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


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

(Published April 2010 )

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  • 1. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKEStroke Improvement ProgrammeImproving post hospital and long term care:case studies from the Stroke ImprovementProgramme projects
  • 2. ContentsIntroduction 3 Rehabilitation 23Transfer of care 4 Aintree University Hospitals 24 NHS Foundation TrustDudley PCT 5 NHS Hampshire 26NHS Lewisham and South East 7London Cardiac and Stroke Network NHS Medway 27Lincolnshire Community Health 9 Norfolk and Norwich University 30Services Hospitals NHS Foundation Trust and NHS NorfolkNHS Milton Keynes and Milton 11Keynes Council Northampton General Hospital, 32 Kettering General Hospital and NHSNottinghamshire County Council and 13 NorthamptonshireNottinghamshire Community Health Portsmouth Hospitals NHS Trust 34Poole Hospital NHS Foundation Trust 15and Bournemouth and Poole NHS West Sussex, West Sussex Health 36Community Health Services and West Sussex County CouncilRoyal Bournemouth and Christchurch 17 York Hospitals NHS Foundation Trust 38Hospitals NHS Foundation Trust Stroke resources 40South West London Cardiac 18and Stroke Network Further information 42Stoke on Trent City Council 20Key learning from the transfer 22of care national projects
  • 3. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 3IntroductionSince 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 for each of the projects areincluded at the end of thepublication. Full case studies of theservice improvements can be foundat
  • 4. 4 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Transfer of care Quality marker 12 of the National TOP TIPS Stroke Strategy set a standard that individuals should have a clear • Manage the health and social discharge plan, covering all their care interface needs, across both health and social • Involve patients in improving care. Nine sites across England transfer of care analysed their systems for transfer of • Provide emotional support for stroke survivors and carers care for people with stroke and • Ensure access to appropriate focused their improvements on services, including rehabilitation, processes influencing this stage of social care and community the stroke pathway and impacting on opportunities several of the National Stroke Strategy quality markers, notably quality marker 12 (transfer of care), 10 (rehabilitation), 3 (information advice and support) and 13 (long term care and support). This section contains information about the improvements made to transfer of care by the nine project teams across England. The case studies provided here are a summary of the improvements and how they were achieved. National Stroke Strategy, Department of Health, 2007. 1
  • 5. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 5Seamless careDudley PCT, Dudley Social Services, Dudley Groupof Hospitals and Dudley Stroke AssociationAims discharge but few referrals included a These have impacted positively onThis joint team established that their comprehensive patient centred workload and consequently improvedkey aims were to: programme with individualised waiting times.• improve communication between patient goals. There was no primary and secondary care dedicated social worker for stroke. All A social worker dedicated to stroke rehabilitation teams of these factors contributed to delays now works full-time in the Dudley• improve staffing levels within the in discharge, with an average length hospitals and a family and carer community rehabilitation team, of stay of 18 days. support worker, employed by Dudley provide more intensive Stroke Association, now goes into the rehabilitation and set up an early Actions hospital three days a week to provide supported discharge service A system of short monthly meetings support as needed.• enable earlier discharges and was established between key staff reduce delayed discharges from Dudley Social Services, Dudley A community stroke coordinator was• increase the involvement of social Group of Hospitals, the Stroke employed. As well as leading the services Association and the PCT to improve Community Support Rehabilitation• improve social and emotional and optimise communication, and Team, she visits the hospital once a support for patients, their families identify and work through the week and works with the hospital and carers improvements needed. Smaller task stroke coordinator to improve groups met separately to tackle communication between the teamsIssues specific problems quickly, as and and identify patients suitable for earlyThe service was very fragmented. when needed. A joint investigation supported discharge.Patients would be brought to A&E, committee was formed to improveseen and assessed when their turn communication and target Outcomescame, admitted to the emergency achievements. A comprehensive stroke serviceadmissions unit, and transferred to specification is in place, with athe stroke ward if there was a bed. Stroke and TIA pathways for primary complete stroke service pathwayStroke beds were regularly used by and secondary care were developed across acute and community services.medical outliers. CT scans were not and agreed. As well as the improvements maderoutinely performed within 24 hours for the project, changes were madeof presentation, with a wait of A comprehensive community service in acute care including the alerting ofsometimes up to three days. The specification that engaged the Dudley hospitals by the ambulanceCommunity Support Rehabilitation existing community team was crew for imminent stroke admissionsTeam waiting times could be up to six developed, resulting in clear and immediate assessment on arrivalweeks post-discharge. Patients were entrance, exit and exclusion criteria. by the stroke team.referred to the community team on
  • 6. 6 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects TOP TIPS ‘Communication, communication, communication.’ The Dudley Team This has positively impacted on A psychologist is now available and Contacts meeting acute stroke clinical assesses patients referred by the Dr Liz Pope guidelines and admission to the medical team. All patients receive GP, Dudley PCT stroke ward. patient centred, individualised care plans and goals on discharge. The PCT invested £75,000 to support Derek Hunter early supported discharge to appoint These improvements have made an Commissioning Lead - health care assistants, releasing impact on delayed discharges, Urgent Care therapists and other clinicians to reducing average length of stay from Dudley PCT focus on appropriate specialist 18 to 15 days, saving £750 per activities. The Community Support patient. Rehabilitation Team contact the patient soon after admission to assess Patients are satisfied with the service for early supported discharge and they receive from the stroke team: now utilise entry and exit criteria and plan patient contact according to “I cannot speak too highly of geography and job roles within the the services I have received … team, to improve productivity and efficiency. Waiting times have Each and everyone involved reduced to an average of 3.4 days for have given a high standard of the first contact with the team. treatment and care, for this I am deeply grateful. It has The family and carer support worker boosted my self-esteem and and social worker are now involved soon after admission to provide made me feel that life is worth support and plan care on discharge. living. I cannot see any area The team demonstrated the post where things could be saved the trust around £94,500 in its improved” first year on crisis admissions and emergency room visits by patients recently discharged from hospital, providing patients and families with a point of contact for any worries and concerns.1 This has avoided patients unnecessarily going to A&E or calling an ambulance or their GP for straightforward issues or concerns. The business case for the Dudley Family and Carers Stroke Support 1 Worker can be found on the Stroke Improvement website:
  • 7. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 7Lewisham integrated stroke projectNHS Lewisham and the South East LondonCardiac and Stroke NetworkAims Only 23% of patients went onto have A pilot neuro-rehabilitation team wasThe project team from NHS Lewisham rehabilitation from either Lewisham formed as part of the integrated carewas jointly led by the PCT and the Intermediate Care team (LINC) or the team to address the lack of strokeSouth East London Cardiac and Lewisham Adult Therapies Team specific community rehabilitation.Stroke Network, and had close links (LATT). Neither team was strokewith social care through joint specific and had long waits, in some At ward level a number of keycommissioning. It aimed to redesign cases up to 12 weeks. improvements were made:the post acute phase to create an • reconfiguration and simplificationintegrated pathway between acute Delays also occurred in securing of the discharge processand community stroke services, placements for specialist neurological • systems for coding patients werethrough both stroke service teams. It rehabilitation for younger people and reviewed and improved after a casealso aimed to improve discharge for complex care packages. There notes review found that 17% ofplanning and communication across was an average length of stay of 40 patients were erroneously codedthe pathway, facilitate earlier transfer days for these patients, and the • implementation of a key workerof care and ensure high quality longest wait was 188 days. systemrehabilitation and enablement. • a single point of referral to social Actions care in hospital, ward based socialIssues The team gained wide stakeholder care workers, location of the socialA typical Lewisham stroke patient engagement and board level support care office close to the stroke wardpassed through five to seven different for the project. Staff, patients and and location of social careteams, leading to a number of quality carers were involved in a process computers in the same room as theproblems relating to patient mapping event to identify bottlenecks multidisciplinary team meetings forexperience. The systems and as well as existing good practice to ease of access to recordsprocesses in place were complex. adopt more widely. • a discharge planning group wasNot all patients were cared for on a established to improve patientdedicated stroke ward and the A project initiation document, project information and wardaverage length of stay for all patients plan, communication plan and risk documentationin 2007/8 was 22.5 days. log were written and a baseline of existing services was established. Current cost and demand analysis was carried out and agreement on measures was gained.
  • 8. 8 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Table 1: Key outcomes in Lewisham Jan 2009 Apr-Jun 2009 Oct 2009 - Mar 2010 Stroke vital sign <40% >80% >80% Proportion of patients spending 90% of time on a stroke unit Average length of stay (days) 22.5 18 19 (Oct-Dec swine flu and norovirus) Waiting time for community Intermediate care SALT - 48 days SALT - 38 days therapy team 4-6 weeks Adult therapies OT - 65 days OT - 44 days team 12 weeks Physio - 96 days Physio - 74 days Number of new patients per month LINC 1-2 - New pilot LINC team 5-6 days Duration of therapy LINC 35 days - New pilot LINC team 28 days The workforce was reconfigured to Co-ordination of care is improved and Contact include some new posts and new a more personalised holistic service Sara Nelson ways of working: with community enablement offers Associate Director and Interim Project • Stroke Association family more personalised care planning and Lead, South East London Cardiac and support worker and communication goal setting. This will be assisted by Stroke Network and NHS Lewisham support worker posts were performing joint single assessments, re-specified and agreed sharing information and joint • the social care grant used for a new documentation, as well as effective ‘back to life’ senior social care post communication. • community health and social care staff attended hospital The length of stay has decreased multidisciplinary team meetings from 22.5 days in 2007/08 to 19 days • rotation of therapy posts between in March 2010. the acute hospital and community teams The improvements made a significant • appointment of a senior therapist impact on access to community to lead the new community neuro waiting times for therapy even before team the planned early supported • Connect and the Stroke Association discharge team was in place. training for care home and social care staff Better patient outcomes and value for money will be realised in the Outcomes integrated team through shared There is now a reconfigured, more resources such as administration, efficient, simplified stroke pathway in shared assessments and reduction in place and enhanced joint working handoffs and duplication. with social care.
  • 9. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 9Assisted discharge service for strokeLincolnshire Community Health ServicesAims The extended length of stay was • timely assessment as soon as aThe team set out to establish identified as a factor that limited patient is identified by the ward asaffordable, value for money care and availability of beds on the stroke suitablerehabilitation for stroke patients units, leading to an above average • attendance by the assistedacross the pathway, in collaboration number of patients who were not discharge team at ward teamwith service providers in secondary accessing stroke units in the three meetings, at referring stroke unitscare, social services and the third main sites in the county. and, in some areas in order tosector. improve rapport and referral Actions numbers, attendance at dailyObjectives to be achieved to meet The service was designed as part of handover sessions with stroke unitthis aim were: a tendering process, including an staff• to develop quality information for in depth and fully costed • setting up systems to ensure the patients and carers to support implementation plan. An team met the performance informed choices and self implementation lead was identified indicators management to drive the project. A core team was• to increase active participation of recruited and a lead for the service Outcomes patient and carers in the planning, identified at an early stage. A patient Average length of stay reduced from development, delivery and and public involvement lead was 29 days to 20 days (see figure 1), and monitoring of the service identified to capture patient waiting times for community therapy• to provide a highly skilled experience from an early stage. reduced from three weeks to around workforce, across the two days (see figure 2). Patient organisational boundaries The new team were clear from the satisfaction with the new service is outset that the service would be high (see figures 3 and 4). PatientIssues performance monitored and outcomes have improved, asAt the start of the project there was managed. Data collection was measured by Barthel scoring from anno community stroke rehabilitation embedded within clinical activity and average of 15 on discharge fromavailable in the county and limited regular meetings with commissioners hospital to 17.5 on discharge fromgeneric community rehabilitation. kept the team focused on outcomes. the assisted discharge service,This was identified as a major reason demonstrating that the team arewhy length of stay in the acute stroke The new assisted discharge service impacting on functionalunits or secondary care was above team was established, informed by improvements.average. patient and carer views, to provide access to a seven day community service across the county, including:
  • 10. 10 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Contact Figure 1: Average number of days from stroke to hospital discharge Joan Lawton Clinical Team Lead 40 AHP/Implementation lead ADSS Average number of days Lincolnshire Community from stroke to home 30 Health Service Days 20 20 0 December January February March April May Months Figure 2: Average number of days from hospital discharge to first face to face contact with the Assisted Discharge Service 8 Average number of days 6 Days 4 2 0 December January February March April May Months Figure 3: The handover of my care from Figure 4: My carer was involved in agreeing the care hospital to home went smoothly plan and their needs were taken into consideration 25 25 20 20 Number of Patients Number of Patients 15 15 10 10 5 5 0 0 Strongly Agree Neither Disagree Strongly Not No Strongly Agree Neither Disagree Strongly Not No Agree agree or disagree applicable comment Agree agree or disagree applicable comment disagree disagree Choice Answers Choice Answers
  • 11. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 11Stroke transfer of care and supportedrehabilitation in the community projectNHS Milton Keynes and Milton Keynes CouncilAims Issues Patients reported a lack ofThe joint commissioner and provider The baseline position for transfer of information and confusion aboutled team from Milton Keynes planned care did not meet National Stroke what services they could access, buta service redesign in anticipation of Strategy standards, with no stroke when they were referred to thefunding for a new early supported specialist rehabilitation staff in the community stroke team this wasdischarge service, due to start in community at the point of discharge highly praised.January 2010. Preparatory work and only a third of patients known toaimed to improve person centred care follow-up services. There was no Actionsplanning, involve the person and their stroke pathway and patient A Local Implementation Team metcarers in decisions and goal setting. It information was poor. every other month and set up a smallwas also intended to improve project group, including usercollaboration between the hospital Length of hospital stay was around representatives, to develop theand community staff, information 25 days and prolonged past the point patient information portfolio. Aduring hospital stay and on where patients were medically fit for project manager in commissioningdischarge, access to professionals discharge due to a lack of confidence was assigned to work closely with thespecialised in stroke care and in community support. An average of hospital project team to ensure thatoutcomes for patients. 45% of patients were never admitted the stroke pathway became as to the stroke unit with most not seamless as possible.Milton Keynes Hospital NHS known to the stroke team. The strokeFoundation Trust was also vital sign was estimated and based on The team developed a vision for theparticipating in the Stroke trajectory, not actual figures. service and a service specification forImprovement Programme acute an early supported discharge service,stroke project, so the teams aligned The hospital multidisciplinary team with widespread user andtheir aims for reduced length of stay, had regular staff changes and lacked stakeholder involvement.increased occupancy rates and direct consistent links with the communityaccess to the acute stroke unit. stroke specialist, so the rehabilitation team missed many patients. Decisions were made by hospital staff about best options for continuing rehabilitation in the community but with little knowledge of the options.
  • 12. 12 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects In preparation for the new service, Despite not being fully established, some improvements were made to the early supported discharge team the process of transfer of care: saw eight patients in the first month, • a new patient pathway reducing the length of stay • a new patient information pack dramatically to below 10 days. The • a new record of patient care, which stroke vital sign improved to 70% of ensured patients’ aspirations were patients spending 90% of their time central to their care and discharge on a stroke unit. planning • a staff competency audit, and A recent change in staffing on the subsequent training programme ward has led to significant • plans for collation of key hospital improvements in the notification of and community data, analysed in a patients to the community stroke robust way to determine the specialist. baseline and points for improvement Contact • development of the role of the Dr Marianne Vinson community stroke specialist, Consultant in Public Health including the interface with the NHS Milton Keynes stroke ward multidisciplinary team Outcomes The team experienced a significant delay in funding of the early supported discharge team, which has delayed the benefits of the work done so far, but due to the team’s persistence the service began at the beginning of April 2010.
  • 13. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 13Access to emotional support forcarers of stroke survivorsNottinghamshire County Council Adult Social Care, NottinghamshireCommunity Health and The Stroke AssociationAims “Joint working between the three agencies has enabled aThe project team fromNottinghamshire focused their shared language and understanding to be developed.improvement on access to emotional Barriers have been discussed and overcome betweensupport for carers of stroke survivors, organisations and a much improved understanding of theby funding and defining a specificrole for a family and carer support world faced by a stroke survivor and their carer isworker on the acute stroke ward to understood by all”provide support to carers into thesouth of the county. The Nottinghamshire project teamIssuesAt the start of the project there was Actions Outcomesan inequitable service for stroke There was integral involvement from The service was evaluated bysurvivors and families to access a stroke survivor and carer on the comparing results for carer strainemotional support. 88% of patients steering group. This led to support index and general healthwere not referred for further being offered to carers once the questionnaire with those of a studyrehabilitation, and received no follow stroke survivor was out of the acute of the community stroke team carriedup, advice or information (data phase, as carers themselves appeared out in 2002.2 The evaluation showedcollected January to June 2009). to be in crisis until this point. Support that carers experience higher levels ofPatients who went on for further by carers was sought after usual stress now than in 2002, but alsorehabilitation were signposted to office hours when they felt they had that the family and carer supportadditional support from social care more time to talk. worker appears to have a positiveand voluntary agencies using a impact on perceived carer health andsignificant amount of clinical time In addition, the new service was wellbeing.and detracting from time available for promoted to the stroke wards toother rehabilitation. increase referrals to the family and There was no difference between the carer support worker. family support worker and the community stroke team for all measures, showing benefits were consistent 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).
  • 14. 14 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects The process of meeting regularly to develop the service and establishing joint objectives improved working relations between the organisations and the success of the support worker role led to commissioning of two further family and carer support services in the county. Contact Christopher Greensmith Team Leader – Community Stroke Team Nottinghamshire Community Health christopher.greensmith@nottscommu Mandy Shiel Interagency Planning and Commissioning Adult Social Care and Health Department, Nottinghamshire County Council
  • 15. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 15Poole together for strokePoole Hospital NHS Foundation Trust, Bournemouth and PooleCommunity Health Services and Dorset Cardiac and Stroke NetworkAims Actions Minimum standards for the quality ofThe team aimed to develop and A patient and carer feedback forum handover of information to thedeliver an aspirational pathway for established the shortfalls in the community team were made and thestroke, provide equity of access to transfer of care pathway and team committed to see patientscare in the community and, working described their aspirations for the within a week of hospital discharge.with Borough of Poole social services, ideal stroke service. The conclusionsto define and integrate the role of were presented to staff from social Social care stroke co-coordinatorthe social care stroke co-ordination care, health and the voluntary sector posts funded by the social care grantteam. who developed a pathway for the were appointed to support stroke service based directly on those survivors in hospital and afterwards.Issues to resolve visions. This pathway formed theFour main problems were identified basis of the team’s action plan for Outcomesat the start of the project: improvements. Measurable improvements include• problems with the discharge improved patient satisfaction scores process meant the hospital length A ‘meet the team’ meeting was for involvement in the transfer of care of stay on the acute ward was established early in the first week of process, reduced waiting times for higher than the national average at the hospital stay, to discuss prognosis community therapy and improved 21 days and plans for rehabilitation and quality of handover information• a patient survey showed that only discharge with the patient and family. between hospital and community 18% of patients felt fully involved teams (see figures 5 and 6). in the discharge process A key worker system was• there was an average wait of 11 implemented on the acute stroke All of the changes made to the days for the generic community ward. service were within existing resources rehabilitation team and largely involved improvements to• significant shortfalls were The content of patient information processes at ward level. The most demonstrated in the quality of and the process for giving significant impact is the radical and information shared between the information to patients and families demonstrable improvement in patient acute trust and the community was reviewed and improved. experience. rehabilitation team
  • 16. 16 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects This project benefited from the Figure 5: Poole Hospital - How involved did you strong leadership of the consultant feel in plans for leaving hospital? physicians who took a hands on approach to both driving and 70 implementing the changes. The 60 cohesive multidisciplinary team 50 embraced and led further change to % of Responses influence all aspects of the transfer of 40 care process. The Dorset Cardiac and 30 Stroke Network were integral in implementing the improvements. 20 Involvement in the Stroke 10 Improvement Programme project 0 improved joint working between the May-Jul Aug-Sep Oct Nov Dec Jan acute trust and community stroke Months teams with the resultant benefits to Not at all Not involved Involved Very Involved patients. Contacts Dr Tracey Villar Stroke Consultant, Poole Hospital Figure 6: Poole Hospital and Woodland Community Rehabilitation Team: NHS Foundation Trust Waiting times for community rehabilitation reduced from 10.7 to 6.8 days 12 Naomi Gibson Senior Physiotherapist, NHS Delay to first appointment 10 10.7 Bournemouth and Poole 8 6 6.8 4 2 0 January 2009 September 2009
  • 17. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 17Making sense of the muddleRoyal Bournemouth and Christchurch Hospitals NHS FoundationTrust and Dorset Cardiac and Stroke NetworkAims satisfaction. Care review OutcomesThis team aimed to clarify the transfer documentation is given to the patient These improvements necessitated aof care pathway from hospital to and carer to reinforce information change in culture by the acute andhome. given during the meeting. rehabilitation ward teams and have taken time to embed. The work doneIssues Training for all registered health in the project between health andThe system for transfer of care was professionals on the new discharge social care teams supports the workmuddled and confused with no clear processes motivated staff and broke identified in Accelerating Strokepathway. Patients had differing down resistance to the new ways of Improvement to improve joint careexperiences of discharge planning working. All staff are now engaged planning. The project took time toand transfer of care, depending on with discharge planning. get started, delayed by waiting forwhich health and social care the funding of a communityprofessional was involved in the Development of written information rehabilitation team, but measurabledischarge process. The bid for a resources has supported verbal improvements to the process of carestroke community rehabilitation team messages for patients and carers. and patient and carer experience arewas unsuccessful and waiting for a Patients are also informed of their anticipated after the lifetime of thisdefinitive answer from the PCT on first appointment with the national project.funding took time. The team then community rehabilitation team priorfocused on making improvements to to discharge. Standardisation of Contactthe current system whilst waiting for paperwork between the acute and Clare Gordonnews of possible future funding for a rehabilitation units now includes a Consultant Stroke Nurse, The Royalcommunity stroke team. discharge checklist and Bournemouth and Christchurch multidisciplinary handover Hospitals NHS Foundation TrustActions information for primary care. clare.gordon@rbch.nhs.ukPatient and carer feedback has beenintegral to this project, and has Closer working of health and socialinformed the team at many levels as care teams is supported by theto the effectiveness of their location of the social workers, animprovements. information support officer and the Stroke Association support staff inFormalised care review meetings with the hospital near to the stroke ward,patients and carers for enhanced rather than at the local authority.communication and discharge A more consistent prediction ofplanning have improved patient estimated discharge date helps this.
  • 18. 18 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Stepping out South West London Cardiac and Stroke Network Aims The project aimed to test the Figure 7: Patient self efficacy scores applicability of a self management programme in Croydon. 130 Pre Post 120 Issues 110 There was a lack of continuity in the 100 development and resolution of 90 treatment plans which were not 80 70 Score incorporated into the whole care of patients or transfer of overall plans. 60 Not all treatment plans were agreed 50 with patients and their carers. Staff 40 were not consistently working 30 towards patient centred goals and 20 outcomes to ensure that treatment 10 was patient led and individualised. 0 1 2 3 4 5 6 7 8 9 10 11 12 Patient Actions A self management approach called the ‘Stepping Out Programme’ (now known as ‘Bridges’) was piloted with which remained high throughout (see 24 staff across the stroke pathway in Outcomes figure 7). Improvements were also Croydon. This approach focuses on 72% of staff participants changed made in patients’ perceptions of the successes, decreases dependence their practice by the end of the impact of the stroke measured using on therapists and facilitates programme towards a more patient the Stroke Impact Scale. No change empowerment of stroke survivors centred, goal orientated approach was shown in hospital anxiety and and carers to set, record and which promoted patients’ self depression scores, although none of evaluate their own goals. efficacy. the participants had scores which indicated the need for intervention Improvements in self efficacy scores (see figure 8). were shown in eight of the 12 patients and two others had scores
  • 19. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 19 Figure 8: Patients perceptions of the impact of the stroke measured using the Stroke Impact Scale 120 Before programme After programme 100 80 60 40 20 0 SIS SIS SIS SIS HAD HAD Self (physical) (recovery) (participation) (emotion) (d) (a) efficacyStaff feedback indicated that theynow use goals that are important topatients and families and facilitatediscussions around living with strokefor both the individual and the familyThis 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
  • 20. 20 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Redesign of stroke care pathway from rehabilitation into the community Stoke on Trent City Council Aims Policies for discharge and for rapid The team aimed to develop a person assessment by the community stroke centred, integrated health and social discharge team were implemented. care service for stroke and use a truly joined up approach. An information database of community services was established Issues as a staff resource for signposting Existing systems inhibited patients to further support after communication between health and discharge. social care, and excluded referral of a range of individuals to social care All staff were encouraged to access who would benefit from long term stroke specific accredited training support. Social care referrals were programmes, facilitating the limited and delayed. development of common skills and knowledge. Actions Both the social care and early Outcomes supported discharge teams adopted These were: the same name, Community Stroke • improved partnership working Discharge Team, to give a strong across health and social care with message about joint working and a resulting development of shared seamless service. A single point of objectives and goals contact on one business card was • establishment of a dedicated social used for patients and carers on care team for stroke discharge. • a steady increase in Barthel index scores demonstrating improved The social care grant for stroke was levels of patient independence (see used to increase social care time, figure 9) enabling a daily visit to the • increased number of social care rehabilitation ward and earlier referrals (see figure 10) referral of patients.
  • 21. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 21 Figure 9: Stroke rehabilitation unit average discharge Bartel score 16 12 Barthel Score 8 4 0 Nov 2009 Dec 2009 Jan 2010 Feb 2010 Mar 2010 Month Average Barthel Score 2006/07 Average 2007/08 Average 2008/09 Average Figure 10: Social care activity since all stroke wards have attached workers 350 300 Number of contacts/visits 250 200 150 100 50 0 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Apr 10 May 10 MonthThe success of the Stoke on Trent Contactteam’s improvements can be Lorraine Cobbattributed to focused leadership by Social Care Team Manager andthe project lead in social care, Project Leadgenuine cross organisational working Stoke on Trent Social Servicesthrough joint health and social care, 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.
  • 22. 22 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Key learning from the transfer of care national projects Understanding the real state of the of stay and access to community and Key principles to accelerate service is essential before long term support. Leaving hospital improvement in the transfer of care improvements can be made. with a clear point of contact for help, can be summarised as follows: Primarily this needs to be from the should it be required, was another • nominate a champion to drive perspective of the stroke survivor and significant feature. improvement in each organisation family, but also from the staff who • co-locate the stroke health and work in the service and from the Strong leadership was another quality social care teams in the same evidence seen from measuring the seen in these national projects. building, preferably in the same service objectively. Measuring where Leaders emerged and developed from room the service is at the start and regularly different members of the project • use a variety of tools to involve reviewing progress towards objectives teams; from clinical staff, some with patients and carers to see where is an essential component of protected time but several with none, the service is and what needs to successful service improvement. and all with a clinical commitment, change from commissioners of services, • actively include the patient and The case studies described here all managers and network staff. With a family in decisions about leaving accurately identified the shortfalls in leader to champion and drive the hospital at the earliest appropriate the service, targeted improvements at project, the likelihood of successful opportunity the points in the service where they outcomes is increased. • nominate a single point of contact were needed, then monitored the as a resource for stroke survivors improvement to ensure it was A consistent theme of the projects is after hospital discharge effective and achieving the that effective communication and intended outcome. genuine joined up working across organisations supports rapid Stroke survivors and their families improvement in transfer of care, need to be central to the process of especially where this includes good improving stroke services as well as working links between health trusts, their early and active involvement in social care and voluntary agencies. their own care and plans for leaving hospital. Several of the projects demonstrated that discussions about transfer of care and early planning was appreciated by patients and families and impacted positively on the measurable outcomes of length
  • 23. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 23RehabilitationQuality marker 10 of the National TOP TIPSStroke Strategy requires services toensure that people who have had • Proactively recruit patients to thestrokes have access to high-quality community servicerehabilitation and, with their carer, • Develop a flexible, stroke skilledreceive support from stroke-skilled workforceservices as soon as possible after they • Develop a team commitment to measuring progresshave a stroke, available in hospital, • Identify and use all services andimmediately after transfer from delivery partnershospital and for as long as they need • Support effective leadershipit. 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.
  • 24. 24 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects To improve the quality and quantity of rehabilitation services for stroke survivors on a combined unit, based on local and national guidelines around quality marker 10 Aintree University Hospitals NHS Foundation Trust Aims Actions Work has been undertaken to To improve the quality and quantity The team undertook an observation improve the aesthetics of the day of rehabilitation services for stroke study of a patient’s day across five room, and it is on the ward induction survivors on a combined unit based domains – nursing, physiotherapy, check list for new patients. on local and national guidelines occupational therapy, medical and around quality marker 10. social. Time was divided into 15 More work is planned around skill minute slots from 7am until 9pm, mix, additional staff, competencies, Issues with observations taking place in the and further data collection, using the Aintree Stroke Centre is a combined female rehabilitation bay. newly established rehabilitation in-patient stroke unit. The hyper metrics as a basis. acute and acute needs of the patients They also undertook feedback have historically been the main focus questionnaires for patients and staff. Outcomes for the multidisciplinary team, The staff questionnaires showed Relationships between the resulting in significant changes in variability in confidence and multidisciplinary team have improved; practice over many years. As a knowledge of handling and nutrition, therapy staff attend the daily nursing consequence, staff identified the amongst all grades and professions. handover, use and update the need to re-focus on the rehabilitation The patients indicated considerable nursing electronic handover and the needs of stroke survivors. periods of boredom, especially in the discharge planning process is afternoons, and lack of awareness of becoming more cohesive. The team is Prior to the project the service had the existence of a day room. considering the re-introduction of already identified several key factors communal eating on the ward, and for further consideration, including a A successful bid for additional implementing a focus group looking lack of true cohesive multidisciplinary handling equipment, with further at patient and carer information. team working and absence of bids for more feeding aids/manual relevant metrics. There were no handling equipment. They have shown that a 24 hour mechanisms in place to collect approach and shared ownership of patient and carer views, and a real A programme of joint training rehabilitation in partnership with the lack of rehabilitation equipment on sessions between therapists and patients can support improvements in the ward. nurses around handling and nutrition care, and enhance multidisciplinary management has been implemented, team effectiveness and cohesion including a process for evaluation. without huge investments of money.
  • 25. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 25Key learning was identified asfollows:• undertaking a national project always requires more time than is anticipated. It is essential to gain support within the organisation for protected time to achieve this• liaison with key stakeholders as early on as possible makes a big difference• specific time bound objectives with well-defined baseline metrics are fundamental for project success. Metrics for quality can be more difficult to develop• sort out a plan for data as soon as possible, including how to collect, store and analyse it, and ensure the resources are there to support this• tap into local resources (the stroke research team, The Stroke Association, the volunteers department, the cardiac and stroke network) to prevent duplication and gain additional support• small, bite sized improvements are deliverable and lead to significant changes over time• ensure you have named individuals at the correct grade who can take responsibility for taking specific issues forward (problems with rotational staff, ownership and commitment)ContactHelen EvansPhysiotherapy ManagerAintree University Hospitals NHSFoundation
  • 26. 26 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Early stroke rehabilitation: development of commissioning specification NHS Hampshire Aims Subsequently, they designed an Key learning was identified as To develop a commissioning approach to pathway development follows: specification for early stroke that accelerated service • establish a core project team and rehabilitation (up to three months transformation. Regular develop them, e.g. through specific post stroke) on behalf of a PCT communication with all key parties team building activities collaborative of NHS Hampshire, NHS was achieved through a project • ensure that all key people are Portsmouth, NHS Southampton and website, which was a repository of all involved at the very beginning so NHS Isle of Wight. information relating to the project. that the project requirements are fully scoped, e.g. it was useful to Issues Outcomes have the contracting template for Mapping of the rehabilitation services The specification was completed to the specification at the beginning across Hampshire revealed wide time and within six months of • develop robust data collection variation in the models of care, often launching the project. It is currently methodologies – establish early on with poor co-ordination and a history being taken to each of the what data is available. This may be of under-funding. The establishment organisations for a decision on particularly difficult for community of community stroke services nearby, commissioning plans. rehabilitation services via the Community Stroke Rehabilitation Team in Portsmouth, Good communication was the key to Contact demonstrated the positive outcomes steering the project through a variety Philippa Darnton that might be achieved by changing of stages, and across many Programme Manager the way in which these services are organisations. The team felt that NHS Hampshire commissioned. coordination of engagement in the project resulted in the development Actions of positive relationships with the local The team obtained views of stroke authorities and commitment to work survivors and carers from surveys together in future to address conducted by The Stroke Association pathway issues as a whole system. and Hampshire County Council, to Cross-functional relationships within support design of the pathway. The the team have developed since the team then tried to collect and start of the project, particularly with interpret data, discovering that in teams such as contracting and community settings it was not finance, which are so critical to the possible to isolate stroke from success of the project. general rehabilitation data.
  • 27. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 27To develop and agree a seven day therapy modelNHS Medway, Medway Community HealthcareAims Actions Those admitted on Saturday were notMedway Community Healthcare, the They piloted an additional therapy always accessible for assessment, dueAcute Stroke Unit at Medway service on Saturdays from 9am to to the admission and investigationMaritime Hospital and the Stroke 3pm on the acute unit over nine process or they were too tired forRehabilitation Unit St Bartholomew’s weeks and on the rehabilitation unit therapy assessment. The findings onHospital in Rochester aimed to work over 12 weeks. This was staffed by the rehabilitation unit were similar.together to develop and agree a volunteers from the existing stroke From this, they concluded that six dayseven day therapy model. They services. working, with the sixth day being awanted to compare the impact of a Sunday, would have greater impactsix day therapy service, with the A variety of metrics were used to on the access to assessment time andtraditional five day service, across two capture a range of possible effects. prevent the backlog of assessmentssites, an acute stroke unit and stroke These included referral to treatment on a Monday more effectively.rehabilitation unit. time, frequency of contact, length of Saturday service only captures those stay, number of new referrals on the new patients admitted on FridayIssues first day of the week, goals, mood afternoon or evening. A seven daysStroke services in Medway did not assessments and treatment plans, service would have even more effect.provide a seven day service across all discharges (weekday and weekend),services. Consultation with stroke discharge destination and package of Admission to assessment timesurvivors, carers and staff had already care. reduced. On the acute unit thistaken place to consider how this reduced from 42 hours running thecould be developed. Feedback There was no funding locally to service on five days, to 35 hoursindicated that patients and carers deliver this, so the team set about when running six days. This servicewould value access to seven day running a pilot as preparation for a has adopted a model of moretherapy in a hospital setting, but not business case. multidisciplinary assessment, havingonce they were home with their physiotherapists and occupationalfamilies. Outcomes therapists assessing patients for both Number of new referrals on first services, which has enabled this to be day of the week stayed the same. measured across one metric, and, On the acute stroke unit, the number with therapy services available for an of patients to be assessed on a extra day, facilitated a reduction in Monday morning reduced by 1.1 time to assessment. when a six day service was available.
  • 28. 28 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects On the rehabilitation unit, there was Six day therapy service impact from 33.5 to 22.06, a reduction of little impact on physiotherapy had minimal impact on weekend 11.4 days, which again if replicated assessment, but significant impact on discharges. Possible reasons for this consistently, could lead to a saving occupational therapy and speech and include the absence of the other for the trust of £746,000 per year. Six language therapy during the six day necessary services at weekends to day therapy provision therefore can service, as the referral to treatment make this viable, i.e. equipment have a very positive effect on length time reduced by one day services and the willingness of of stay, in both acute and (occupational therapy), and a 35 hour medical staff to support this. rehabilitation settings, but the greater reduction for speech and language However, the data showed that the benefit is evident in rehabilitation, therapy, lowering it to two days. The six day service did bring forward the possibly due to the more stable status impact on physiotherapy, that was date of discharge to an earlier point of the patients, their availability for already meeting the RCP guidelines, within the working week. On the treatment sessions and general was less than on OT and SLT, whose rehabilitation unit, there was a 100% tolerance levels. There are also admission to assessment times were increase in the number of Friday hidden benefits such as access to well outside of the RCP guidelines. discharges during the six day period. family and carers for information This can be improved further, if A change in culture and processes exchange and education, and to therapy services can develop an within the pathway may also be nursing staff for mutual support and integrated approach to assessment, necessary to ensure that both education, promoting more effective for example on the acute stroke unit patients and the service may benefit team planning, goal setting and in Medway Maritime Hospital, from the provision of weekend discharge planning. patients can access even more timely, therapy through safe discharges at holistic assessment. weekends. Six day therapy service provision does not significantly affect Total therapy contacts increased Bed occupancy in the discharge destination in the acute on the rehabilitation unit where rehabilitation unit rose from phase, reflecting that this is the six day service resulted in a 68.88% to 79.44%, even with an determined across a range of significant increase in therapy time absence of additional discharges over parameters including medical status, for patients across all professions. weekends. It is thought that so that additional sessions during the This occurred against a background additional therapy staff on the ward comparatively early time after stroke of depleted staffing, so the results at weekends may impact on decision does not influence this significantly. could have been even better if the making by the ward staff and bed Very few patients transferred from team had been fully staffed at this managers. Examples include the acute setting directly into care time. On the acute unit it was not therapists guiding the bed managers’ homes during the five or six day possible to audit this meaningfully, as decisions around selection of patients service, reflecting the staff felt that intensity was based on to move off of the ward when this inappropriateness of making such a what the patient was able to tolerate, has become suddenly necessary, decision within the first week of rather than 45 minutes of therapy, facilitating unanticipated but safe admission before the patients have because of their medical status. weekend discharges, preventing had a reasonable opportunity for Contributing factors include the inappropriate transfers off of the rehabilitation. Most of the patients ‘fitness’ of patients to cope with ward, or when beds have suddenly who returned home quickly could therapy, their availability, prioritisation become available, identifying an access the existing early supported of their needs, and tolerance levels. appropriate stroke patient on another discharge, or had minimal package of ward for transfer across. care needs. Transfers out from the rehabilitation unit to care homes Length of stay reduced in the acute were also unchanged. In the unit from 8.2 to 5.1 days which, if rehabilitation stage, availability of replicated for all patients over a good community services, including year, would equate to a saving of those provided to care homes, may £574,200. On the rehabilitation unit have more impact on discharge the impact was significant, reducing destination.
  • 29. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 29 Figure 11: Impact on length of stay in NHS Medway Length of Stay, SRU, 5 Day Therapy Undertaken using less than 25 points 100 92 90 80 60 Value 56 Target 56 46 47 40 Mean 33.5 31 28 20 19 15 4b 12 11 12 8 LCL 2 0 Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Interval Length of Stay, SRU, 6 Day Therapy Undertaken using less than 25 points 80 UCL 73.48 65 60 57 Target 56 Value 40 34 27 Mean 22.06 20 15 19 20 21 18 4b 15 12 10 9 3 5 LCL 0 0 Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Interval Value Mean UCL LCL TargetA reduction in the number of Contactpeople requiring care packages. Fiona JenkinsThere is a significant difference in the Stroke Services Managernumber requiring care packages and Medway Community Healthcarethe number of carers required. It is fiona.jenkins@medwaypct.nhs.uknot 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.
  • 30. 30 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Stroke rehabilitation: a seamless journey from day one Norfolk and Norwich University Hospitals NHS Foundation Trust and NHS Norfolk Aims Recruitment of Band 3 rehabilitation Outcomes To provide specialist rehabilitation for assistants and Band 4 assistant On the acute stroke unit length of stay patients following a stroke from practitioners was initially difficult, due has been reduced by one day and in onset, through inpatient rehabilition to the lack of specialist skills in stroke the rehabilitation unit by eight days. and/or stroke early supported and the need for the post holder to discharge. be competent in skills from all No patients have waited longer than professions. In response, the team 24 hours to be admitted to the early To ensure that the service is unified developed their own set of core supported discharge service once and that patients feel they are competencies reflecting the core they were considered fit for transfer. moving along a pathway rather than professions and requirements, and This has been achieved through the moved between different devised a strategy to deliver the team’s proactive assessment service. organisations or services. training themselves. This is now supported by a continuous education Caseload has steadily risen and Actions programme and competency packs. stabilised to an average of 27-32 The early supported discharge pilot patients each month. In line with this, team went live in August 2009, as This occurred against a background the early supported discharge team part of the Central Norfolk Stroke of noro-virus, staff shortages, and the has seen a rise in direct patient Services Stroke Care pathway to inevitable challenges associated with contact, reflecting in part the provide rehabilitation to patients in transforming a building site into a increasing competence of staff, their their own home. It was also a pilot fully operational stroke rehabilitation ability to work independently, and scheme to look at the demand and unit. highlighting their value to the team. the effect the team would have on both the patient and existing stroke services. Figure 12: The impact on caseload In January 2010, the new purpose 30 Actual Trajectory Target (15) built stroke rehabilitation unit was Number of admissions 25 opened on the same site as the early 20 supported discharge base, several miles away from the acute stroke 15 unit. 10 5 0 Aug09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10 Month
  • 31. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 31Review of patients’ Barthel scoresshows a statistically significant Figure 13: Patient recoveryimprovement (P=<0.05) in levels of 10independence at discharge from earlysupported discharge. 8 Number of patients 8 6 7The team were successful in beingable to support 90% of patients at 4 5 5 4 4home, 6% in nursing homes and 2% 2 3in residential homes. Two wererehabilitated in other places such as 0 0 0 0 0 0 10 20 30 40 50 60 70 80 90 100social services planning beds. Six Percentagepatients were readmitted, four due tonon stroke causes.There was a positive effect on the Figure 14: Patient experienceoverall demand for packages of carefor stroke patients both in number 25and intensity. The project team is 23 20 Number of patientsconsidering further work to look atthe longer term levels of packages of 15care within the early supporteddischarge service. Their throughput 10costs have also reduced steadily, as 5 7 2the team settles and improves its 0 0 0 0 0 1 0 4efficiency. 0 0 10 20 30 40 50 60 70 80 90 100 PercentageA patient satisfaction survey wascarried out and 62% patients ratedtheir experience as 100%, and 92%rated it as over 80%. They have Contactreceived encouraging feedback from John Mallettservice users such as: Stroke Care Team Leader, Community Rehabilitation – Inpatients, Norwich Community Hospital‘I have no suggestions to john.mallett@norfolk-pct.nhs.ukimprove the service as I wasfully satisfied.’Key learning was identified asfollows:• good data is important for preparing the basis of additional business cases. Proactive in-reach and developing a good rapport with the other parts of the stroke pathway is important. In addition, building a good team from scratch takes time, and recruitment may be a slow process, so creativity helps
  • 32. 32 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Northamptonshire community stroke team Northampton General Hospital, Kettering General Hospital and NHS Northamptonshire Aims One of the main problems arising In September 2009 they established The development and from this was the long length of stay the Northamptonshire Stroke implementation of a stroke specific in the acute hospitals, since the Steering Group to provide a forum community rehabilitation team, to majority of rehabilitation had to be for the planning and development of provide equitable and appropriate provided in an inpatient setting. post acute stroke care across health high quality patient centred and social care. rehabilitation to all stroke survivors Actions discharged from hospital in An audit of stroke discharges from The team held a community stroke Northamptonshire. the two acute hospitals in 2009 gave pathway redesign workshop with the data about outcome, and a case note participation of a range of health, Issues review concluded that 18 patients social care, voluntary sector and At the commencement of the project could have been discharged earlier if patients to develop the outline of a there were no community stroke appropriate stroke specific model for a community rehabilitation specific rehabilitation services within rehabilitation were available in the team. Elements in the pathway are Northamptonshire. Patients were community, with a saving of 271 bed being refined to ensure a successful discharged from the two acute days to the acute hospital. delivery model has been achieved, hospitals into a variety of different with quality, innovation, productivity settings, with varying quality and The team arranged meetings and and prevention embedded in it. quantity of rehabilitation provision. presentations to the key stakeholders The service was fragmented, in the local health community to Collectively, they are involved in a uncoordinated and inequitable and it explain the importance and benefits piece of work using the expertise of was not possible to provide any of improving stroke services within business intelligence colleagues and useful measures of patient outcome. the county. They used examples of the NHS Scenario Generator tool to good practice and innovation assist with mapping the new and The north of the county had access to accessed from the Stroke existing pathway to cost a stroke a number of community Improvement Programme to illustrate patient package of care. This will rehabilitation beds but little in the their points and more recently have facilitate stroke patients being way of home based therapy, whilst in used the Accelerated Stroke enrolled into the personal health the south of the county the majority Improvement programme as a driver budgets pilot in the county. of patients were discharged with for change. support from an intermediate care Outcomes team.
  • 33. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 33The team successfully raised the ‘Don’t give up, even if you have to give the same talk overprofile of stroke care andchampioned the need for stroke and over again. Explain the need for your servicespecific rehabilitation within the local improvement as widely as possible. Just because you realisehealth community, leading to the how important it is, others (including those who can moveformation of a Stroke Steering Group and shake) may not.’with wide stakeholder engagement.As clinicians with a wealth of The Northamptonshire teamexperience 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 Servicesjan.matthew@northants.nhs.ukMelanie BlakeConsultant Stroke Physician,Northampton General
  • 34. 34 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects To ensure Portsmouth community stroke rehabilitation team is a stroke specialist team, fit to deliver quality markers 10 and 18 Portsmouth Hospitals NHS Trust Aims The Portsmouth CSRT Core Stroke They decided to pilot a PROMs Portsmouth Community Stroke Skills Framework launched in measure alongside the other two, to Rehabilitation Team (CSRT) has been February 2009 was used as the basis see its effect, selecting the SAQOL-39 working in an interdisciplinary, of skill development. because it included an aphasia patient focused way since February section. 2005, supporting early transfer home Outcomes from hospital for patients following When the team repeated the staff The results showed that the stroke. This project was set up to skills survey it showed that each difference between admission and establish the skills and competence member of staff had increased their discharge Barthel Index and CSRT level of all CSRT staff and then to learning over the year; 15 out of 20 Independence Scores present in a provide the opportunity to improve staff perceived that they have made similar pattern, but a very different so that a high quality, skilled and good progress in developing their picture with the PROM, suggesting competent service is delivered. skills and knowledge and have that how a patient reports their confidence in working in stroke ability across a range of items post Issues rehabilitation. All 20 have completed stroke does not necessarily compare A survey of each individual’s skills and over 50% of their competencies. with functional outcome (see figures knowledge was completed, followed 15, 16 and 17). Further analysis by a gap analysis. Only Band 3 and The team wanted to see whether the showed the extent of the negative Band 4 staff had CSRT competencies, improvement in competencies was changes (see figures 18 and 19). which were written several years reflected in patient outcomes and before. Registered professionals had feedback. They were already using a The extent of this reduction in scores, national and professional documents. series of clinical metrics successfully greatest for the physical domain, may No one had completed over 50% of including the Barthel index and their reflect the shift in patient perceptions their competencies. own ‘CSRT Independence Score’. on return home. In hospital many Actions A programme of structured education Figure 15: Difference between Barthel index from admission to discharge sessions was drawn up. This was Difference in Barthel index 12 supported by cross professional 10 8 working with patients, plus support 6 given to ‘on the job’ training, with 4 2 robust clinical supervision. The overall 0 aim was to ensure an ongoing culture -2 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 -4 of learning, rather than formal, single -6 sessions. Patient Identifier
  • 35. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 35 patients believe that it will all be ‘fine’Figure 16: Difference between independence score once they get home. In reality itfrom admission to discharge takes a few weeks to appreciate the 50 extent of their impairment and how 40 this is impacting on their life, and the 30 need for time to adjust. It Difference in IS 20 demonstrates the importance of 10 timely and comprehensive support at 0 the time of transfer home from -10 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 hospital, both for the patient and their family. -20 Patient Identifier Portsmouth CSRT has had no complaints and a consistently high satisfaction response. Whilst this isFigure 17: Difference between SAQOL-39 from admission to discharge good for staff morale, it does not 2.5 assist the team with the process of 2.0 improvement. Redesign of the 1.5 questionnaire enabled them to 1.0 SAQOL-39 identify the level of patient and carer 0.5 0 knowledge and understanding and -0.5 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 reflect changes made during their -1.0 time with CSRT. The quality of the -1.5 responses in almost every single -2.0 returned form demonstrated that the Patient Identifier patient and their family understand what they had achieved, what they are still not able to achieve, and theirFigure 18: Number of people reporting negative outcomes by domain plans for the future. 25 Contact Sarah EastonNumber of people 20 15 CSRT Leader, Portsmouth Hospitals NHS Trust 10 5 0 PROM Physical Communication Physco/Social Energy DomainsFigure 19: Number of people reporting negative outcome domains 14 12Number of people 10 8 6 4 2 0 0 1 2 3 4 5 Number of negative domains
  • 36. 36 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects To develop a service specification and commission a community stroke rehabilitation team for West Sussex NHS West Sussex, West Sussex Health and West Sussex County Council Aims them. Once the specification had The service has been agreed and To develop a service specification and been developed, they ‘sense checked’ becomes operational at the commission a community stroke again with the people who had been beginning of June 2010. The metrics rehabilitation team for West Sussex. involved with the input data. will reflect a range of qualitative and The service should meet key quantitative health and social care objectives around patient centred The team appointed an experienced outcomes via a monthly dashboard of care, dignity and respect, lead from social care into the core data on key performance indicators, empowerment, and fulfilling project team, to enable social work presented to an Oversight Group. It is potential. perspectives to be embedded in the planned to incorporate learning PCT stroke commissioning team, and gained from the evaluation into the Issues bring a social model of disability into service specification in preparation for There was a gap in, and disparity of the culture and planning of the the tendering process, and adoption access to, community services and service. into mainstream services. rehabilitation for stroke patients across the county, reflecting the The funding situation was clarified, as Social care and personalisation former merger of five PCTs. As the estimates of required budget was perspectives are embedded fourth largest PCT in England, West agreed with by the internal protocols throughout the process. The provider Sussex has a diverse population, with and processes within the PCT. As this and social care leads have provided a large population of older people on project was to be a pilot, the local continuity and leadership in their the south coast and rural pockets. NHS provider who had worked with organisations and driven the project them in a strong and constant forward. There is also a strong Actions partnership to determine the need commitment from a wide range of Initially the team hosted a large scale for this service was appropriate to therapies and current community consultation event, including a wide deliver it. services (e.g. intermediate care) who range of organisations from across are integral to joint working with the the county. Consensus was achieved The project experienced some team. about what would be seen as an end problems with staff recruitment, and product, which in turn would inform a restructuring within the PCT. This There are now lay people on all local the stroke service specification and delayed the start date and the service implementation groups as well as the which outcomes were needed and to model was rewritten to be stroke Stroke Programme Board, and this define how the PCT would measure specific, with a reduced budget. ensures a focus on outcomes of ordinary living for people who Outcomes experience stroke and their carers.
  • 37. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 37Key learning was identified asfollows:• the continuity of key staff is essential for the sustainability of the project plan, along with good contingency planning. This will then enable the team to successfully cope with set backs, if these should occur• it is important to identify a range of stroke leaders across the organisations and consult with them throughout and they may exist in unexpected places. It may be their enthusiasm and support that keeps a project afloat in hard times• the support and engagement of people and carers who have experienced stroke at all design, planning, implementation and oversight group meetings enriches the final product significantly.• health and social care colleagues are already assessing and providing services to meet the needs of people whose lives are impacted upon by a stroke. It is not all new work, but does require teams to work differently. Joint working is a challenge but the benefits are worth itContactJane RalphStroke ServicesDevelopment Manager,West Sussex County Counciland NHS West
  • 38. 38 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Making the most of stroke rehabilitation York Hospitals NHS Foundation Trust Aims A three month pilot ran with agreed the project lead and her efforts to To achieve a high quality inpatient protocols and staffing rotas. This was keep the relevance of this work high therapy service which meets the provided on a voluntary basis by on the IT agenda. requirements of national standards existing staff. As it occurred during a and local priorities. This included time of annual leave and high Outcomes ensuring that all patients should sickness levels, it appeared to drain Comparison of baseline and pilot receive physiotherapy and staff from the ward during the data has shown the impact of a occupational therapy up to five days traditional working week, causing Saturday therapy service across a a week, with the plan to extend to six some concern for medical staff. It range of metrics, and some days, and that relevant patients also had the effect of skewing the unanticipated benefits, and much should receive speech and language potential impact on some aspects of data for further analysis: therapy and dietetic input at a level the additional service, around the • referral time to treatment for appropriate to their needs. number of sessions per week. As a physiotherapy was improved to result, the project lead spent a lot of 64% patients within 48 hours - a Issues unscheduled time reassuring, 14% increase The working week for therapists, explaining and discussing the project • treatment frequency improved Monday to Friday, was driven by with others to keep it on track. access to physiotherapy from four standard practice rather than patient to five sessions per week need or benefit. The team wanted to The team established its data • treatment intensity increased by examine the efficiency of this service collection process, by working with IT 28% - 90% of appropriate patients within a 24 hour hospital colleagues on the practicalities of received 45 minutes or more of environment and to determine establishing a database, and with occupational therapy whether it met the Royal College of staff to identify project metrics, data • length of stay was reduced to an Physicians’ guidelines within the to be collected and how it could be average to 21 days, a 14 day standard therapy week. collected. The requirements for the reduction on the ward, and 26 days project were additional to the usual overall for stroke. If this was Actions data collected by therapists, and replicated over a year, it would Once the multidisciplinary team and would be difficult to record, and equate to a saving of approximately key stakeholders were established, evaluate and the team identified early £403,200 for the trust per year. the team devised a process for on that the support from IT was a From this it would be possible to keeping everyone updated via a prerequisite. Access to data input and fund a suitable additional service newsletter and networking. The team analysis has been achieved through for Saturday, or a whole weekend consulted with clinical staff and HR. the sustained proactive approach of therapy service
  • 39. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 39Patient feedback has shown that they Key learning was identified asenjoy coming to therapy on a follows:Saturday, can concentrate better as • projects are more likely to succeedthe treatment room is quieter, feel with strong leadership of a corethey get more done, get more committed team and a dedicatedfocused attention on their current project lead. Things always takeissues and can speak about their much longer than you expect, so itneeds more freely. Carers were happy is important to allow sufficient timewith more therapy and the chance to for sign up to the project, planning,speak to therapists. informing, regular meetings, engaging and consulting onStaff felt that Saturday is a more changes and problem solvingproductive day than any other during • sort out support with datathe week as there were no collection and analysis early on andinterruptions from phones, radiology build in sufficient time for glitchesor ward rounds. The ward staff were and problems to occur within theappreciative of therapists being data collection timeframe. Ensurearound. data collection answers the questions you are asking and whatThe team identified an increase in you need to know, especially if youmultidisciplinary team working that are considering using abrought the project together, with a questionnairelocal effect on ward communicationand mutual respect for each Contactprofession and, through this, an Ina Jamesincreased profile for stroke Stroke Project Lead/Team Leaderrehabilitation locally. They worked Stroke Physiotherapisthard to ensure that they York Hospitals NHS Foundation Trustcommunicated throughout with all ina.james@york.nhs.ukkey 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.
  • 40. 40 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Stroke Resources Stroke Improvement Programme website Trainer’s Resource Pack – An Introduction to Service The Stroke Improvement Programme website offers Improvement, NHS Improvement information and resources on improving stroke and TIA The Trainers Resource Pack - An Introduction to Service services, including: Improvement, is a collection of tried and tested training • information on topical issues affecting stroke and modules for service redesign tools and techniques, and TIA services change management skills. • presentations from events and meetings • examples of successful redesign and stroke improvement in stroke and TIA services Guidance on Risk Assessment and Stroke Prevention • information on measures for Atrial Fibrillation (GRASP-AF) Tool This tool should be used as part of a systematic approach to the identification, diagnosis and optimal management Sustainability Checklist, NHS Cancer of patients with AF to reduce their risk of stroke. Improvement Programme Developed collaboratively and piloted by the West A checklist containing key questions to ask about your Yorkshire Cardiovascular Network, the Leeds Arrhythmia project or service to ensure plans are in place to sustain team and PRIMIS+, as part of the AF in primary care the improvement. projects, made available nationally through NHS Improvement. Sustainability_Checklist.pdf The Sustainability Toolkit, NHS Heart Stroke Improvement Programme e-bulletin Improvement Programme Containing updates, news and information for anyone Although focused on improving cardiac pathways, The interested in developing stroke services, the Stroke Sustainability Toolkit provides useful information and Improvement Programme e-bulletin is essential for examples on how to sustain improvements. It also anyone working in stroke and TIA services. contains resources on capturing data, measurement and analysis. The Stroke Improvement Programme e-bulletin is published every two weeks and the latest edition is available on the Stroke Improvement website If you would like to subscribe to the Stroke Improvement e-bulletin, please email
  • 41. Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects | 41NHS 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 support@improvement.nhs.ukSustainability 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 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 website provides evidence to support strokerehabilitation assessment 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
  • 42. 42 | Improving post hospital and long term care: case studies from the Stroke Improvement Programme projects Further information Stroke Improvement Programme National Team NHS Improvement - Stroke Improvement Programme 3rd Floor, St Johns House, East Street, Leicester LE1 6NB Tel: 0116 222 5184 Fax: 0116 222 5101 Email:
  • 43. NHSCANCER NHS ImprovementDIAGNOSTICSHEARTLUNGSTROKE NHS Improvement With over ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart, lung and stroke services. 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 ©NHS Improvement 2010 | All Rights Reserved | June 2010 Delivering tomorrow’s improvement agenda for the NHS