Dorset Improving Psychological Support after Stroke Project
Sara Leonard Lead Manager
Dorset Cardiac and Stroke Network
Dorset Improving Psychological Support after Stroke in the Community Project
The scale of the problem
Summary of original pilot project
Issues and sustainability
Progress since pilot
Ongoing challenges and next steps
Today I will cover…….
A significant proportion of stroke patients with depression
remain undiagnosed or inadequately treated (Hackett et al 2005).
0
10
20
30
40
50
60
70
80
90100
Cognition Anxiety Depression
Up to 75% experience cognitive impairment
(RCP 2009)
Prevalence of post stroke depression
independent of disability is approx
33% (Hackett et al, 2005)
Anxiety rates of 30- 49% up to 12 years post stroke
(South London Stroke Register)
The scale of the problem
National Stroke Strategy (2007) Central importance of a psychological pathway of rehabilitation
RCP National Clinical Guidelines for Stroke (2009) Patients with stroke should be routinely screened for depression anxiety and cognition
NICE Quality Standard for Stroke (2010) Screen within 6 weeks of diagnosis … to identify mood disturbance and cognitive impairment
NICE Quality Standard for Depression in Adults (2011)People with depression should receive appropriate psychosocial interventions or collaborative care according to the degree of depression, associated chronic health problems and its impact on function
National Guidance
Collaborative Care
Close collaboration between primary and secondary physical health services and specialist mental health services
Case management supported from senior mental health professionals
A range of interventions including patient education, psychological and pharmacological interventions
Long term coordination of care and follow up.
Collaborative Care
Mental Health Strategy 2011
The National ambition for psychological care after stroke
Little had been done. STRONG support from
local people. Pilot Site – North and
South West Dorset. Collaborative working New Pathway Training – developed
and provided Monitored Accreditation & Oscar
Summary of original pilot project
Step 1
Under Step 1 DIPSS trained staff are able to:
Ask initial screening questions
Employ nationally validated screening assessment tools as appropriate
(e.g. PHQ9, GAD-7, SADQ-10)
Risk Assess.
Provide initial support and information.
(Including for sub-threshold scores).
Progress to Step 2 (persistent sub-threshold, mild to moderate)
Refer on as appropriate.
Step 2 Initial Management
Under Step 2 DIPSS trained staff are able to:
Offer Sleep Hygiene Advice
Undertake Active Monitoring
(discussing problems, providing information on depression and arranging a further assessment)
Provide information on self-referral/refer to local IAPT services for Step 2 low intensity psychosocial interventions and/or drug treatment.
PPI Involvement
• Patient & carer representatives on steering group
• Patient & Carer easy-read feedback forms
• Dorset Stroke Network PPI Forums – ongoing and specific
• Stroke Network PPI Members with aphasia
PPI Involvement
Band Costs per hour with on costs (mid
point)
Hours Total cost
Clinical Neuropsychologist
8D £46.94 15.0 £704.10
Service Improvement Manager
7 £22.02 15.0 £330.30
UK Forum for Stroke Training accreditation £300.00
DEVELOPMENT & ACCREDITATION OF TRAINING £1,334.40*
*One off cost – funded by Network
Cost of Psychology Training - DEVELOPMENT
Band Cost per
hour
Hours Cost per course*
Number of
courses
Total cost
Clinical Neuropsychologist
8D £46.94
7.5 £352.05 3 £1,056.15
Assistant 7 £22.02
7.5 £165.15 3 £495.45
COST TO DELIVER TRAINING (3 x courses @ £517.20 each) £1,551.60*
*plus: – administrative support for booking venue/confirming places– catering costs
• Funded by Network
Cost of Psychology Training - DELIVERY
Band Cost per
hour
Hours Cost per course
Places Total cost
Community Rehab Team Leader
7 £22.02 7.5 £165.15
Community Senior Physio/OT/SALT
6 £18.38 7.5 £137.85 20 £2757.00
Physiotherapist 5 £15.26 7.5 £114.45
COST TO ATTEND TRAINING £2757.00*
*Cost to provider
• Does not include travel expenses
Cost of Psychology Training - ATTENDANCE
• Not including accreditation process:
• Delivery: £517.20 per course
• Attendance: £2,757.00 per course
= £3,274.20 per course
(20 delegates)
Total cost of psychology training
*One off cost
Both costs funded by Network
Cost of Communication Training –
DEVELOPMENT & DELIVERY
UK Forum for Stroke Training accreditation
(existing training package)
£300.00*
Delivery of 3 day course by Speech & Language Therapist £750.00
Band equivalent
Cost per
hour
Hours Cost per
person
Places Total cost
Psychological wellbeing
practitioners
6 £18.38 22.5 £413.55 12 £4,962.60
COST TO ATTEND TRAINING £4,962.60*
*Cost to provider
• Does not include travel expenses
Cost of Communication Training – ATTENDANCE
• Not including accreditation process:
• Delivery: £750.00 per course
• Attendance: £4,962.60 per course
= £5,712.60 per 3 day course
(12 delegates)
Total cost of Communication Training
Training delivered
end of January
Proportion of clients formally screened
3
7
27
3532
45
72
Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
%
Training
Proportion of stroke patients receiving formal screening for
psychological issues after stroke during contact with community teams
Training delivered
end of January
Proporportion of clients receiving psychological support
4846
68
76
93 93
89
Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
%
Training
Proportion of stroke patients receiving support for psychological issues
after stroke during contact with community teams
Number of stroke survivors and carers each month supported by PCMH
1
2 2
5
2 2
0
1
2
3
4
5
6
Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11month
Community rehabilitation/stroke staff are well placed to screen for psychological issues after stroke in the
community.
With support and training they are able to provide low level support for psychological issues as an integrated part of
holistic care, referring those with persistent or more significant levels of distress to specialist primary mental
health and clinical neuropsychology services.
It was decided to roll the project out across Dorset!
Following evaluation it was concluded…
Issues and sustainability
Issue Action
Data Collection • Forms redesigned• Seeking national advice – ongoing!
Need for refresher training • Now being provided!
People not seen by Communication Trained staff
• New pathway - to ensure happens.
Physical barriers to access • Looking into – home visits?
Including Carers? • Included in Pilot• Re ongoing practice – responsibility lies with social care. Carers assessments.• Possible to review in future?
Huge demands on community rehab teams
• Building relations / open communication• Make process as easy as possible.• Ongoing issue!
Progress since pilot. We will now look at….
• Communication Training
• Psychology Training
• Ongoing challenges & next steps
• 2 additional 3 day training courses
• 18 additional CMHT/IAPT staff
• Total now trained = 26
• Process to ensure stroke patients are seen by communication trained staff
• Reflective practice/refresher training – to be provided
Communication Training
Better Communication Training
Better Communication TrainingPre and Post Training Knowledge Scores
02468
1012141618
1 2 3 4 5 6 7 8 9 10 11 12 13
Individual trainees
Kn
ow
led
ge
sc
ore
s (
Ma
x
po
ss
ible
sc
ore
= 1
6)
Pre-Score Post-Score
Better Communication Training
Did the Communication Training meet your needs?Yes, completely 17 (94.5%)
Yes, partly 1 (5.5%)
No, not at all 0 (0.0%)
””Very good balance between “Theory based” and practical knowledge. I think the course enabled me to enhance my ability to communicate better with, and understand the difficulties faced by, people who have had a stroke.”
Better Communication Training
What was the most useful aspect of the training?72% specified meeting and talking to people with aphasia
“All of it! Understanding how a stroke affects a person mentally as well as physically. Meeting and talking to stroke patients”
“The conversations with the aphasic people. This exercise was very important – to experience these conversations and for my own confidence.”
• 3 training sessions in rollout area Jan-Mar 2012• 46 new rehabilitation/stroke staff trained. Including new
areas/stages of pathway• Total trained to date = 92• 1 more training session – April 2012. 13 staff signed up.• Total trainees by end April 2012 = 105• Refresher training April (for pilot) & Aug/Oct 2012 (for
recent training)
Psychology Training
0
1
2
3
4
5
6
7
8
9
Kn
ow
led
ge
sco
re (
Max
10)
1 2 3 4 5 6 7 8 9
9 different knowledge areas
Knowledge gained in 9 DIPSS Training Areas
Knowledge before training Knowledge gained
Knowledge Gained – top 5 areas
DIPSS Knowledge Area Knowledge Gained
What can be done to improve coping and well being after stroke
22%
Normal adjustment process after stroke 19%
Signs of anxiety and depression and how to screen using formal screening tools
17%
Simple strategies which can support services users who are distressed
17%
Situations when referral on for more formal or intensive input might be needed
16%
65%
16%
72%
13%
81%
9%
81%
9%
56%
19%
71%
13%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Ph
ysio
OT
SA
LT
Str
oke
Co
ord
ina
tor
Oth
er
Ove
rall
Self evaluated learning achieved by profession
Previous Knowledge Knowledge Gained
60%
20%
72%
14%
75%
12%
72%
9%
60%
21%
66%
16%
0%10%
20%30%40%
50%60%70%
80%90%
Phy
sio
OT
SA
LT
Str
oke
Coo
rdin
ator
Oth
er
Ove
rall
Self evaluated learning achieved by profession 2011 & 2012
Previous Knowledge Knowledge Gained
Distribution of DIPSS psychology trained staff
20112012
• Feedback from 18 people so far in rollout period
• 88% said a member of the stroke team had discussed how they were coping emotionally since they came home.
• Of these people:– 100% ‘Helpful’ or ‘Very Helpful”– 100% member of staff understood their concerns “A
great deal” or “quite a lot”
• 2 people didn’t discuss how they were coping emotionally - 1 would have liked to.
Qualitative Feedback
• I enjoyed our chat and I felt quite reassured to be told I appeared to be coping well with my disability.
• Comforted• Relieved to have someone to discuss my
problems with• Very pleased for their advice• I found it very reassuring to discuss my
problems• It was important to be asked about ones
emotions it helps towards coping• Relieved to have some support - someone who
understands what is happening
How people felt ….
Ongoing challenges & next stepsIssue Action
•Data Collection
•Physical barriers to accessing IAPT
•Capacity of rehab/stroke teams
• Ongoing issues!
• New screening tools • DISCS (Aphasia) & BASDEC (older people)
• Sustainability – training & funding • To be discussed
• IAPT/Talking Therapies going out to “Any Qualified Provider”
• Ensure AQP sign up to pathway
• Communicate referral changes to all staff
• Provision of Step 2 psychosocial interventions
• Explore possibilities for clinical supervision to enable additional Step 2 support
•Review new innovative ways of providing support e.g. i-pod apps, tele-support etc.
• Patient and Carer Feedback • Further work planned
• Roll out to all Long Term Conditions • Work has started
Frances AvissPatient and Public Involvement Lead
& Service Improvement ManagerDorset Cardiac and Stroke Network
Tel: 07736 245 266
e-mail: [email protected]
For further information…..