Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects

Stroke Improvement Programme

Improving post hospital and long term care:case studies from the Stroke ImprovementProgramme projects

NHSNHS Improvement

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Introduction

Transfer of care

Dudley PCT

NHS Lewisham and South EastLondon Cardiac and Stroke Network

Lincolnshire Community HealthServices

NHS Milton Keynes and MiltonKeynes Council

Nottinghamshire County Council andNottinghamshire Community Health

Poole Hospital NHS Foundation Trustand Bournemouth and PooleCommunity Health Services

Royal Bournemouth and ChristchurchHospitals NHS Foundation Trust

South West London Cardiacand Stroke Network

Stoke on Trent City Council

Key learning from the transferof care national projects

Contents

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Rehabilitation

Aintree University HospitalsNHS Foundation Trust

NHS Hampshire

NHS Medway

Norfolk and Norwich UniversityHospitals NHS Foundation Trust andNHS Norfolk

Northampton General Hospital,Kettering General Hospital and NHSNorthamptonshire

Portsmouth Hospitals NHS Trust

NHS West Sussex, West Sussex Healthand West Sussex County Council

York Hospitals NHS Foundation Trust

Stroke resources

Further information

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Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 3

Introduction

Since March 2009, the StrokeImprovement Programme has beenrunning projects looking at the keyareas of transfer of care andrehabilitation. This publication givesthe detail of each project.

The suggestions, experiences andexamples provided in this documentare intended to generate ideas, toshow what is possible when teamswork constructively together and toguide planning for improvementactivities.

The Stroke Improvement Programmecontinuously publishes materials tohelp those striving to improve strokeand TIA services. All materials areavailable on the Stroke ImprovementProgramme web site at:www.improvement.nhs.uk/stroke.

Contacts for each of the projects areincluded at the end of thepublication. Full case studies of theservice improvements can be foundat www.improvement.nhs.uk/stroke

www.improvement.nhs.uk/stroke

4 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects

Transfer of care

Quality marker 12 of the NationalStroke Strategy set a standard thatindividuals should have a cleardischarge plan, covering all theirneeds, across both health and socialcare. Nine sites across Englandanalysed their systems for transfer ofcare for people with stroke andfocused their improvements onprocesses influencing this stage ofthe stroke pathway and impacting onseveral of the National StrokeStrategy quality markers, notablyquality marker 12 (transfer of care),10 (rehabilitation), 3 (informationadvice and support) and 13 (longterm care and support).

This section contains informationabout the improvements made totransfer of care by the nine projectteams across England. The casestudies provided here are a summaryof the improvements and how theywere achieved.


1National Stroke Strategy, Department of Health, 2007.

TOP TIPS

• Manage the health and socialcare interface

• Involve patients in improvingtransfer of care

• Provide emotional support forstroke survivors and carers

• Ensure access to appropriateservices, including rehabilitation,social care and communityopportunities


Seamless care

AimsThis joint team established that theirkey aims were to:• improve communication betweenprimary and secondary carerehabilitation teams

• improve staffing levels within thecommunity rehabilitation team,provide more intensiverehabilitation and set up an earlysupported discharge service

• enable earlier discharges andreduce delayed discharges

• increase the involvement of socialservices

• improve social and emotionalsupport for patients, their familiesand carers

IssuesThe service was very fragmented.Patients would be brought to A&E,seen and assessed when their turncame, admitted to the emergencyadmissions unit, and transferred tothe stroke ward if there was a bed.Stroke beds were regularly used bymedical outliers. CT scans were notroutinely performed within 24 hoursof presentation, with a wait ofsometimes up to three days. TheCommunity Support RehabilitationTeam waiting times could be up to sixweeks post-discharge. Patients werereferred to the community team on

discharge but few referrals included acomprehensive patient centredprogramme with individualisedpatient goals. There was nodedicated social worker for stroke. Allof these factors contributed to delaysin discharge, with an average lengthof stay of 18 days.

ActionsA system of short monthly meetingswas established between key stafffrom Dudley Social Services, DudleyGroup of Hospitals, the StrokeAssociation and the PCT to improveand optimise communication, andidentify and work through theimprovements needed. Smaller taskgroups met separately to tacklespecific problems quickly, as andwhen needed. A joint investigationcommittee was formed to improvecommunication and targetachievements.

Stroke and TIA pathways for primaryand secondary care were developedand agreed.

A comprehensive community servicespecification that engaged theexisting community team wasdeveloped, resulting in clearentrance, exit and exclusion criteria.


These have impacted positively onworkload and consequently improvedwaiting times.

A social worker dedicated to strokenow works full-time in the Dudleyhospitals and a family and carersupport worker, employed by DudleyStroke Association, now goes into thehospital three days a week to providesupport as needed.

A community stroke coordinator wasemployed. As well as leading theCommunity Support RehabilitationTeam, she visits the hospital once aweek and works with the hospitalstroke coordinator to improvecommunication between the teamsand identify patients suitable for earlysupported discharge.

OutcomesA comprehensive stroke servicespecification is in place, with acomplete stroke service pathwayacross acute and community services.As well as the improvements madefor the project, changes were madein acute care including the alerting ofDudley hospitals by the ambulancecrew for imminent stroke admissionsand immediate assessment on arrivalby the stroke team.

Dudley PCT, Dudley Social Services, Dudley Groupof Hospitals and Dudley Stroke Association

This has positively impacted onmeeting acute stroke clinicalguidelines and admission to thestroke ward.

The PCT invested £75,000 to supportearly supported discharge to appointhealth care assistants, releasingtherapists and other clinicians tofocus on appropriate specialistactivities. The Community SupportRehabilitation Team contact thepatient soon after admission to assessfor early supported discharge andnow utilise entry and exit criteria andplan patient contact according togeography and job roles within theteam, to improve productivity andefficiency. Waiting times havereduced to an average of 3.4 days forthe first contact with the team.

The family and carer support workerand social worker are now involvedsoon after admission to providesupport and plan care on discharge.The team demonstrated the postsaved the trust around £94,500 in itsfirst year on crisis admissions andemergency room visits by patientsrecently discharged from hospital,providing patients and families with apoint of contact for any worries andconcerns.1 This has avoided patientsunnecessarily going to A&E or callingan ambulance or their GP forstraightforward issues or concerns.



A psychologist is now available andassesses patients referred by themedical team. All patients receivepatient centred, individualised careplans and goals on discharge.

These improvements have made animpact on delayed discharges,reducing average length of stay from18 to 15 days, saving £750 perpatient.

Patients are satisfied with the servicethey receive from the stroke team:

I cannot speak too highly ofthe services I have received …Each and everyone involvedhave given a high standard oftreatment and care, for this Iam deeply grateful. It hasboosted my self-esteem andmade me feel that life is worthliving. I cannot see any areawhere things could beimproved”

TOP TIPS

Communication, communication,communication.’The Dudley Team

‘

ContactsDr Liz PopeGP, Dudley [email protected]

Derek HunterCommissioning Lead -Urgent CareDudley [email protected]

“

1The business case for the Dudley Family and Carers Stroke SupportWorker can be found on the Stroke Improvement website:www.improvement.nhs.uk/stroke/SocialCareforStroke/SocialCareforStrokeResources.aspx



Lewisham integrated stroke projectNHS Lewisham and the South East LondonCardiac and Stroke Network

AimsThe project team from NHS Lewishamwas jointly led by the PCT and theSouth East London Cardiac andStroke Network, and had close linkswith social care through jointcommissioning. It aimed to redesignthe post acute phase to create anintegrated pathway between acuteand community stroke services,through both stroke service teams. Italso aimed to improve dischargeplanning and communication acrossthe pathway, facilitate earlier transferof care and ensure high qualityrehabilitation and enablement.

IssuesA typical Lewisham stroke patientpassed through five to seven differentteams, leading to a number of qualityproblems relating to patientexperience. The systems andprocesses in place were complex.Not all patients were cared for on adedicated stroke ward and theaverage length of stay for all patientsin 2007/8 was 22.5 days.

Only 23% of patients went onto haverehabilitation from either LewishamIntermediate Care team (LINC) or theLewisham Adult Therapies Team(LATT). Neither team was strokespecific and had long waits, in somecases up to 12 weeks.

Delays also occurred in securingplacements for specialist neurologicalrehabilitation for younger people andfor complex care packages. Therewas an average length of stay of 40days for these patients, and thelongest wait was 188 days.

ActionsThe team gained wide stakeholderengagement and board level supportfor the project. Staff, patients andcarers were involved in a processmapping event to identify bottlenecksas well as existing good practice toadopt more widely.

A project initiation document, projectplan, communication plan and risklog were written and a baseline ofexisting services was established.Current cost and demand analysiswas carried out and agreement onmeasures was gained.

A pilot neuro-rehabilitation team wasformed as part of the integrated careteam to address the lack of strokespecific community rehabilitation.

At ward level a number of keyimprovements were made:• reconfiguration and simplificationof the discharge process

• systems for coding patients werereviewed and improved after a casenotes review found that 17% ofpatients were erroneously coded

• implementation of a key workersystem

• a single point of referral to socialcare in hospital, ward based socialcare workers, location of the socialcare office close to the stroke wardand location of social carecomputers in the same room as themultidisciplinary team meetings forease of access to records

• a discharge planning group wasestablished to improve patientinformation and warddocumentation



The workforce was reconfigured toinclude some new posts and newways of working:• Stroke Association familysupport worker and communicationsupport worker posts werere-specified and agreed

• the social care grant used for a new‘back to life’ senior social care post

• community health and social carestaff attended hospitalmultidisciplinary team meetings

• rotation of therapy posts betweenthe acute hospital and communityteams

• appointment of a senior therapistto lead the new community neuroteam

• Connect and the Stroke Associationtraining for care home and socialcare staff

OutcomesThere is now a reconfigured, moreefficient, simplified stroke pathway inplace and enhanced joint workingwith social care.

Co-ordination of care is improved anda more personalised holistic servicewith community enablement offersmore personalised care planning andgoal setting. This will be assisted byperforming joint single assessments,sharing information and jointdocumentation, as well as effectivecommunication.

The length of stay has decreasedfrom 22.5 days in 2007/08 to 19 daysin March 2010.

The improvements made a significantimpact on access to communitywaiting times for therapy even beforethe planned early supporteddischarge team was in place.

Better patient outcomes and value formoney will be realised in theintegrated team through sharedresources such as administration,shared assessments and reduction inhandoffs and duplication.

ContactSara NelsonAssociate Director and Interim ProjectLead, South East London Cardiac andStroke Network and NHS [email protected]

Table 1: Key outcomes in Lewisham

Stroke vital signProportion of patients spending90% of time on a stroke unit

Average length of stay (days)

Waiting time for communitytherapy

Number of new patients per month

Duration of therapy

<40%

22.5

Intermediate careteam 4-6 weeks

Adult therapiesteam 12 weeks

LINC 1-2

LINC 35 days

>80%

18

SALT - 48 days

OT - 65 days

Physio - 96 days

-

-

>80%

19 (Oct-Dec swine flu and norovirus)

SALT - 38 days

OT - 44 days

Physio - 74 days

New pilot LINC team 5-6 days

New pilot LINC team 28 days

Jan 2009 Apr-Jun 2009 Oct 2009 - Mar 2010



AimsThe team set out to establishaffordable, value for money care andrehabilitation for stroke patientsacross the pathway, in collaborationwith service providers in secondarycare, social services and the thirdsector.

Objectives to be achieved to meetthis aim were:• to develop quality information forpatients and carers to supportinformed choices and selfmanagement

• to increase active participation ofpatient and carers in the planning,development, delivery andmonitoring of the service

• to provide a highly skilledworkforce, across theorganisational boundaries

IssuesAt the start of the project there wasno community stroke rehabilitationavailable in the county and limitedgeneric community rehabilitation.This was identified as a major reasonwhy length of stay in the acute strokeunits or secondary care was aboveaverage.

Assisted discharge service for strokeLincolnshire Community Health Services

The extended length of stay wasidentified as a factor that limitedavailability of beds on the strokeunits, leading to an above averagenumber of patients who were notaccessing stroke units in the threemain sites in the county.

ActionsThe service was designed as part ofa tendering process, including anin depth and fully costedimplementation plan. Animplementation lead was identifiedto drive the project. A core team wasrecruited and a lead for the serviceidentified at an early stage. A patientand public involvement lead wasidentified to capture patientexperience from an early stage.

The new team were clear from theoutset that the service would beperformance monitored andmanaged. Data collection wasembedded within clinical activity andregular meetings with commissionerskept the team focused on outcomes.

The new assisted discharge serviceteam was established, informed bypatient and carer views, to provideaccess to a seven day communityservice across the county, including:

• timely assessment as soon as apatient is identified by the ward assuitable

• attendance by the assisteddischarge team at ward teammeetings, at referring stroke unitsand, in some areas in order toimprove rapport and referralnumbers, attendance at dailyhandover sessions with stroke unitstaff

• setting up systems to ensure theteam met the performanceindicators

OutcomesAverage length of stay reduced from29 days to 20 days (see figure 1), andwaiting times for community therapyreduced from three weeks to aroundtwo days (see figure 2). Patientsatisfaction with the new service ishigh (see figures 3 and 4). Patientoutcomes have improved, asmeasured by Barthel scoring from anaverage of 15 on discharge fromhospital to 17.5 on discharge fromthe assisted discharge service,demonstrating that the team areimpacting on functionalimprovements.



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Average number of daysfrom stroke to home

Figure 1: Average number of days from stroke to hospital discharge

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Average number of days

Figure 2: Average number of days from hospital discharge to first faceto face contact with the Assisted Discharge Service

Figure 3: The handover of my care fromhospital to home went smoothly

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Choice Answers

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Agree Neitheragree ordisagree

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Notapplicable

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Choice Answers

Figure 4: My carer was involved in agreeing the careplan and their needs were taken into consideration

ContactJoan LawtonClinical Team LeadAHP/Implementation lead ADSSLincolnshire CommunityHealth [email protected]



AimsThe joint commissioner and providerled team from Milton Keynes planneda service redesign in anticipation offunding for a new early supporteddischarge service, due to start inJanuary 2010. Preparatory workaimed to improve person centred careplanning, involve the person and theircarers in decisions and goal setting. Itwas also intended to improvecollaboration between the hospitaland community staff, informationduring hospital stay and ondischarge, access to professionalsspecialised in stroke care andoutcomes for patients.

Milton Keynes Hospital NHSFoundation Trust was alsoparticipating in the StrokeImprovement Programme acutestroke project, so the teams alignedtheir aims for reduced length of stay,increased occupancy rates and directaccess to the acute stroke unit.

IssuesThe baseline position for transfer ofcare did not meet National StrokeStrategy standards, with no strokespecialist rehabilitation staff in thecommunity at the point of dischargeand only a third of patients known tofollow-up services. There was nostroke pathway and patientinformation was poor.

Length of hospital stay was around25 days and prolonged past the pointwhere patients were medically fit fordischarge due to a lack of confidencein community support. An average of45% of patients were never admittedto the stroke unit with most notknown to the stroke team. The strokevital sign was estimated and based ontrajectory, not actual figures.

The hospital multidisciplinary teamhad regular staff changes and lackedconsistent links with the communitystroke specialist, so the rehabilitationteam missed many patients. Decisionswere made by hospital staff aboutbest options for continuingrehabilitation in the community butwith little knowledge of the options.

Patients reported a lack ofinformation and confusion aboutwhat services they could access, butwhen they were referred to thecommunity stroke team this washighly praised.

ActionsA Local Implementation Team metevery other month and set up a smallproject group, including userrepresentatives, to develop thepatient information portfolio. Aproject manager in commissioningwas assigned to work closely with thehospital project team to ensure thatthe stroke pathway became asseamless as possible.

The team developed a vision for theservice and a service specification foran early supported discharge service,with widespread user andstakeholder involvement.

Stroke transfer of care and supportedrehabilitation in the community projectNHS Milton Keynes and Milton Keynes Council



In preparation for the new service,some improvements were made tothe process of transfer of care:• a new patient pathway• a new patient information pack• a new record of patient care, whichensured patients’ aspirations werecentral to their care and dischargeplanning

• a staff competency audit, andsubsequent training programme

• plans for collation of key hospitaland community data, analysed in arobust way to determine thebaseline and points forimprovement

• development of the role of thecommunity stroke specialist,including the interface with thestroke ward multidisciplinary team

OutcomesThe team experienced a significantdelay in funding of the earlysupported discharge team, which hasdelayed the benefits of the workdone so far, but due to the team’spersistence the service began at thebeginning of April 2010.

Despite not being fully established,the early supported discharge teamsaw eight patients in the first month,reducing the length of staydramatically to below 10 days. Thestroke vital sign improved to 70% ofpatients spending 90% of their timeon a stroke unit.

A recent change in staffing on theward has led to significantimprovements in the notification ofpatients to the community strokespecialist.

ContactDr Marianne VinsonConsultant in Public HealthNHS Milton [email protected]



AimsThe project team fromNottinghamshire focused theirimprovement on access to emotionalsupport for carers of stroke survivors,by funding and defining a specificrole for a family and carer supportworker on the acute stroke ward toprovide support to carers into thesouth of the county.

IssuesAt the start of the project there wasan inequitable service for strokesurvivors and families to accessemotional support. 88% of patientswere not referred for furtherrehabilitation, and received no followup, advice or information (datacollected January to June 2009).Patients who went on for furtherrehabilitation were signposted toadditional support from social careand voluntary agencies using asignificant amount of clinical timeand detracting from time available forother rehabilitation.

ActionsThere was integral involvement froma stroke survivor and carer on thesteering group. This led to supportbeing offered to carers once thestroke survivor was out of the acutephase, as carers themselves appearedto be in crisis until this point. Supportby carers was sought after usualoffice hours when they felt they hadmore time to talk.

In addition, the new service waspromoted to the stroke wards toincrease referrals to the family andcarer support worker.

OutcomesThe service was evaluated bycomparing results for carer strainindex and general healthquestionnaire with those of a studyof the community stroke team carriedout in 2002.2 The evaluation showedthat carers experience higher levels ofstress now than in 2002, but alsothat the family and carer supportworker appears to have a positiveimpact on perceived carer health andwellbeing.

There was no difference between thefamily support worker and thecommunity stroke team for allmeasures, showing benefits wereconsistent across all services.

2N B Lincoln ,M F Walker, A Dixon, P Knights (2004) Evaluation of a multiprofessional communitystroke team: a randomized controlled trial Clinical Rehabilitation 18:40-47).

Access to emotional support forcarers of stroke survivorsNottinghamshire County Council Adult Social Care, NottinghamshireCommunity Health and The Stroke Association

Joint working between the three agencies has enabled ashared language and understanding to be developed.Barriers have been discussed and overcome betweenorganisations and a much improved understanding of theworld faced by a stroke survivor and their carer isunderstood by all”

The Nottinghamshire project team

“



The process of meeting regularly todevelop the service and establishingjoint objectives improved workingrelations between the organisationsand the success of the supportworker role led to commissioning oftwo further family and carer supportservices in the county.

ContactChristopher GreensmithTeam Leader – CommunityStroke TeamNottinghamshire Community [email protected]

Mandy ShielInteragency Planning andCommissioningAdult Social Care and HealthDepartment, NottinghamshireCounty [email protected]



AimsThe team aimed to develop anddeliver an aspirational pathway forstroke, provide equity of access tocare in the community and, workingwith Borough of Poole social services,to define and integrate the role ofthe social care stroke co-ordinationteam.

Issues to resolveFour main problems were identifiedat the start of the project:• problems with the dischargeprocess meant the hospital lengthof stay on the acute ward washigher than the national average at21 days

• a patient survey showed that only18% of patients felt fully involvedin the discharge process

• there was an average wait of 11days for the generic communityrehabilitation team

• significant shortfalls weredemonstrated in the quality ofinformation shared between theacute trust and the communityrehabilitation team

ActionsA patient and carer feedback forumestablished the shortfalls in thetransfer of care pathway anddescribed their aspirations for theideal stroke service. The conclusionswere presented to staff from socialcare, health and the voluntary sectorwho developed a pathway for theservice based directly on thosevisions. This pathway formed thebasis of the team’s action plan forimprovements.

A ‘meet the team’ meeting wasestablished early in the first week ofthe hospital stay, to discuss prognosisand plans for rehabilitation anddischarge with the patient and family.

A key worker system wasimplemented on the acute strokeward.

The content of patient informationand the process for givinginformation to patients and familieswas reviewed and improved.

Minimum standards for the quality ofhandover of information to thecommunity team were made and theteam committed to see patientswithin a week of hospital discharge.

Social care stroke co-coordinatorposts funded by the social care grantwere appointed to support strokesurvivors in hospital and afterwards.

OutcomesMeasurable improvements includeimproved patient satisfaction scoresfor involvement in the transfer of careprocess, reduced waiting times forcommunity therapy and improvedquality of handover informationbetween hospital and communityteams (see figures 5 and 6).

All of the changes made to theservice were within existing resourcesand largely involved improvements toprocesses at ward level. The mostsignificant impact is the radical anddemonstrable improvement in patientexperience.

Poole together for strokePoole Hospital NHS Foundation Trust, Bournemouth and PooleCommunity Health Services and Dorset Cardiac and Stroke Network



This project benefited from thestrong leadership of the consultantphysicians who took a hands onapproach to both driving andimplementing the changes. Thecohesive multidisciplinary teamembraced and led further change toinfluence all aspects of the transfer ofcare process. The Dorset Cardiac andStroke Network were integral inimplementing the improvements.Involvement in the StrokeImprovement Programme projectimproved joint working between theacute trust and community stroketeams with the resultant benefits topatients.

ContactsDr Tracey VillarStroke Consultant, Poole HospitalNHS Foundation [email protected]

Naomi GibsonSenior Physiotherapist, NHSBournemouth and [email protected]

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%of

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MonthsMay-Jul Aug-Sep Oct Nov Dec Jan

Not at all Not involved Involved Very Involved

Figure 5: Poole Hospital - How involved did youfeel in plans for leaving hospital?

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8

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Del

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appo

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January 2009 September 2009

10.7

6.8

Figure 6: Poole Hospital and Woodland Community Rehabilitation Team:Waiting times for community rehabilitation reduced from 10.7 to 6.8 days



AimsThis team aimed to clarify the transferof care pathway from hospital tohome.

IssuesThe system for transfer of care wasmuddled and confused with no clearpathway. Patients had differingexperiences of discharge planningand transfer of care, depending onwhich health and social careprofessional was involved in thedischarge process. The bid for astroke community rehabilitation teamwas unsuccessful and waiting for adefinitive answer from the PCT onfunding took time. The team thenfocused on making improvements tothe current system whilst waiting fornews of possible future funding for acommunity stroke team.

ActionsPatient and carer feedback has beenintegral to this project, and hasinformed the team at many levels asto the effectiveness of theirimprovements.

Formalised care review meetings withpatients and carers for enhancedcommunication and dischargeplanning have improved patient

satisfaction. Care reviewdocumentation is given to the patientand carer to reinforce informationgiven during the meeting.

Training for all registered healthprofessionals on the new dischargeprocesses motivated staff and brokedown resistance to the new ways ofworking. All staff are now engagedwith discharge planning.

Development of written informationresources has supported verbalmessages for patients and carers.Patients are also informed of theirfirst appointment with thecommunity rehabilitation team priorto discharge. Standardisation ofpaperwork between the acute andrehabilitation units now includes adischarge checklist andmultidisciplinary handoverinformation for primary care.

Closer working of health and socialcare teams is supported by thelocation of the social workers, aninformation support officer and theStroke Association support staff inthe hospital near to the stroke ward,rather than at the local authority.A more consistent prediction ofestimated discharge date helps this.

Making sense of the muddleRoyal Bournemouth and Christchurch Hospitals NHS FoundationTrust and Dorset Cardiac and Stroke Network

OutcomesThese improvements necessitated achange in culture by the acute andrehabilitation ward teams and havetaken time to embed. The work donein the project between health andsocial care teams supports the workidentified in Accelerating StrokeImprovement to improve joint careplanning. The project took time toget started, delayed by waiting forthe funding of a communityrehabilitation team, but measurableimprovements to the process of careand patient and carer experience areanticipated after the lifetime of thisnational project.

ContactClare GordonConsultant Stroke Nurse, The RoyalBournemouth and ChristchurchHospitals NHS Foundation [email protected]



AimsThe project aimed to test theapplicability of a self managementprogramme in Croydon.

IssuesThere was a lack of continuity in thedevelopment and resolution oftreatment plans which were notincorporated into the whole care ofpatients or transfer of overall plans.Not all treatment plans were agreedwith patients and their carers. Staffwere not consistently workingtowards patient centred goals andoutcomes to ensure that treatmentwas patient led and individualised.

ActionsA self management approach calledthe ‘Stepping Out Programme’ (nowknown as ‘Bridges’) was piloted with24 staff across the stroke pathway inCroydon. This approach focuses onsuccesses, decreases dependenceon therapists and facilitatesempowerment of stroke survivorsand carers to set, record andevaluate their own goals.

Outcomes72% of staff participants changedtheir practice by the end of theprogramme towards a more patientcentred, goal orientated approachwhich promoted patients’ selfefficacy.

Improvements in self efficacy scoreswere shown in eight of the 12patients and two others had scores

Stepping outSouth West London Cardiac and Stroke Network

which remained high throughout (seefigure 7). Improvements were alsomade in patients’ perceptions of theimpact of the stroke measured usingthe Stroke Impact Scale. No changewas shown in hospital anxiety anddepression scores, although none ofthe participants had scores whichindicated the need for intervention(see figure 8).

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Scor

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1 2 3 4 5 6 7 8 9 10 11 12Patient

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Figure 7: Patient self efficacy scores



Staff feedback indicated that theynow use goals that are important topatients and families and facilitatediscussions around living with strokefor both the individual and the family

This project demonstrated that a selfmanagement programme could besuccessfully implemented in usualclinical practice with positive benefitson patients’ self efficacy and facilitatethe goal orientated approachendorsed in national clinicalguidance.

ContactElaine HaywardSenior Project Manager, SouthLondon Cardiac and Stroke [email protected]

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0SIS

(physical)SIS

(recovery)SIS

(participation)SIS

(emotion)HAD(d)

HAD(a)

Selfefficacy

Before programme After programme

Figure 8: Patients perceptions of the impact of the strokemeasured using the Stroke Impact Scale


AimsThe team aimed to develop a personcentred, integrated health and socialcare service for stroke and use a trulyjoined up approach.

IssuesExisting systems inhibitedcommunication between health andsocial care, and excluded referral of arange of individuals to social carewho would benefit from long termsupport. Social care referrals werelimited and delayed.

ActionsBoth the social care and earlysupported discharge teams adoptedthe same name, Community StrokeDischarge Team, to give a strongmessage about joint working and aseamless service. A single point ofcontact on one business card wasused for patients and carers ondischarge.

The social care grant for stroke wasused to increase social care time,enabling a daily visit to therehabilitation ward and earlierreferral of patients.

Policies for discharge and for rapidassessment by the community strokedischarge team were implemented.

An information database ofcommunity services was establishedas a staff resource for signpostingpatients to further support afterdischarge.

All staff were encouraged to accessstroke specific accredited trainingprogrammes, facilitating thedevelopment of common skills andknowledge.

OutcomesThese were:• improved partnership workingacross health and social care withresulting development of sharedobjectives and goals

• establishment of a dedicated socialcare team for stroke

• a steady increase in Barthel indexscores demonstrating improvedlevels of patient independence (seefigure 9)

• increased number of social carereferrals (see figure 10)

Redesign of stroke care pathway fromrehabilitation into the communityStoke on Trent City Council


The success of the Stoke on Trentteam’s improvements can beattributed to focused leadership bythe project lead in social care,genuine cross organisational workingthrough joint health and social careobjectives, and practical support fromthe Shropshire and StaffordshireCardiac and Stroke Network. Theseobjectives were implemented at anoperational level by dynamic healthand social staff who worked regularlyand closely together.

ContactLorraine CobbSocial Care Team Manager andProject LeadStoke on Trent Social [email protected]



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0Nov 2009 Dec 2009 Jan 2010 Feb 2010 Mar 2010

Month

Average Barthel Score

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helS

core

2006/07 Average 2007/08 Average 2008/09 Average

Figure 9: Stroke rehabilitation unit average discharge Bartel score

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Figure 10: Social care activity since all stroke wards have attached workers

of stay and access to community andlong term support. Leaving hospitalwith a clear point of contact for help,should it be required, was anothersignificant feature.

Strong leadership was another qualityseen in these national projects.Leaders emerged and developed fromdifferent members of the projectteams; from clinical staff, some withprotected time but several with none,and all with a clinical commitment,from commissioners of services,managers and network staff. With aleader to champion and drive theproject, the likelihood of successfuloutcomes is increased.

A consistent theme of the projects isthat effective communication andgenuine joined up working acrossorganisations supports rapidimprovement in transfer of care,especially where this includes goodworking links between health trusts,social care and voluntary agencies.

Key principles to accelerateimprovement in the transfer of carecan be summarised as follows:• nominate a champion to driveimprovement in each organisation

• co-locate the stroke health andsocial care teams in the samebuilding, preferably in the sameroom

• use a variety of tools to involvepatients and carers to see wherethe service is and what needs tochange

• actively include the patient andfamily in decisions about leavinghospital at the earliest appropriateopportunity

• nominate a single point of contactas a resource for stroke survivorsafter hospital discharge



Key learning from the transferof care national projects

Understanding the real state of theservice is essential beforeimprovements can be made.Primarily this needs to be from theperspective of the stroke survivor andfamily, but also from the staff whowork in the service and from theevidence seen from measuring theservice objectively. Measuring wherethe service is at the start and regularlyreviewing progress towards objectivesis an essential component ofsuccessful service improvement.

The case studies described here allaccurately identified the shortfalls inthe service, targeted improvements atthe points in the service where theywere needed, then monitored theimprovement to ensure it waseffective and achieving theintended outcome.

Stroke survivors and their familiesneed to be central to the process ofimproving stroke services as well astheir early and active involvement intheir own care and plans for leavinghospital. Several of the projectsdemonstrated that discussions abouttransfer of care and early planningwas appreciated by patients andfamilies and impacted positively onthe measurable outcomes of length



Rehabilitation

Quality marker 10 of the NationalStroke Strategy requires services toensure that people who have hadstrokes have access to high-qualityrehabilitation and, with their carer,receive support from stroke-skilledservices as soon as possible after theyhave a stroke, available in hospital,immediately after transfer fromhospital and for as long as they needit. Eight sites across England analysedtheir rehabilitation services and madeimprovements to them based onwhat they found, establishing newcommunity and early supporteddischarge services, improving theskills of the multidisciplinary teams,and developing plans to provideweekend therapy.

This section contains informationabout those improvements made bythe project teams. The case studiesprovided here are a summary of theimprovements and how they wereachieved.

TOP TIPS

• Proactively recruit patients to thecommunity service

• Develop a flexible, stroke skilledworkforce

• Develop a team commitment tomeasuring progress

• Identify and use all services anddelivery partners

• Support effective leadership

AimsTo improve the quality and quantityof rehabilitation services for strokesurvivors on a combined unit basedon local and national guidelinesaround quality marker 10.

IssuesAintree Stroke Centre is a combinedin-patient stroke unit. The hyperacute and acute needs of the patientshave historically been the main focusfor the multidisciplinary team,resulting in significant changes inpractice over many years. As aconsequence, staff identified theneed to re-focus on the rehabilitationneeds of stroke survivors.

Prior to the project the service hadalready identified several key factorsfor further consideration, including alack of true cohesive multidisciplinaryteam working and absence ofrelevant metrics. There were nomechanisms in place to collectpatient and carer views, and a reallack of rehabilitation equipment onthe ward.

ActionsThe team undertook an observationstudy of a patient’s day across fivedomains – nursing, physiotherapy,occupational therapy, medical andsocial. Time was divided into 15minute slots from 7am until 9pm,with observations taking place in thefemale rehabilitation bay.

They also undertook feedbackquestionnaires for patients and staff.The staff questionnaires showedvariability in confidence andknowledge of handling and nutrition,amongst all grades and professions.The patients indicated considerableperiods of boredom, especially in theafternoons, and lack of awareness ofthe existence of a day room.

A successful bid for additionalhandling equipment, with furtherbids for more feeding aids/manualhandling equipment.

A programme of joint trainingsessions between therapists andnurses around handling and nutritionmanagement has been implemented,including a process for evaluation.

Work has been undertaken toimprove the aesthetics of the dayroom, and it is on the ward inductioncheck list for new patients.

More work is planned around skillmix, additional staff, competencies,and further data collection, using thenewly established rehabilitationmetrics as a basis.

OutcomesRelationships between themultidisciplinary team have improved;therapy staff attend the daily nursinghandover, use and update thenursing electronic handover and thedischarge planning process isbecoming more cohesive. The team isconsidering the re-introduction ofcommunal eating on the ward, andimplementing a focus group lookingat patient and carer information.

They have shown that a 24 hourapproach and shared ownership ofrehabilitation in partnership with thepatients can support improvements incare, and enhance multidisciplinaryteam effectiveness and cohesionwithout huge investments of money.



To improve the quality and quantity ofrehabilitation services for stroke survivors on acombined unit, based on local and nationalguidelines around quality marker 10Aintree University Hospitals NHS Foundation Trust

Key learning was identified asfollows:• undertaking a national projectalways requires more time than isanticipated. It is essential to gainsupport within the organisation forprotected time to achieve this

• liaison with key stakeholders asearly on as possible makes a bigdifference

• specific time bound objectives withwell-defined baseline metrics arefundamental for project success.Metrics for quality can be moredifficult to develop

• sort out a plan for data as soon aspossible, including how to collect,store and analyse it, and ensure theresources are there to support this

• tap into local resources (the strokeresearch team, The StrokeAssociation, the volunteersdepartment, the cardiac and strokenetwork) to prevent duplicationand gain additional support

• small, bite sized improvements aredeliverable and lead to significantchanges over time

• ensure you have named individualsat the correct grade who can takeresponsibility for taking specificissues forward (problems withrotational staff, ownership andcommitment)

ContactHelen EvansPhysiotherapy ManagerAintree University Hospitals NHSFoundation [email protected]



Key learning was identified asfollows:• establish a core project team anddevelop them, e.g. through specificteam building activities

• ensure that all key people areinvolved at the very beginning sothat the project requirements arefully scoped, e.g. it was useful tohave the contracting template forthe specification at the beginning

• develop robust data collectionmethodologies – establish early onwhat data is available. This may beparticularly difficult for communityrehabilitation services

ContactPhilippa DarntonProgramme ManagerNHS [email protected]



AimsTo develop a commissioningspecification for early strokerehabilitation (up to three monthspost stroke) on behalf of a PCTcollaborative of NHS Hampshire, NHSPortsmouth, NHS Southampton andNHS Isle of Wight.

IssuesMapping of the rehabilitation servicesacross Hampshire revealed widevariation in the models of care, oftenwith poor co-ordination and a historyof under-funding. The establishmentof community stroke services nearby,via the Community StrokeRehabilitation Team in Portsmouth,demonstrated the positive outcomesthat might be achieved by changingthe way in which these services arecommissioned.

ActionsThe team obtained views of strokesurvivors and carers from surveysconducted by The Stroke Associationand Hampshire County Council, tosupport design of the pathway. Theteam then tried to collect andinterpret data, discovering that incommunity settings it was notpossible to isolate stroke fromgeneral rehabilitation data.

Subsequently, they designed anapproach to pathway developmentthat accelerated servicetransformation. Regularcommunication with all key partieswas achieved through a projectwebsite, which was a repository of allinformation relating to the project.

OutcomesThe specification was completed totime and within six months oflaunching the project. It is currentlybeing taken to each of theorganisations for a decision oncommissioning plans.

Good communication was the key tosteering the project through a varietyof stages, and across manyorganisations. The team felt thatcoordination of engagement in theproject resulted in the developmentof positive relationships with the localauthorities and commitment to worktogether in future to addresspathway issues as a whole system.Cross-functional relationships withinthe team have developed since thestart of the project, particularly withteams such as contracting andfinance, which are so critical to thesuccess of the project.

Early stroke rehabilitation: developmentof commissioning specificationNHS Hampshire



Those admitted on Saturday were notalways accessible for assessment, dueto the admission and investigationprocess or they were too tired fortherapy assessment. The findings onthe rehabilitation unit were similar.From this, they concluded that six dayworking, with the sixth day being aSunday, would have greater impacton the access to assessment time andprevent the backlog of assessmentson a Monday more effectively.Saturday service only captures thosenew patients admitted on Fridayafternoon or evening. A seven daysservice would have even more effect.

Admission to assessment timereduced. On the acute unit thisreduced from 42 hours running theservice on five days, to 35 hourswhen running six days. This servicehas adopted a model of moremultidisciplinary assessment, havingphysiotherapists and occupationaltherapists assessing patients for bothservices, which has enabled this to bemeasured across one metric, and,with therapy services available for anextra day, facilitated a reduction intime to assessment.

AimsMedway Community Healthcare, theAcute Stroke Unit at MedwayMaritime Hospital and the StrokeRehabilitation Unit St Bartholomew’sHospital in Rochester aimed to worktogether to develop and agree aseven day therapy model. Theywanted to compare the impact of asix day therapy service, with thetraditional five day service, across twosites, an acute stroke unit and strokerehabilitation unit.

IssuesStroke services in Medway did notprovide a seven day service across allservices. Consultation with strokesurvivors, carers and staff had alreadytaken place to consider how thiscould be developed. Feedbackindicated that patients and carerswould value access to seven daytherapy in a hospital setting, but notonce they were home with theirfamilies.

ActionsThey piloted an additional therapyservice on Saturdays from 9am to3pm on the acute unit over nineweeks and on the rehabilitation unitover 12 weeks. This was staffed byvolunteers from the existing strokeservices.

A variety of metrics were used tocapture a range of possible effects.These included referral to treatmenttime, frequency of contact, length ofstay, number of new referrals on thefirst day of the week, goals, moodassessments and treatment plans,discharges (weekday and weekend),discharge destination and package ofcare.

There was no funding locally todeliver this, so the team set aboutrunning a pilot as preparation for abusiness case.

OutcomesNumber of new referrals on firstday of the week stayed the same.On the acute stroke unit, the numberof patients to be assessed on aMonday morning reduced by 1.1when a six day service was available.

To develop and agree a seven day therapy modelNHS Medway, Medway Community Healthcare



On the rehabilitation unit, there waslittle impact on physiotherapyassessment, but significant impact onoccupational therapy and speech andlanguage therapy during the six dayservice, as the referral to treatmenttime reduced by one day(occupational therapy), and a 35 hourreduction for speech and languagetherapy, lowering it to two days. Theimpact on physiotherapy, that wasalready meeting the RCP guidelines,was less than on OT and SLT, whoseadmission to assessment times werewell outside of the RCP guidelines.This can be improved further, iftherapy services can develop anintegrated approach to assessment,for example on the acute stroke unitin Medway Maritime Hospital,patients can access even more timely,holistic assessment.

Total therapy contacts increasedon the rehabilitation unit wherethe six day service resulted in asignificant increase in therapy timefor patients across all professions.This occurred against a backgroundof depleted staffing, so the resultscould have been even better if theteam had been fully staffed at thistime. On the acute unit it was notpossible to audit this meaningfully, asstaff felt that intensity was based onwhat the patient was able to tolerate,rather than 45 minutes of therapy,because of their medical status.Contributing factors include the‘fitness’ of patients to cope withtherapy, their availability, prioritisationof their needs, and tolerance levels.

Six day therapy service impacthad minimal impact on weekenddischarges. Possible reasons for thisinclude the absence of the othernecessary services at weekends tomake this viable, i.e. equipmentservices and the willingness ofmedical staff to support this.However, the data showed that thesix day service did bring forward thedate of discharge to an earlier pointwithin the working week. On therehabilitation unit, there was a 100%increase in the number of Fridaydischarges during the six day period.A change in culture and processeswithin the pathway may also benecessary to ensure that bothpatients and the service may benefitfrom the provision of weekendtherapy through safe discharges atweekends.

Bed occupancy in therehabilitation unit rose from68.88% to 79.44%, even with anabsence of additional discharges overweekends. It is thought thatadditional therapy staff on the wardat weekends may impact on decisionmaking by the ward staff and bedmanagers. Examples includetherapists guiding the bed managers’decisions around selection of patientsto move off of the ward when thishas become suddenly necessary,facilitating unanticipated but safeweekend discharges, preventinginappropriate transfers off of theward, or when beds have suddenlybecome available, identifying anappropriate stroke patient on anotherward for transfer across.

Length of stay reduced in the acuteunit from 8.2 to 5.1 days which, ifreplicated for all patients over ayear, would equate to a saving of£574,200. On the rehabilitation unitthe impact was significant, reducing

from 33.5 to 22.06, a reduction of11.4 days, which again if replicatedconsistently, could lead to a savingfor the trust of £746,000 per year. Sixday therapy provision therefore canhave a very positive effect on lengthof stay, in both acute andrehabilitation settings, but the greaterbenefit is evident in rehabilitation,possibly due to the more stable statusof the patients, their availability fortreatment sessions and generaltolerance levels. There are alsohidden benefits such as access tofamily and carers for informationexchange and education, and tonursing staff for mutual support andeducation, promoting more effectiveteam planning, goal setting anddischarge planning.

Six day therapy service provisiondoes not significantly affectdischarge destination in the acutephase, reflecting that this isdetermined across a range ofparameters including medical status,so that additional sessions during thecomparatively early time after strokedoes not influence this significantly.Very few patients transferred fromthe acute setting directly into carehomes during the five or six dayservice, reflecting theinappropriateness of making such adecision within the first week ofadmission before the patients havehad a reasonable opportunity forrehabilitation. Most of the patientswho returned home quickly couldaccess the existing early supporteddischarge, or had minimal package ofcare needs. Transfers out from therehabilitation unit to care homeswere also unchanged. In therehabilitation stage, availability ofgood community services, includingthose provided to care homes, mayhave more impact on dischargedestination.

A reduction in the number ofpeople requiring care packages.There is a significant difference in thenumber requiring care packages andthe number of carers required. It isnot possible to attribute this whollyto the additional therapeutic inputthese patients received during theirstay, but as this occurred on abackground of additional therapeuticinput, over 12 weeks, and a shorterlength of stay, it is likely that there issome link.

ContactFiona JenkinsStroke Services ManagerMedway Community [email protected]



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Figure 11: Impact on length of stay in NHS Medway

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AimsTo provide specialist rehabilitation forpatients following a stroke fromonset, through inpatient rehabilitionand/or stroke early supporteddischarge.

To ensure that the service is unifiedand that patients feel they aremoving along a pathway rather thanmoved between differentorganisations or services.

ActionsThe early supported discharge pilotteam went live in August 2009, aspart of the Central Norfolk StrokeServices Stroke Care pathway toprovide rehabilitation to patients intheir own home. It was also a pilotscheme to look at the demand andthe effect the team would have onboth the patient and existing strokeservices.

In January 2010, the new purposebuilt stroke rehabilitation unit wasopened on the same site as the earlysupported discharge base, severalmiles away from the acute strokeunit.

Recruitment of Band 3 rehabilitationassistants and Band 4 assistantpractitioners was initially difficult, dueto the lack of specialist skills in strokeand the need for the post holder tobe competent in skills from allprofessions. In response, the teamdeveloped their own set of corecompetencies reflecting the coreprofessions and requirements, anddevised a strategy to deliver thetraining themselves. This is nowsupported by a continuous educationprogramme and competency packs.

This occurred against a backgroundof noro-virus, staff shortages, and theinevitable challenges associated withtransforming a building site into afully operational stroke rehabilitationunit.

OutcomesOn the acute stroke unit length of stayhas been reduced by one day and inthe rehabilitation unit by eight days.

No patients have waited longer than24 hours to be admitted to the earlysupported discharge service oncethey were considered fit for transfer.This has been achieved through theteam’s proactive assessment service.

Caseload has steadily risen andstabilised to an average of 27-32patients each month. In line with this,the early supported discharge teamhas seen a rise in direct patientcontact, reflecting in part theincreasing competence of staff, theirability to work independently, andhighlighting their value to the team.



Stroke rehabilitation: a seamlessjourney from day oneNorfolk and Norwich University HospitalsNHS Foundation Trust and NHS Norfolk

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Figure 12: The impact on caseload

Review of patients’ Barthel scoresshows a statistically significantimprovement (P=<0.05) in levels ofindependence at discharge from earlysupported discharge.

The team were successful in beingable to support 90% of patients athome, 6% in nursing homes and 2%in residential homes. Two wererehabilitated in other places such associal services planning beds. Sixpatients were readmitted, four due tonon stroke causes.

There was a positive effect on theoverall demand for packages of carefor stroke patients both in numberand intensity. The project team isconsidering further work to look atthe longer term levels of packages ofcare within the early supporteddischarge service. Their throughputcosts have also reduced steadily, asthe team settles and improves itsefficiency.

A patient satisfaction survey wascarried out and 62% patients ratedtheir experience as 100%, and 92%rated it as over 80%. They havereceived encouraging feedback fromservice users such as:

‘I have no suggestions toimprove the service as I wasfully satisfied.’

Key learning was identified asfollows:• good data is important forpreparing the basis of additionalbusiness cases. Proactive in-reachand developing a good rapportwith the other parts of the strokepathway is important. In addition,building a good team from scratchtakes time, and recruitment may bea slow process, so creativity helps

ContactJohn MallettStroke Care Team Leader, CommunityRehabilitation – Inpatients, NorwichCommunity [email protected]



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In September 2009 they establishedthe Northamptonshire StrokeSteering Group to provide a forumfor the planning and development ofpost acute stroke care across healthand social care.

The team held a community strokepathway redesign workshop with theparticipation of a range of health,social care, voluntary sector andpatients to develop the outline of amodel for a community rehabilitationteam. Elements in the pathway arebeing refined to ensure a successfuldelivery model has been achieved,with quality, innovation, productivityand prevention embedded in it.

Collectively, they are involved in apiece of work using the expertise ofbusiness intelligence colleagues andthe NHS Scenario Generator tool toassist with mapping the new andexisting pathway to cost a strokepatient package of care. This willfacilitate stroke patients beingenrolled into the personal healthbudgets pilot in the county.

Outcomes

AimsThe development andimplementation of a stroke specificcommunity rehabilitation team, toprovide equitable and appropriatehigh quality patient centredrehabilitation to all stroke survivorsdischarged from hospital inNorthamptonshire.

IssuesAt the commencement of the projectthere were no community strokespecific rehabilitation services withinNorthamptonshire. Patients weredischarged from the two acutehospitals into a variety of differentsettings, with varying quality andquantity of rehabilitation provision.The service was fragmented,uncoordinated and inequitable and itwas not possible to provide anyuseful measures of patient outcome.

The north of the county had access toa number of communityrehabilitation beds but little in theway of home based therapy, whilst inthe south of the county the majorityof patients were discharged withsupport from an intermediate careteam.

One of the main problems arisingfrom this was the long length of stayin the acute hospitals, since themajority of rehabilitation had to beprovided in an inpatient setting.

ActionsAn audit of stroke discharges fromthe two acute hospitals in 2009 gavedata about outcome, and a case notereview concluded that 18 patientscould have been discharged earlier ifappropriate stroke specificrehabilitation were available in thecommunity, with a saving of 271 beddays to the acute hospital.

The team arranged meetings andpresentations to the key stakeholdersin the local health community toexplain the importance and benefitsof improving stroke services withinthe county. They used examples ofgood practice and innovationaccessed from the StrokeImprovement Programme to illustratetheir points and more recently haveused the Accelerated StrokeImprovement programme as a driverfor change.

Northamptonshire community stroke teamNorthampton General Hospital, Kettering General Hospitaland NHS Northamptonshire



The team successfully raised theprofile of stroke care andchampioned the need for strokespecific rehabilitation within the localhealth community, leading to theformation of a Stroke Steering Groupwith wide stakeholder engagement.As clinicians with a wealth ofexperience in stroke care they arenow able to positively influence thedevelopment of their local servicesand tailor them to meet the need.

ContactsJan MatthewClinical Specialist Physiotherapist,Northants Provider [email protected]

Melanie BlakeConsultant Stroke Physician,Northampton General [email protected]

‘Don’t give up, even if you have to give the same talk overand over again. Explain the need for your serviceimprovement as widely as possible. Just because you realisehow important it is, others (including those who can moveand shake) may not.’

The Northamptonshire team



AimsPortsmouth Community StrokeRehabilitation Team (CSRT) has beenworking in an interdisciplinary,patient focused way since February2005, supporting early transfer homefrom hospital for patients followingstroke. This project was set up toestablish the skills and competencelevel of all CSRT staff and then toprovide the opportunity to improveso that a high quality, skilled andcompetent service is delivered.

IssuesA survey of each individual’s skills andknowledge was completed, followedby a gap analysis. Only Band 3 andBand 4 staff had CSRT competencies,which were written several yearsbefore. Registered professionals hadnational and professional documents.No one had completed over 50% oftheir competencies.

ActionsA programme of structured educationsessions was drawn up. This wassupported by cross professionalworking with patients, plus supportgiven to ‘on the job’ training, withrobust clinical supervision. The overallaim was to ensure an ongoing cultureof learning, rather than formal, singlesessions.

The Portsmouth CSRT Core StrokeSkills Framework launched inFebruary 2009 was used as the basisof skill development.

OutcomesWhen the team repeated the staffskills survey it showed that eachmember of staff had increased theirlearning over the year; 15 out of 20staff perceived that they have madegood progress in developing theirskills and knowledge and haveconfidence in working in strokerehabilitation. All 20 have completedover 50% of their competencies.

The team wanted to see whether theimprovement in competencies wasreflected in patient outcomes andfeedback. They were already using aseries of clinical metrics successfullyincluding the Barthel index and theirown ‘CSRT Independence Score’.

They decided to pilot a PROMsmeasure alongside the other two, tosee its effect, selecting the SAQOL-39because it included an aphasiasection.

The results showed that thedifference between admission anddischarge Barthel Index and CSRTIndependence Scores present in asimilar pattern, but a very differentpicture with the PROM, suggestingthat how a patient reports theirability across a range of items poststroke does not necessarily comparewith functional outcome (see figures15, 16 and 17). Further analysisshowed the extent of the negativechanges (see figures 18 and 19).

The extent of this reduction in scores,greatest for the physical domain, mayreflect the shift in patient perceptionson return home. In hospital many

To ensure Portsmouth community strokerehabilitation team is a stroke specialist team,fit to deliver quality markers 10 and 18Portsmouth Hospitals NHS Trust

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patients believe that it will all be ‘fine’once they get home. In reality ittakes a few weeks to appreciate theextent of their impairment and howthis is impacting on their life, and theneed for time to adjust. Itdemonstrates the importance oftimely and comprehensive support atthe time of transfer home fromhospital, both for the patient andtheir family.

Portsmouth CSRT has had nocomplaints and a consistently highsatisfaction response. Whilst this isgood for staff morale, it does notassist the team with the process ofimprovement. Redesign of thequestionnaire enabled them toidentify the level of patient and carerknowledge and understanding andreflect changes made during theirtime with CSRT. The quality of theresponses in almost every singlereturned form demonstrated that thepatient and their family understandwhat they had achieved, what theyare still not able to achieve, and theirplans for the future.

ContactSarah EastonCSRT Leader, PortsmouthHospitals NHS [email protected]

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The service has been agreed andbecomes operational at thebeginning of June 2010. The metricswill reflect a range of qualitative andquantitative health and social careoutcomes via a monthly dashboard ofdata on key performance indicators,presented to an Oversight Group. It isplanned to incorporate learninggained from the evaluation into theservice specification in preparation forthe tendering process, and adoptioninto mainstream services.

Social care and personalisationperspectives are embeddedthroughout the process. The providerand social care leads have providedcontinuity and leadership in theirorganisations and driven the projectforward. There is also a strongcommitment from a wide range oftherapies and current communityservices (e.g. intermediate care) whoare integral to joint working with theteam.

There are now lay people on all localimplementation groups as well as theStroke Programme Board, and thisensures a focus on outcomes ofordinary living for people whoexperience stroke and their carers.

AimsTo develop a service specification andcommission a community strokerehabilitation team for West Sussex.The service should meet keyobjectives around patient centredcare, dignity and respect,empowerment, and fulfillingpotential.

IssuesThere was a gap in, and disparity ofaccess to, community services andrehabilitation for stroke patientsacross the county, reflecting theformer merger of five PCTs. As thefourth largest PCT in England, WestSussex has a diverse population, witha large population of older people onthe south coast and rural pockets.

ActionsInitially the team hosted a large scaleconsultation event, including a widerange of organisations from acrossthe county. Consensus was achievedabout what would be seen as an endproduct, which in turn would informthe stroke service specification andwhich outcomes were needed and todefine how the PCT would measure

them. Once the specification hadbeen developed, they ‘sense checked’again with the people who had beeninvolved with the input data.

The team appointed an experiencedlead from social care into the coreproject team, to enable social workperspectives to be embedded in thePCT stroke commissioning team, andbring a social model of disability intothe culture and planning of theservice.

The funding situation was clarified, asestimates of required budget wasagreed with by the internal protocolsand processes within the PCT. As thisproject was to be a pilot, the localNHS provider who had worked withthem in a strong and constantpartnership to determine the needfor this service was appropriate todeliver it.

The project experienced someproblems with staff recruitment, anda restructuring within the PCT. Thisdelayed the start date and the servicemodel was rewritten to be strokespecific, with a reduced budget.

Outcomes

To develop a service specification andcommission a community stroke rehabilitationteam for West SussexNHS West Sussex, West Sussex Healthand West Sussex County Council



Key learning was identified asfollows:• the continuity of key staff isessential for the sustainability ofthe project plan, along with goodcontingency planning. This willthen enable the team tosuccessfully cope with set backs, ifthese should occur

• it is important to identify a range ofstroke leaders across theorganisations and consult withthem throughout and they mayexist in unexpected places. It maybe their enthusiasm and supportthat keeps a project afloat in hardtimes

• the support and engagement ofpeople and carers who haveexperienced stroke at all design,planning, implementation andoversight group meetings enrichesthe final product significantly.

• health and social care colleaguesare already assessing and providingservices to meet the needs ofpeople whose lives are impactedupon by a stroke. It is not all newwork, but does require teams towork differently. Joint working is achallenge but the benefits areworth it

ContactJane RalphStroke ServicesDevelopment Manager,West Sussex County Counciland NHS West [email protected]



the project lead and her efforts tokeep the relevance of this work highon the IT agenda.

OutcomesComparison of baseline and pilotdata has shown the impact of aSaturday therapy service across arange of metrics, and someunanticipated benefits, and muchdata for further analysis:• referral time to treatment forphysiotherapy was improved to64% patients within 48 hours - a14% increase

• treatment frequency improvedaccess to physiotherapy from fourto five sessions per week

• treatment intensity increased by28% - 90% of appropriate patientsreceived 45 minutes or more ofoccupational therapy

• length of stay was reduced to anaverage to 21 days, a 14 dayreduction on the ward, and 26 daysoverall for stroke. If this wasreplicated over a year, it wouldequate to a saving of approximately£403,200 for the trust per year.From this it would be possible tofund a suitable additional servicefor Saturday, or a whole weekendtherapy service

AimsTo achieve a high quality inpatienttherapy service which meets therequirements of national standardsand local priorities. This includedensuring that all patients shouldreceive physiotherapy andoccupational therapy up to five daysa week, with the plan to extend to sixdays, and that relevant patientsshould receive speech and languagetherapy and dietetic input at a levelappropriate to their needs.

IssuesThe working week for therapists,Monday to Friday, was driven bystandard practice rather than patientneed or benefit. The team wanted toexamine the efficiency of this servicewithin a 24 hour hospitalenvironment and to determinewhether it met the Royal College ofPhysicians’ guidelines within thestandard therapy week.

ActionsOnce the multidisciplinary team andkey stakeholders were established,the team devised a process forkeeping everyone updated via anewsletter and networking. The teamconsulted with clinical staff and HR.

A three month pilot ran with agreedprotocols and staffing rotas. This wasprovided on a voluntary basis byexisting staff. As it occurred during atime of annual leave and highsickness levels, it appeared to drainstaff from the ward during thetraditional working week, causingsome concern for medical staff. Italso had the effect of skewing thepotential impact on some aspects ofthe additional service, around thenumber of sessions per week. As aresult, the project lead spent a lot ofunscheduled time reassuring,explaining and discussing the projectwith others to keep it on track.

The team established its datacollection process, by working with ITcolleagues on the practicalities ofestablishing a database, and withstaff to identify project metrics, datato be collected and how it could becollected. The requirements for theproject were additional to the usualdata collected by therapists, andwould be difficult to record, andevaluate and the team identified earlyon that the support from IT was aprerequisite. Access to data input andanalysis has been achieved throughthe sustained proactive approach of

Making the most of stroke rehabilitationYork Hospitals NHS Foundation Trust



Patient feedback has shown that theyenjoy coming to therapy on aSaturday, can concentrate better asthe treatment room is quieter, feelthey get more done, get morefocused attention on their currentissues and can speak about theirneeds more freely. Carers were happywith more therapy and the chance tospeak to therapists.

Staff felt that Saturday is a moreproductive day than any other duringthe week as there were nointerruptions from phones, radiologyor ward rounds. The ward staff wereappreciative of therapists beingaround.

The team identified an increase inmultidisciplinary team working thatbrought the project together, with alocal effect on ward communicationand mutual respect for eachprofession and, through this, anincreased profile for strokerehabilitation locally. They workedhard to ensure that theycommunicated throughout with allkey people, which had the addedbenefit of gaining good support frommanagers and the chief executive.

The success of the work is evidentfrom the commitment of therapystaff who volunteered for the six dayworking rota and post pilot feedbackreporting increased productivity, acalmer working environment and amore sustained rate of recovery.

Key learning was identified asfollows:• projects are more likely to succeedwith strong leadership of a corecommitted team and a dedicatedproject lead. Things always takemuch longer than you expect, so itis important to allow sufficient timefor sign up to the project, planning,informing, regular meetings,engaging and consulting onchanges and problem solving

• sort out support with datacollection and analysis early on andbuild in sufficient time for glitchesand problems to occur within thedata collection timeframe. Ensuredata collection answers thequestions you are asking and whatyou need to know, especially if youare considering using aquestionnaire

ContactIna JamesStroke Project Lead/Team LeaderStroke PhysiotherapistYork Hospitals NHS Foundation [email protected]

Stroke Improvement Programme websiteThe Stroke Improvement Programme website offersinformation and resources on improving stroke and TIAservices, including:• information on topical issues affecting stroke andTIA services

• presentations from events and meetings• examples of successful redesign and strokeimprovement in stroke and TIA services

• information on measureswww.improvement.nhs.uk/stroke

Sustainability Checklist, NHS CancerImprovement ProgrammeA checklist containing key questions to ask about yourproject or service to ensure plans are in place to sustainthe improvement.www.improvement.nhs.uk/cancer/documents/inpatients/Sustainability_Checklist.pdf

The Sustainability Toolkit, NHS HeartImprovement ProgrammeAlthough focused on improving cardiac pathways, TheSustainability Toolkit provides useful information andexamples on how to sustain improvements. It alsocontains resources on capturing data, measurementand analysis.www.improvement.nhs.uk/heart/sustainability

Trainer’s Resource Pack – An Introduction to ServiceImprovement, NHS ImprovementThe Trainer's Resource Pack - An Introduction to ServiceImprovement, is a collection of tried and tested trainingmodules for service redesign tools and techniques, andchange management skills.www.heart.nhs.uk/trainers_resource_pack.htm

Guidance on Risk Assessment and Stroke Preventionfor Atrial Fibrillation (GRASP-AF) ToolThis tool should be used as part of a systematic approachto the identification, diagnosis and optimal managementof patients with AF to reduce their risk of stroke.Developed collaboratively and piloted by the WestYorkshire Cardiovascular Network, the Leeds Arrhythmiateam and PRIMIS+, as part of the AF in primary careprojects, made available nationally through NHSImprovement.www.improvement.nhs.uk/graspaf

Stroke Improvement Programme e-bulletinContaining updates, news and information for anyoneinterested in developing stroke services, the StrokeImprovement Programme e-bulletin is essential foranyone working in stroke and TIA services.

The Stroke Improvement Programme e-bulletin ispublished every two weeks and the latest edition isavailable on the Stroke Improvement websitewww.improvement.nhs.uk/stroke. If you would like tosubscribe to the Stroke Improvement e-bulletin, pleaseemail [email protected].

Stroke Resources



NHS Improvement SystemThe NHS Improvement System is a free, comprehensiveonline resource supporting quality improvement in NHSservices, offering a range of service improvement tools,case studies and resources.

The Improvement System gives NHS staff the capability torecord, track and report on projects, share improvementstories and documents, access Statistical Process Control(SPC) software, Demand and Capacity tools and a PatientPathway Analyser, all within a secure environment.www.improvement.nhs.uk/improvementsystemEmail: [email protected]

Sustainability Model, NHS Institute of Innovationand ImprovementThe Sustainability Model is a diagnostic tool that is usedto predict the likelihood of sustainability for yourimprovement project and provides practical advice onhow you might increase the likelihood of sustainability foryour improvement initiative.www.institute.nhs.uk/sustainability_model/general/welcome_to_sustainability.html

Improvement Leaders’ Guides, NHS Institute forInnovation and ImprovementA series of service improvement guides, including a guideto sustainability and how it can be used in improvementwork. The NHS Institute for Innovation and Improvementwebsite also contains worksheets for measuringimprovement.www.institute.nhs.uk/index.php?option=com_content&task=view&id=134&Itemid=351

StrokEngine-AssessThis website provides evidence to support strokerehabilitation assessment tools.www.medicine.mcgill.ca/strokengine-assess

Spreading good practice documents andinformation, Sarah Fraser & Associates LtdSarah Fraser is an independent consultant who workswith NHS organisations on how good practice spreadsand how improvements can be made. The websitecontains a number of free resources on spreading goodpractice and improvements.www.sfassociates.biz/sitebody/MultiMedia/Documents.php





Stroke Improvement ProgrammeNational TeamNHS Improvement - StrokeImprovement Programme3rd Floor, St John's House,East Street, Leicester LE1 6NB

Tel: 0116 222 5184Fax: 0116 222 5101www.improvement.nhs.uk/strokeEmail: [email protected]

Further information

3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101


NHS Improvement

With over ten years practical service improvement experience in cancer,diagnostics and heart, NHS Improvement aims to achieve sustainableeffective pathways and systems, share improvement resources andlearning, increase impact and ensure value for money to improve theefficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England,NHS Improvement helps to transform, deliver and build sustainableimprovements across the entire pathway of care in cancer, diagnostics,heart, lung and stroke services.

Delivering tomorrow’simprovement agendafor the NHS

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Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects