixture of mental stimulation activities throughout each day. The groupexercise class concentrates on upper and lower limb strengthening and balance exercises asrecommended in the UK Stroke guidelines. The group format and class size allows for groupinteraction while also enabling tailoring of exercises for each individual ensuring everyone ischallenged and progresses each week of the programme. The individual physiotherapysessions allow progression of exercises specific to each client. Guest speakers/therapists havebeen introduced throughout each programme including mindfulness/yoga/groupcounselling/Occupational therapy. Participants are provided with a meal each day and thisdining time facilitates interaction and peer support amongst the participants -see sampledaily schedule in Appendix 1.

The programme began as a 6-week programme. It has now been extended in response tofeedback from the participants and is now a 10 – 12 week programme. In order to enhance theservice provided and following feedback from the participants the staff have also receivedtraining from Speech and Language Therapists and Occupational Therapists thus enabling staffto assist in the enhancement of communication skills and encouraging functional rehabilitationthroughout the course of each day.

Tralee IT CollaborationIn an attempt to encourage participants continued participation in exercise, visits wereorganised to the gym at IT Tralee where final year students from the BSc. in Health and LeisureStudies facilitated the Stroke Day Service participants in completing a gym session. For someparticipants this was their first time in a gym. Based on the success of this visit participantsfrom the Stroke Day Service were invited to participate in the Exercise Referral Programmeoffered at IT Tralee, and facilitated by the students completing the BSc. in Health and LeisureStudies. Six of the participants from the Stroke Day Service participated in the Exercise ReferralProgramme which provided each participant with a tailor made gym based exercise programmewhich they practiced under the supervision of one of the students during the 6 weekprogramme. The feedback from both the participants and the students was excellent and thisopportunity for the Stroke Day Service participants will continue to be provided each year.

Post Assessment ProcessOn completion of the Stroke Day Service programme each participant is provided with a postprogramme evaluation appointment which allows for feedback, assessment of outcomemeasurements and an opportunity to receive a Home Exercise Booklet which is tailor made for each client.


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Participants are linked in and referred to relevant community based supports such as theTralee IT exercise referral programmes or other voluntary agencies such as Acquired BrainInjury Ireland. Carers and family members also partake in pre and post assessment whichfocuses on their well-being and perception of their carer’s role.

Table 2.0 below outlines the number of programmes facilitated and the number of participantsattending the programme in each centre in 2019.

Table 2.0 Programmes and Programme Participants

Baile Mhuire

Ard Chúram

Number ofStroke Day

ServiceProgrammes

6

4

Number ofReferrals in

2019

59

34

Number ofParticipants

in 2019

49

29

Waiting List

13

0


3. Research Aim and Objectives

In evaluating the impact of the Stroke Day Service programme the aim of the researchundertaken was twofold as follows;

1. To determine if engagement in a Stroke Day Service programme enhanced client physical and psychological well-being.

2. To determine if engagement in a Stroke Day Service Programme enhanced carers well- being and reduced the perception of burden.

In achieving, the aims identified above the following were the research objectives identified;

1. To determine if engagement in the Stroke Day Service Programme enhanced; a) Participant’s perceptions of their well-being. b) Participant’s perceptions of their quality of life. c) Participant’s aerobic endurance, mobility and balance. d) Carer perception of their well-being.

3. To determine if engagement in the Stroke Day Service Programme reduced carers perceptions of carer burden.

4. To explore participants perceptions of the Stroke Day Service Programme.

5. To explore carers perceptions of the Stroke Day Service Programme.

*Within the context of the research undertaken, well-being is understood as the presence ofpositive emotions and moods (e.g., contentment, happiness), the absence of negativeemotions (e.g., depression, anxiety), satisfaction with life, fulfillment and positive functioning(CDC, 2018).

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4. MethodologyAs described in the previous section the aim of the research undertaken was twofold as follows;

1. To determine if engagement in a Stroke Day Service Programme enhanced client physical and psychological well-being.

2. To determine if engagement in a Stroke Day Service Programme enhanced carers well- being and reduced their perception of burden.

In achieving the aims listed above a number of data collection methods were used as illustrated below;

Figure 4.0 Research Methodology: Data Collection Methods

As described previously the evaluation undertaken is based on an evaluation of the first first7 programmes.

• WHO-5 Well-being Index• WHOQOL-BREF• Berg Balance Scale10m Walking Test• Elderly Mobility

Focus Group

• WHO-5 Well-being Index• Carer Burden

Focus Group

Client

Carer


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4.1 Participants

The following table depicts the total number of participants that engaged in the programmeevaluation and the number of focus groups conducted with both participants and carers forthis evaluation period.

Table 4.0 Participants Engaged in the Programme Evaluation

4.2 Test Instruments

The following provides a brief overview of each test instrument used in the evaluation process.

WHO-5 Well-being indexThe WHO-5 Well-being Index is a short self-reported measure of current mental well-being.The WHO-5 Well-being Index is among the most widely used questionnaires assessingsubjective psychological well-being. The WHO-5 Well-being Index has been found to haveadequate validity in screening for depression and in measuring outcomes in clinical trials(Topp et al., 2015).

WHOQOL-BREFThe World Health Organisation Quality of Life Instrument, WHOQOL-BREF is a shorted versionof the WHOQOL-100. It produces scores for four domains related to quality of life: physicalhealth, psychological, social relationships and environment. It also includes one facet onoverall quality of life and general health. WHOQOL-BREF domain scores have demonstratedgood discriminant validity, content validity, internal consistency and test–retest reliability(WHOQOL Group, 1998). The table below, table 1.3 outlines the facets associated with each domain.

Baile Mhuire

Ard Chúram

Total

Participants

31

22

53

No of FocusGroups withParticipants

4

3

7

No of FocusGroups with

Carers

3

3

6


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Table 4.1 WHOQOL-BREF Domains

Berg Balance ScaleThe Berg Balance Scale (BBS) is a 14-item scale that quantitatively assesses balance and riskfor falls in older community-dwelling adults through direct observation of their performance(Berg at al 1992). The scale requires 10 to 20 minutes to complete and measures the patient'sability to maintain balance—either statically or while performing various functionalmovements—for a specified duration of time. The items are scored from 0 to 4, with a scoreof 0 representing an inability to complete the task and a score of 4 representing independentitem completion. A global score is calculated out of 56 possible points. Scores of 0 to 20 represent balance impairment, 21 to 40 represent acceptable balance, and 41 to 56 represent good balance (Blum & Korner-Bitensky, 2008).

Domain

1. Physical Health

2. Psychological

3. Social Relationships

4. Environment

Facets Incorporated within Domains

Activities of daily livingDependence on medicinal substances and medical aidsEnergy and fatigueMobilityPain and discomfortSleep and restWork capacity

Body image and appearanceNegative feelingPositive feelingsSelf-esteemSpirituality/religion/personal beliefsThinking, learning, memory and concentration

Personal relationshipsSocial supportSexual activity

Financial resourcesFreedom, physical safety and securityHealth and social care: accessibility and qualityHome environmentOpportunities for acquiring new information and skillsParticipation in and opportunities for recreation/leisure activitiesPhysical environment (pollution/noise/traffic/climate)Transport


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10m Walking testThe 10 metre walking test measures walking speed and is a common functional mobilityassessment for people with neurological diagnosis including stroke. Walking speed has beencorrelated with walking ability and can classify whether a person can safely walk indoors oroutdoors (Perry et al 1995). A speed of greater than .85m/s indicates a safe community walker(SeungHoen et al, 2015). The test is completed by timing the person walking at their normalwalking speed along a 10 metre distance.

Elderly MobilityThe elderly mobility scale was developed to assess mobility in frail elderly individuals andcontains seven items considered essential for performing the basic activities of daily living.These items include gait and balance tasks, scored from 0 (totally dependent) to 20(representing independent mobility in a clinical environment) (Smith, 1994).

Carer BurdenThe Caregiver Burden questionnaire (Zarit et al, 1985) comprises of twenty-two questionsgraded on a scale from 0 to 4, according to the presence or intensity of an affirmative response.The questions refer to the caregiver/patient relationship and evaluate the caregiver's healthcondition, psychological well-being, finances, and social life. The caregiver burden is evaluatedby means of the total score obtained from the sum total of questions. The reliability of theoriginal version was excellent ICC (intra-class correlation coefficient = 0.71; alpha = 0.91).

Focus Groups:Thirteen focus groups were undertaken (7 focus groups with participants and 6 with carers)to explore both client and careers perceptions of the Stroke Day Service Programme. Thepurpose of the focus groups was to explore the following;

(1) Motives for engagement with the Stroke Day Service Programme.(2) Motives for continued engagement with the Stroke Day Service Programme. (3) Activities participants most enjoyed.(4) What engagement with the Stroke Day Service Programme meant to the Carers and their families.(5) Challenges faced in their engagement with the Service, (6) Recommendations for the future delivery of the service.


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5. ResultsFifty-three participants (31 from Baile Mhuire and 22 from Ard Chúram) who had completedthe Stroke Day Service Programme engaged with the evaluation component of the Service.The following section provides a profile of those that engaged with the Stroke Day ServiceProgramme and the outcomes of its associated evaluation.

5.1 Client Profile

GenderAs depicted in the chart below the majority (62%) of participants engaging with the DayService programme were male, while 38% were female.

Figure 5.0 Gender

62%

38%

Male

Female


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AgeAs depicted in table 1.4 below the mean age of participants engaging with the programmewas 72yrs, the youngest client being 53ys and the oldest 89yrs.

Table 5.0 Ages of Participants

A total of 61% of participants that engaged with the programme were over 70 years of age.The majority of participants (37%) engaged with the programme were aged between 71-79years as illustrated in the chart below, while just under a quarter (23%) were aged 60-70 and80-89yrs respectively. Sixteen per cent of participants were aged 53-61 years.

Figure 5.1 Age Categories

16%

23%

37%

24%

53 - 61

62 - 70

71 - 79

80 - 89

Age

Minimum

53.00

Maximum

89.00

Mean

72.2353

Std. Deviation

9.37569


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Length of Time since StrokeThe majority of participants (28.6%) engaging in the Stroke Day Service Programme had astroke 1 year or less prior to their engagement with the programme. Just over half (51%) ofthe participants had a stroke in the previous 2 years (24 months), as depicted in the table 1.5below. Just over three quarters (77.6%) of participants had a stroke six years prior to theirengagement with the programme, in addition 1 client engaging in the programme had theirstroke 18 years prior to their engagement with the Service Programme.

Table 5.1 Length of Time Since stroke

Months\Years

0-12

13-24

25-36

37-48

49-60

61-72

73-84

85-96

97-108

109-120

133-144

145-156

157-168

181-192

193-204

205-216

Frequency

14

11

7

2

2

2

1

2

1

1

1

1

1

1

1

1

Percent

26.4

20.8

13.2

3.8

3.8

3.8

1.9

3.8

1.9

1.9

1.9

1.9

1.9

1.9

1.9

1.9

Vaid Percent

28.6

22.4

14.3

4.1

4.1

4.1

2.0

4.1

2.0

2.0

2.0

2.0

2.0

2.0

2.0

2.0

Cumulative Percent

28.6

51.0

65.3

69.4

73.5

77.6

79.6

83.7

85.7

87.8

89.8

91.8

93.9

95.9

98.0

100.0


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Referrals to Stroke Day Service ProgrammeThe majority (29%) of the clients were referred to the Stroke Day Service Programme by thepublic health nurse (PHN), with 17% of participants either self-referring or being referred tothe Service by their GP. The participant’s family or their physiotherapist referred 10.5% ofclients, respectively, to the Day Service Programme.

Figure 5.2 Referrals to the Programme

5.3 Service Impact: Participants

In evaluating the impact of engagement with the Stroke Day Service Programme onparticipants’ physical and psychological well-being a number of measurements wereundertaken as outlined in the previous section of this report. The following provides adescription of the results obtained in the evaluations completed pre (before) and post (after)engagement with the programme. A comparison of pre and post evaluation scores has beencompleted to determine if participants' engagement with the programme enhanced theirphysical and psychological well-being.

As the data was deemed to be non-parametric (Kolmogorov-Sminorv p<0.05) the WilcoxonRank Test was used to determine the level of significance in the difference between pre andpost test results.

2%

6%

10.5% 10.5%8%

17%

29%

17%

0%

5%

10%

15%

20%

25%

30%

35%

HH Geria�cian Family Physiotherapist Speech & Language Therapist Self PHN GP


22

5.3.1 Physical Measures

The following measures were undertaken pre and post programme implementation todetermine if participants balance (Berg Balance Scale), walking speed (10m timed walkingtest) and mobility (elderly mobility) improved post their engagement with the Stroke DayService physical activity programme.

As illustrated in the table below mean scores (average scores) in all tests increased post theirengagement with the programme. The rank test z values and their associated p values aresignificant (p<0.05). It can therefore be concluded that participants balance, aerobicendurance and mobility had increased post their engagement with the programme.

Table 5.2 Physical Measures

5.3.2 Psychological Measures

In determining if participants’ psychological well-being was enhanced post their engagementwith the Stroke Day Service Programme, the WHO-5 Well-being Index and the WHO Qualityof Life (WHOQOL_BREF) questionnaire were distributed to participants pre (on the first dayof the service) and post (on the last day of the service) their engagement with the programme.As the data was deemed to be non-parametric (Kolmogorov-Sminorv p<0.05) the WilcoxonRank Test was used to determine the level of significance in the difference between pre andpost test results.

Berg Balance Scale Pre

Berg Balance Scale Post

10m Timed Walking Test Pre

10m Timed Walking Test Post

Elderly Mobility Pre

Elderly Mobility Post

Mean

43.2500

46.5425

23.9167

13.3684

14.0833

28.300

Std. Deviation

10.09633

10.46276

24.16000

28.07873

4.82137

4.25245

M Rank

23.00

12.04

14.13

5.86

.00

4.50

Z

3.638 (p=0.00)*

2.777 (p=0.005)*

2.530 (p=0.011)*


23

WHO-5 Well-Being IndexAs illustrated in the table below the mean/average well-being index scores did increase overthe duration of participants engagement with the programme (mean pre 67.89 – mean post69.75) however this increase was not statistically significant (p=.372).

Table 5.3 Participants Well-Being Index

The World Health Organization Quality of Life (WHOQOL_BREF)As described, in Section 4, The WHOQOL_BREF questionnaire produces a quality of life profileand enables an assessment of four key quality of life domains, physical health, psychologicalwell-being, social relationships and environment. Two separate components are also included,perception of quality of life and satisfaction with health. The following presents the resultsobtained during and post evaluations and compares pre and post test results.

Quality of LifeAs illustrated in the table below participants mean Quality of Life Scores increased post theirparticipation in the physical activity programme. The rank test z value and the associated pvalue is significant (p=0.05). It can therefore be concluded that clients' perceptions of theirquality of life increased post their participation in the physical activity programme.

Table 5.4 Quality of Life

WHO Well-being Index Pre

WHO Well-being Index Post

Mean

67.86

69.75

Max

100

100

Min

5

12

Std. Deviation

20.655

21.355

M Rank

18.28

19.55

Z

.893 (p= .372)

Quality of Life Pre

Quality of Life Post

Mean

3.5094

3.9756

Std. Deviation

1.03073

.75789

M Rank

7.50

10.83

Z

-3.58 (p=.000)*


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Satisfaction with HealthParticipants’ satisfaction with their health increased post their engagement with the DayService Programme, as illustrated in the table below. The rank test z value and the associatedp value is significant (p=0.001). It can therefore be concluded that participants’ satisfactionwith their health increased post their engagement with the Day Service Programme.

Table 5.5 Satisfaction with Health

Quality of Life Domains In evaluating the impact of engagement with the Stroke Day Service Programme on the variousquality of life domains (physical, psychological, social and environmental) increases in meanvalues pre to post engagement are evidenced, see table 5.6 below. However, the increase in meanvalue for each with the exception of the physical domain (p=.003) is not statistically significant(p>0.05). It can therefore be concluded that engagement with the Stroke Day Service Programmedid increase participants' perceptions of their physical health, it did not have a statisticallysignificant impact on their psychological, social and environmental quality of life domains.

Table 5.6 Quality of Life Domains

Satisfaction with Health Pre

Satisfaction with Health Post

Mean

3.4340

3.8573

Std. Deviation

.99052

.85326

M Rank

7.50

11.03

Z

-3.216 (p=0.001)*

Physical Domain Pre

Physical Domain Post

Psychological Domain Pre

Psychological Domain Post

Social Domain Pre

Social Domain Post

Environmental Domain Pre

Environmental Domain Post

Mean

61.3585

65.6923

60.0337

58.6154

73.8491

75.2308

71.8163

77.2571

Std. Deviation

17.28838

16.16063

10.61741

7.91273

20.95453

14.18202

16.39064

11.49256

M Rank

8.75

14.34

11.29

11.75

10.04

13.25

10.20

14.14

Z

2.970 (p=.003)*

-.296 (p=.767)

-1.96 (p=.844)

-1.379 (p=.168)


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5.3.3 Participants Perceptions of theStroke Day Service Programme

Seven focus groups were conducted with participants to gain an understanding of theparticipants' perceptions of the Stroke Day Service Programme.

The following pictorial depicts the information obtained from the analysis of the focus groupdata, the information is explored in detail in the following sections.

Figure 5.3 Participants Perceptions of the Stroke Day Service Programme

Motive for Engagement with the Stroke Day ServiceFocus group participants were asked to identify the key factors that motivated them to engagewith the Stroke Day Service Programme.

Participants described the social element of the programme to be one of the main motivesfor participating in the programme with many participants referring to the potential to meetpeople, to reconnect with people and to meet people in similar situations. For example, twoof the participants described their main motive for participating as follows;

“To meet people, get support from people who are in the same boat” (Client, 1T)

“To meet other people who have suffered a stroke” (Client, 2T)


26

Meeting others in similar situations enabled participants to “share problems and difficulties”(Client, 2L). In addition another client described how isolated they felt post their stroke andhow the Stroke Day Services provided an opportunity to socialise, they stated that they;

“Felt very alone and isolated and felt it would be a good way to reconnect with people” (Client, 3T).

Participants also described how engagement with the Day Service Programme would helpsupport and progress their rehabilitation, enabling them, as one participant stated “improvetheir situation” (Client, 1L). For many access to physiotherapy was a significant motive forattending, with many stating that their main motive for attending was “for physio” (Client, 1T),“to help support their rehabilitation” (Client, 3T). One participant describes below how accessto physiotherapy services post hospital discharge can be limited;

“to have access to physiotherapy as services post hospital discharge was little or nothing”(Client, 1L).

Thus engagement with the Stroke Day Service Programme enabled access to physiotherapypost hospital discharge, which one client explained “was a vital and necessary progressionfor people who have had a Stroke and those attending the Stroke Support Group” (Client 1L).

Motives for Continued Engagement with the Stroke Day Service ProgrammeParticipants were asked to identify factors that encouraged them to continue to engage withthe programme. Many of the participants described the physiotherapy received in the contextof the exercise programme as the main motive for their continued engagement with the DayService, with participants describing the programme as follows;

“The physiotherapy and exercise programme is absolutely excellent” (Client, 3T).

Some participants commended the activities, and the variety of activities presented as follows;

“The programme of activities was wonderful” (Client, 3T)

“The variety of the programme was most engaging and participative” (Client, 2T).

Many of the participants stated that the support from staff was a key motive for continuedengagement with the Stroke Day Service. With one staff member being described as “the jewelof the HSE” (Client, 2T), while others “lifted our spirits” (Client, 4T), and were “very good,brilliant” (Client, 4T).

The social element of the Stroke Day Service Programme was also identified as a key motive for continued engagement. One client described how “meeting lovely people and connecting with people” (Client, 3T) encouraged them to continue to engage with the programme.


27

For others it was the “social contact and chat” (Client, 2T), “friendships” (Client, 1T) and the“strong bond between all the participants which was lovely” (Client, 3T).

Some of the participants described how seeing improvements that were made motivated themto continue their engagement with the programme. Thus “seeing improvement” (Client 1T),“getting better… “ (Client, 1T), “progress and standing” (Client, 4T) and “seeing others improve”(Client, 1T) motivated many to continue their engagement in the programme. In addition twoof the participants, also commended the quality of food provided as part of the serviceprovision, for example Client 3T stated that the “food ……. was wonderful” (Client, 3T)

Activities Most EnjoyedWhile participants attended and participated in all activities that were provided at eachsession, some activities appealed more to them than others. Many of the participantscommended the variety of activities presented, with many enjoying the in-house games andactivities in particular.

Some participants enjoyed the session presented by the Occupational Therapist whichfocused on functional tasks and felt “it provided them with useful information” (Client, 1L),regarding “aid and memory technology”, (Client, 2L) in particular.

Others enjoyed the visit to the gym which for some promoted the concept of a follow onactivity, and felt that “it may encourage people to join the gym after” (Client, 2L).

There were varying opinions on the yoga and the body confidence and mindfulness sessionpresented, with some participants enjoying these elements of the Service offering and othersnot enjoying these activities, with one participant stating that with respect to these activities“once off sessions were difficult to get into” (Client, 1L).

RecommendationsIn enabling improvement to the Stroke Day Service, participants were asked to identify aspectsof the programme that they would like to see improved or enhanced. Participants were askedinitially to consider the time and length of the programme. A consensus was evidenced inclients' responses with many stating that the time of day was appropriate as was the lengthof the programme. Some did however express, a necessity to participate in another 12-weekprogramme as they felt it was vital for their recovery. Some participants felt that servicesreceived post their hospitalisation was very poor and that this programme had been the onlypositive service they had received.


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In addition, participants made recommendations with respect to the physical activityprogramme, the need for additional information regarding Stroke, further engagement fromoccupational therapists and the need for a support group post the programme ending. Theserecommendations are outlined below;

One of the aspects of the programme participants commented on was the physical activityelement of the programme with many of the participants recommending opportunities foradditional engagement in physiotherapy and physical activity, “more gym” (Client, 1T). Othersreferred specifically to the need for “more upper limb work” (Client, 3L).

Some made recommendations related to the need to continue aspects of the programme suchas the “physio and exercise” (Client, 1T), and the need for follow on or home based programmeto ensure that participants “have a programme for when we finish the programme” (Client, 3L).

The need for information in relation to Stroke was also identified as a recommendation withparticipants stating the need for information in relation to the pathophysiology of Stroke,treatment and recovery. Information regarding the trauma associated with having a strokewas also identified thus the psychological impact of having a stroke on the patient warrantsattention, many spoke about “their life being overturned in minutes” (Client, 1L), and having“no idea what life was going to be like after Stroke” (Client, 2L). Thus a focus on educationand the application of “coping strategies to help with trauma” (Client, 3T) was also identifiedas a recommendation.

Another recommendation cited was the need for additional focus on functional tasks andcommunication skills. One client specified the need to focus on functional occupationaltherapy providing assistance with the development of skills relating to “getting dressed,opening and closing buttons, putting on socks” (Client, 4T)

Some participants identified as “having communication difficulties” (Client, 1T) stated thatthey would have benefited from an additional focus on the development or enhancement ofcommunication skills.

A final recommendation made was the need for a support group or continued engagementwith the Stroke Day Service participants, thus providing “other opportunities to meet peoplewho have had a Stroke and want to stay in contact with people” (Client, 3L).

Feedback obtained from the focus groups illustrated that all participants really enjoyed theprogramme and emphasised that it was a great boost to them, particularly from a socialaspect, one client explained that they are

“sad to leave but glad that they had the opportunity to attend the monthly group where they would meet each other again” (Client, 3T).


29

In addition, many expressed their deep appreciation of all the staff that engaged with themduring the programme.

In conclusion, in exploring participants’ perspectives on the Stroke Day Service Programme,as outlined above, the social aspect of the programme was a significant motivator for bothinitial and continued engagement in the programme. Participants described how thephysiotherapy, in the form of the exercise programme, enabled progression with many seeingimprovements. Many of the participants commended the support received and engagementfrom a multi-disciplinary team (therapists, nurses, care attendants, volunteers) with manyrecommending opportunities to continue engagement with the programme itself and theprogramme client group in general.

5.4 Service Impact: Carers

In evaluating the impact of participants’ engagement with the Stroke Day Service Programmeon carers’ psychological well-being a number of measurements were undertaken as outlinedin the previous section, of this report. The following provides a description of the resultsobtained in the evaluations completed pre (before) and post (after) engagement with theprogramme. A comparison of pre and post evaluation scores have been completed todetermine if participants engagement with the Day Service Programme enhanced the carerspsychological well-being and reduced their sense of burden.

5.4.1 Psychological Wellbeing

WHO-5 Well-being IndexParticipants Well-Being Index score did not significantly change over the course of the client’sengagement with the Stroke Day Service Programme. As illustrated in the table belowmean/average well-being index scores did increase however this increase was not statisticallysignificant (p=.325).

Table 5.7 Carers Well-Being Index

WHO Well-being Index Pre

WHO Well-being Index Post

Min

12.00

28.00

Max

100.00

92.00

Mean

63.6667

71.7333

Std. Deviation

19.27545

18.48345

t

-1.007 (p=.325)

df

21


30

Carer BurdenAs evidenced in the table below, table 5.8, carers perception of burden did decrease post theparticipants engagement with the Stroke Day Service, however this decrease is not statisticallysignificant (p=.569).

Table 5.8 Carer Burden

5.4.2 Carers Perceptions of the Stroke Day Service

Six focus groups with carers of Stroke Day Service participants were conducted which aimedto gain an understanding of their perception of the Stroke Day Service Programme.

The following pictorial depicts the information obtained from the analysis of the focus groupdata, the information is explored in detail in the sections following.

Figure 5.4 Carers Perceptions of the Stroke Day Service Programme

Carer Burden Pre

Carer Burden Post

Min

.00

3.00

Max

35.00

32.00

Mean

13.0556

11.8000

Std. Deviation

8.24255

8.18710

t

-.577 (p=.569)

df

23


31

Motives for Engagement with the Stroke Day Service ProgrammeCarers were initially asked why their family member engaged with the programme. One of themain reasons identified was to enable their family member to “connect and meet other people”(Carer, 3.T), “…..who had similar experiences” (Carer, 1T) and to utilise the service as a socialoutlet.

In addition the opportunity to gain service in the form of physiotherapy was also a key motivefor engagement with the service, thus enabling their family member “to improve physicallyunder the guidance of a physiotherapist” (Carer, 1L), “to improve physically” (Carer, 1T).

Some carers described how engagement with the service assisted in “building confidence”(Carer, 1T), and “provided a focus for their family member” (Carer, 3T). In addition, engagementwith the service had the potential of giving carers a break, in essence it enabled “time out forus as carers” (Carer, 1T).

What the Service Meant to the Carer and their FamilyIn describing what the Stroke Day Service meant for the carer and their family all carersemphasised that the Day Service was a great support to both them and their family members,one client noted that;

“It has been the start of getting one’s life back” (Carer, 3T).

Many of the carers described how the programme has assisted in enhancing their familymembers’ independence and confidence specifically as described by some of the carers asfollows;

“Supported ... (family member) to develop their confidence and self-esteem” (Carer, 1L).

Enabling family members to “survive without their carer” (Carer, 1T), having “news of their own”(Carer, 1T) and being independent for the perspective of evidencing “practical improvementssuch as making a cup of tea and tying buttons on clothes” (Carer, 1T). As one carer stated “itis so good to see ... (family member) becoming more independent” (Carer, 4T).

This enhanced sense of confidence and independence has, for many, led to their familymember being happier as two of the carers explained;

“There was a sense of a ‘Friday feeling’ in the house as the person came home happy and thehouse was happy and ready for the weekend………… It meant everything as they were happier”(Carer, 4T)


32

“Comes home happier because they are with people that are similar. Better than other socialevents because they feel awkward or ashamed” (Carer, 1T)

Some carers also stated that engagement with the Stroke Day Service Programme providedthem, as carers, with a break from their role as carer. For some it was “freedom, escapism,and time to get other work done” (Carer, 1L), or “peace of mind knowing someone else islooking after them” (Carer, 1T).

Challenges faced in their Engagement with the ProgrammeThe majority of the carers were happy with the time and duration of the programme howevermany felt that the length of the programme was too short, particularly the second phase ofthe programme which ran for 4 weeks as one carer explained;

“I’d have him just dropped off when I’d be turning around to go back in to collect him” (Carer, 1L).

On the other hand, many liked the tapered programme, running every second week, as itprolonged engagement with the service.

Some carers felt that the provision of transportation to the programme would have assisted“particularly for anyone that was wheelchair bound” as, in some cases, family members hadto take time off work to transport their family members to the service, or taxis were requiredto transport family members. One family member stated the provision of “transportationwould be icing on the cake” (Carer, 3T), as it was a challenge for some.

RecommendationsAll carers felt that a vital component of the programme should include counselling orpsychological support for the person who has had a stroke, to assist them in dealing with thetrauma of having had a stroke, as one carer stated;

“The suddenness of the stroke and loss of independence is a huge issue and needs to be dealtwith” (Carer, 1L).

Thus for many the need to include an element which focused on coping strategies was deemednecessary as some of the participants lost their careers as a result of stroke.

Many of the carers spoke at length about the isolation and lack of support they felt whentheir family member was discharged from hospital. The loss of their family membersindependence is reflected in one comment when they explained “it was like bringing home anew baby” (Carer, 1L).


33

Many recommended additional emphasis to be placed on functional tasks, focusing on lifeskills particularly, such as using the phone, writing their signature, putting on shoes, brushinghair, making a sandwich, making tea, cooking, etc. For others emphasis on the developmentor enhancement of communication skills would be a welcome addition.

The inclusion of additional physical activities was also recommended “more gym” (Carer, 1T),“more active games” (Carer, 1T), “the more physical activity the better” (Carer, 1L). Carershowever cautioned that this inclusion needs to be progressive as some felt that in the secondstage of the physical activity programme, the last four weeks, regression was evidenced, “inthe final four weeks they went from standing back to chair based exercises” (Carer, 1T).

Other recommendations provided focused on how the Stroke Day Service may improve thedaily life of the carer, a need for carers support was clearly identified. Many stating the needfor a “carers support group for carers of stroke patients” (Carer, 1L), where carers could meet“other Stroke carers and share information” (Carer, 1T). Carers spoke of the need for moreinformation regarding stroke in general, patient needs and information relating toentitlements, home maintenance schemes etc. that would assist in caring for their familymember.

In conclusion, in exploring carers’ perspectives of the Stroke Day Service Programme, asoutlined above, the social aspect of the programme was a significant motivator for the initialengagement with the service. Carers felt that the physical activity programme/physiotherapyand engagement with other service users led to the enhancement of their family member’sconfidence and sense of independence. Engagement with the service also provided carerswith respite. Carers outlined some challenges they experienced in enabling their familymembers engagement with the service, namely transportation challenges, and programmelength. Carers also provided recommendations, which may assist in developing the programmefurther; these included expanding the programme by incorporating additional physicalactivities and additional focus on functional tasks and communication skills. Carers alsorecommended the inclusion of a counselling or psychological support element to the service.In addition a need to support carers in their respective roles as carers through thedevelopment of a carer support group was also identified as a key recommendation for futureprovision.


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5.5 Case Studies

In augmenting the results described above regarding the impact engagement with the StrokeDay Service Programme has had on participants physical and psychological well-being, twocase studies are presented below which evidences this impact. Pseudonyms have been usedin the presentation of the case studies to protect the anonymity of the participants.

Case Study AMary is a 67 year old lady who was 1 year post her stroke when she was referred to the StrokeDay Service. Mary was walking short distances with a stick with close supervision and requiredassistance with all her personal care and activities of daily living (ADLs) due to significantweakness and reduced balance. Mary was recently retired and living with her husband, shehad been very active and independent prior to her stroke, however had now reduced hersocial outings post her stroke as she was conscious of her appearance and speech deficits.Mary was unable to attend the National Hospital for Rehabilitation in Dublin due to beingover 65yrs and she had completed her community physiotherapy input prior to herparticipation in the Stroke Day Programme.

Mary completed the Stroke Day Service Programme which she thoroughly enjoyed. Sheparticipated fully in the exercise sessions which concentrated on strengthening and balancere-education and also in the other programme activities. During the course of the programmeMary received input from occupational therapy which concentrated on rehabilitation of herupper limb. Mary did experience a medical set back half-way through the programme, howeveron completion of the programme Mary reported feeling more confident, requiring lessassistance for her personal care and ADLs and less supervision when walking indoors. Marywas now beginning to go on social outings with her husband and friends.

Many people after a stroke go on to develop ‘learnt non-use’ which means that in additionto weakness as a result of the stroke they also develop secondary weakness as a result ofnot using the residual power in their limbs and hence become more reliant on carers/familymembers. This in combination with reduced opportunities to exercise safely all contribute todeconditioning and an increased risk of falls. Family members often assist more than isrequired due to a fear of the person with the stroke not being ‘able’ and hence they are notprovided with the opportunity to practice functional tasks which is often the best way tomaintain strength and mobility.


35

The Stroke Day Service Programme allowed Mary to participate in a graded exercise programmeover the 10 weeks that aimed to improve strength and balance; it also provided her with a safeenvironment to communicate with peers, something which she would have been reluctant topartake in prior to participating in the programme. This improvement was borne out in the postprogramme assessment which showed an increase in three of the domains of the WHO Qualityof Life Questionnaire and in both her balance and walking assessments.

The Stroke Day Service Programme was a significant resource for Mary and her husband afterfinishing with existing community services. Mary’s rehabilitation is slow and will probablycontinue at this pace over the next period. Bursts of ‘rehabilitation’ to continue to facilitateand encourage this recovery are essential to ensure Mary reaches her goals. Mary’s husbandfound the programme provided him with the opportunity to catch up on work and also tohave some ‘down time’ where he could meet friends. He found the safety net of the supportfrom the staff and the opportunity to discuss issues/problems over the 10 week course veryhelpful and provided him with the confidence to manage in his role as carer.

Case Study BJohn is a 53 year old gentleman who had suffered a stroke in 2017, he had spent a significantlength of time in the National Hospital for Rehabilitation and the Royal Hospital, Donnybrook.He had significant bilateral power and sensory loss with severely reduced balance whichmeant he was dependent on a rollator frame for mobility and was largely restricted to indoorwalking. Prior to his stroke John was working and completely independent, post stroke herelied on home help hours throughout the day to assist and supervise with ADLs.

In view of Johns age and stage of rehabilitation he completed two Stroke Day ServiceProgrammes. John was highly motivated and participated fully in both programmes. Inaddition John also participated in an exercise referral programme which was part of thecollaboration between the Stroke Day Service and the Institute of Technology Tralee. Theexercise referral programme was set up with the BSc Health and Leisure Degree Coursewhereby final year student provide a supervised 6 week gym based programme for strokeparticipants referred from the Stroke Day Service. John participated in this programme for afurther 6 weeks after having completed the Stroke Day Programme. At the end of this periodJohn’s balance and walking had improved (as demonstrated in his walking distance and speed)and he was less reliant on assistance at home. He was walking long distances outside andwhile still needing the assistance of his frame he no longer needed to be supervised. John’sconfidence increased significantly and he had joined a local pool and gym where he was ableto make further improvements with the assistance of his Rehabilitation Assistant.


36

The establishment of the stroke day service was opportune timing for John as this and theexercise referral programme in the IT were able to facilitate his on-going rehabilitation. John’sfamily acknowledged the Stroke Day Service as a significant resource for them asdemonstrated in the significant improvements in both their ‘Well-being’ and’ Burden of Care’questionnaires.

After almost a year of intense support/rehabilitation in Dublin John's family feared a possibleregression both psychologically and physically when John returned home. Without on-goingsupport the potential for regression and loss of function can often be a reality as participantsare unable to maintain functional achievements without access to opportunities for targetedintervention and exercise. John exemplifies the slow but steady improvements that arepossible for participants post stroke but that may not be realised without on-going communitybased supports such as the stroke day service.


37

6. Conclusion and Recommendations

6.1 Conclusion

The majority of participants engaging with the Stroke Day Service Programme were male (62%)and the average age of participants engaging with the service was 72yrs. Over half of thosethat engaged with the programme had a stroke in the 2 years prior to their engagement withthe Stroke Day Service Programme.

Referral to the day service is predominantly via the public health nurse (27%), through self-referral (17%) or via their GP (17%).

The evaluation has demonstrated both physical and psychological benefits as a direct resultof the programme thus demonstrating that the mixture of physical activity, socialisation andmental stimulation provides an effective model of service. Many of the participants describedhow the physiotherapy, in the form of the exercise programme, enabled progression withmany seeing improvements. Engagement with the service has led to significant improvementsin participants balance (Berg Balance Scale), walking speed (10min Walking test) and mobility(Elderly Mobility) scores (p<0.05).

In utilising WHO-5 Wellbeing Index to determine the impact programme engagement mayhave had on the mental well-being of participants, an increase in well-being index scores wasevident however, the increase was not statistically significant (p >0.05). It must be notedhowever, that pre evaluations (psychological well-being measures) took place once an offerof a place on the Day Service was received. Thus the ‘offer’ of the service may have affectedthe psychological well-being scores pre engagement with the programme. Thus while anincrease was evidenced the timing of the pre-evaluation may have negated a statisticallysignificant increase.

Scores obtained from the WHOQOL-BERF questionnaire evidenced a statistically significantincrease in participants perceptions of their quality of life (p=0.00) and an increase in theirsatisfaction with their health (p=.001) post their engagement with the Stroke Day ServiceProgramme.


38

In exploring both the participants’ and carers perspectives on the Stroke Day ServiceProgramme, via the facilitation of numerous focus groups, the consistent message was thatthe service is beneficial, for both participants and their carers/families, and should continuewith all participants requesting to repeat the programme. The availability of physiotherapy,support from all the staff members, suitability of the venues and the benefits of socialisationwere some of the key components that led to the success of the programme. Carershighlighted the respite received was as a direct result of the service and a feeling of supportobtained when they often felt isolated and forgotten about once their family member had leftthe acute setting post stroke. The social aspect of the programme was a significant motivatorfor both the initial and continued engagement in the programme. Some carers did highlightchallenges they faced in enabling their family members to engage with the service, the keychallenge faced was that of transportation to the Day Service, which is not surprising giventhe lack of transportation available locally.

The engagement of staff was a key factor that led to the success of the programme. In essence,the support received and engagement from a multi-disciplinary team (therapies, nursing staff,care attendants, volunteers and the physical activity leader) was identified as a significantfactor that can be attributed to the success of the programme.

6.2 Recommendations

The recommendations provided below stem from feedback obtained from the participants,their carers, family members and from the programme facilitators.

Model of DeliveryOne of the key factors that enabled the successful delivery of the programme was the modelof partnership, between the HSE and the voluntary agencies, which underpinned thefacilitation of the programme. This partnership enabled an effective model of service provision.It is therefore imperative that voluntary agencies continue to be supported through the HSEand the Community Work Department, the National Office for Services for Older Persons &Palliative Care Strategy (Services for Older People and Palliative Care Strategy) and theprimary care teams particularly, to enable effective service provision for stroke survivors.


39

Thus from the perspective of the Stroke Day Service, this service is providing communitybased support, enabling participants who were accessing outpatient services in the acutesetting to access these services through the day service. This in turn alleviates pressure onthe acute services as seen by the increasing number of referrals from the acute Stroke Unitto the Day Service, this in itself evidences success. It also facilitates participants who aremany years post stroke, and have completed their community therapy, to access thisprogramme and benefit physically and or psychologically, thus mitigating against the longterm effects of a chronic condition.

Thus the model of practice utilised in the provision of the Stroke Day Service is a keyrecommendation going forward in the provision of community based care for stroke survivors.

The ProgrammeOne of the key recommendations, evidenced from feedback obtained from the participants,their carers and family members and through improvements evidenced in both the physicaland psychological well-being assessment scale, was the continuation of the Stroke Day Serviceprogramme. The continuation of the programme is thus imperative in its provision of a holisticapproach to both participants and their carers health and well-being. Incorporating a mixtureof physical activity with opportunities for socialisation and mental stimulation has been ofimmense benefit to the participants as evidenced in the results obtained from the results ofthe evaluation undertaken.

To ensure the continued success of the programme the following programme specificrecommendations are presented;

• Continue to ensure the needs of the participants and their families are being met through consultation via regular focus groups and pre and post programme assessments.

• Continue to adapt and grow the programme to ensure the identified needs are met through the existing multi-disciplinary team and or through externally sourced supports.

• The service should continue to be provided in a community setting. The current community based programme has proven successful as demonstrated in the referral and participation rates. In addition there are clear cost benefits associated with the provision of Day Service by comparison to long term residential care

• Extend the programme to facilitate the current referral rate.

• Expand the programme to allow for more frequent participation in the programme thus increasing the opportunity to participate in exercise and benefit from the social aspect of meeting other people on similar journeys.


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• Develop an add on service which would enable additional rehabilitation support for people who have completed the programme. This drop-in service in conjunction with the Kerry Stroke Support Group would enable participants to participate in tailor based programmes to continue their on-going rehabilitation.

• Work with the acute services in enhancing the patient journey between the community and acute setting for both the client and their families.

• Provide transport to facilitate access for all participants, as a need highlighted through the focus groups.

• Continue to support the carers through the provision of the programme and through separate workshops and support evenings/events.

• Administrative support will be required in the completion of future programme evaluations and in the production of associated interim and final reports.

• Continued collaboration with the Institute of Technology Tralee to create further opportunities in terms of programme provision and evaluation.

6.3 Summary

The gap in the provision of stroke services is well acknowledged and the Stroke Day Serviceis addressing this gap in Kerry through the provision of a community based service which isa direct example of the shift from acute care to the community as recommended in manypolicies including Sláinte Care. While pockets of good practice in terms of stroke services areevidenced around the country many of these programmes are generally underpinned by aunidisciplinary outpatient model of service, few if any provide programmes that areunderpinned by a holistic approach to care provision. The incorporation of physical activitywith opportunities for socialisation and mental stimulation is a unique attribute orcharacteristic of this Stroke Day Service which as described within this report has been ofimmense benefit to both stroke participants and their carers. The Stroke day service modelexemplifies an innovative partnership between HSE community and voluntary organisationswhich have facilitated a person centred approach to supporting the health and well being ofpeople with stroke.


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Appendices


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Appendix 1Sample daily schedule from Stroke day Service).

*Participants also attend for individual physiotherapy session

throughout the course of the day.

Time

10.00am

10.30am - 11.30am

11.30am - 1.00pm

1.00pm - 2.00pm Lunch

2.00pm - 3.00pm

Activity*

Participants arrive, chat and refreshments are provided

Group exercise class- all eight participants are provided with assistance/supervision to participate fully in seated andstanding/walking exercises

Mental stimulation activities e.g. memory games/word quizzes etc.

& circuit course which incorporates hand function and balance activities

Lunch is provided on site

Guest speakers e.g. Counsellor/Life coach/Tai Chi/Yoga


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Appendix 2Photographs taken from individual and group exercise sessions held

during the Stroke day Service


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Stroke Day Service Evaluation Steering

CommitteeThe steering committee provided instruction and direction to the evaluation process.

• Aidan Kelly, Baile Mhuire CLG.

• Dolores McElligott, Community Work Department

• Eibhlis Cahalane, National Office for Services for Older Persons & Palliative care strategy

• Jackie Gallagher, Department of Health and Leisure Studies, Tralee Institute of Technology

• Michael Hall, Department of Health and Leisure Studies,Tralee Institute of Technology


Final Stroke Day Service Evaluation Report

Documents