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Delivering rehabilitation in the communitythe community
Rebecca Fisher, Satu Baylan, Terry Quinn, Katrina Brennan, Neil Muir, Marion Walker, Lynn Reid, Peter
Langhorne
Overview
Implementation of Community Stroke Rehabilitation in Scotland: Chest Heart & Stroke Scotland Action research study
• Collaboration with the Scottish Stroke Care Audit team and Scottish
Stroke Improvement programme
• Phase 1: SSCA post-acute audit
• Phase 2: qualitative multiple case study• Phase 2: qualitative multiple case study• To facilitate improvements in the provision of post-acute care in
Scotland
• Evidence and policy
• Description of service provision
• Themes across sites
• Recommendations
Evidence based guidelines
Scottish Intercollegiate Guidelines Network
Patients with mild/moderate stroke should be able to access stroke specialist early
supported discharge services in addition to conventional organised stroke inpatient
services.
ESD teams should consist of a specialist multidisciplinary group including nursing,
medical, physiotherapy, speech and language therapy and occupational therapy medical, physiotherapy, speech and language therapy and occupational therapy
staff.
Stroke patients in the community should have access to specialist therapy-based
rehabilitation services
Government Policy
Integration is the most significant change to health and social care services in Scotland since the creation of the NHS in 1948 (www.gov.scot)
Everyone is able to live longer healthier lives at home, or in
a homely setting
Reducing inappropriate use of hospital services; shifting Reducing inappropriate use of hospital services; shifting
resources to primary and community care; and supporting
capacity of community care.
Expand the multi-disciplinary community care team
Develop and roll out new models of care that are person-
and relationship-centred and not focused on conditions
alone
Alignment or Tension?
Early Supported Discharge • Integration and co-ordination: hospital & community • Facilitation of transfer of care from hospital to home• Multidisciplinary team based in the community• Rehabilitation: recovery and independence
Stroke specificity• Stroke specialist: necessary knowledge and skills• Stroke specialist team: group of specialists who
work together managing people with stroke• Team does not have to manage stroke exclusively,
but the team should have specific experience of, and knowledge about, people with stroke
SCCA 2017
Do you refer stroke patients to the following community services on
discharge from your stroke unit if eligible/suitable for rehabilitation?
(May 2017):
Service Health Boards (14) Health Boards (14)
No Yes
Return for one Health board inferred from 2016 data
No Yes
Early Supported Discharge (ESD) 6 7 & 1 partial
Stroke ESD 13 1 partial
Generic community rehab 2 12
Stroke community rehab 9 2 yes & 3 partial
Case study sites
Forth Valley
LanarkshireEarly supported
discharge & community
rehabilitation
Greater Glasgow & ClydeStroke ESD & Community
stroke rehabilitation
Forth ValleyEarly supported discharge &
community rehabilitation
Semi-structured interviews
GGC Lanarkshire Forth Valley Total
Specialist Stroke Nurses 1 6 0 7
Physiotherapists 3 1 3 7
Occupational Therapists 3 3 7 13
Speech and Language
Therapists
1 0 1 2
Generic Support Workers 1 2 1 4Generic Support Workers 1 2 1 4
Stroke consultant 1 1 1 3
Psychologist 1 1 0 2
MCN manager 1 1 0 2
AHP lead 2 0 1 3
Corporate planning 1 0 0 1
Total 15 15 14 44
Core components of stroke Early Supported Discharge:
Stroke specificity, multidisciplinary team composition, co-ordination,
responsive and intensive, eligibility
Description of service: Glasgow & Clyde
Community stroke service• Two geographically located teams: Glasgow & Clyde
Team Composition• Glasgow: Stroke nurse, Physiotherapist, Occupational Therapist,
Speech & Language therapist, Support workers, Psychology• Clyde: Physiotherapist, Occupational Therapist, Support workers
Weekly MDT meetings Overall team leader
Service• Stroke survivors only • Eligibility criteria: transfer independently or with assistance from one• 5 days/week• 8 weeks (max 12 weeks)
Description of service: Lanarkshire
Generic Community Rehabilitation services• Two areas: North & South• Community Assessment & Rehabilitation Service (North, 2)• Integrated Community Support Teams (South, 11)
Team Composition• Physiotherapist, Occupational Therapist, Support workers• Stroke MCN managed: Stroke specialist nurse, Physiotherapist trainer • Stroke MCN managed: Stroke specialist nurse, Physiotherapist trainer
(stroke specific), Occupational Therapist trainer (stroke specific), Young stroke support worker, stroke psychologist
Meetings• Weekly (CARS, ICSTs), Monthly (MCN)
Service• Part of caseload are stroke survivors• 5 days/week• Six week service & stroke nurse support up to 1 year
Description of service: Forth Valley
Generic Community Rehabilitation service• Referrals made through a single point• Three regional teams: Stirling, Falkirk and Clackmannan• Falkirk: Rehabilitation and Assessment in the community at
home (ReACH) Over 65s and Under 65s• Stirling, Clackmannan Over 65s
Team CompositionTeam Composition• Physiotherapist, Occupational Therapist, Support workers• Falkirk Over 65s only: Speech & language therapist (access),
Psychology, Dietician
Meetings• Teams work separately• Team meetings weekly or every two weeks
Service• Part of caseload are stroke survivors• 5 days/week (weekend cover in Falkirk)
Findings across sites
Community Rehabilitation provision• One site stroke specific• Mainly generic rehabilitation provided with pockets of stroke specificity• Waiting lists
“they are prioritised on the referrals now, just 'cause our caseloads were getting a
lot bigger. They are prioritised now as high, medium, or low”
Working together as a team• Some positive experiences of multidisciplinary team working• Dispersed working: individuals operating within a large and complex
service structure
“we do have a sense of, like, a good sense of team work and we get the job done.
And if one person can’t do it, you know, kinda like somebody will step in”.
“I think it's so important to have a multidisciplinary team. I think that's essential that
we're all based here”
Findings across sites
Challenges• Inequality in service provision (age & geographically related)• Fragmentation: multiple teams working in isolation
“if you were over 65 we could access them more quickly, versus the ones that were
under 65, and we felt that was disadvantaging our younger people”
“…it was acute and it was community services, and there's certainly silo working “…it was acute and it was community services, and there's certainly silo working
going on there”
Strengths• Patient centred-care and involvement of the family
“I think it works really well that it's a stroke speciality service and that you see
people in their own home, I think that that's invaluable.”
“I mean, I know on a personal level that my input is really valued. I know that
because people tell me”.
Findings across sites
Training and Education• Stroke Training and Awareness Resources (STARS) training• Skill trainer support
“I think the staff within the team that I have just now are very experienced, and I
think they support stroke people very, very well”
“I’m a bit worried about losing my skills in that area (stroke)…you’re not dealing
with it on a daily basis”with it on a daily basis”
Monitoring performance• Data is collected – currently for own purposes“[We report] on the acute part of the journey, yes, but not on the back-end of the
journey”.
Future planning• All sites planning or undergoing change (integration / evidence)• Service re-organisation• Address inequalities: age barrier & geographical
Summary & Recommendations
Alignment between evidence based guidelines and policy• Identify common ground• Use research evidence to support change
Multidisciplinary team intervention• Need defined team roles and create leadership opportunities• Consider structure and frequency of team meetings• Break down geographical boundaries
Stroke specificity• Provision of stroke specific training to community rehabilitation team
members• Defined and recognised roles for stroke specialist staff in the community• Stroke training audit
Summary & Recommendations
Address service inequality• Review and simplify: consider patient perspective• Agree a defined care pathway for post-acute stroke care
Audit and Feedback• Annual organisational audit to include questions about community stroke
rehabilitation services• Clinical audit to include core community data set
Next Steps• CHSS study report• Quantitative evaluation of service provision
www.nottingham.ac.uk/research/groups/strokerehabilitation/projects/wise
