Stroke rehabilitation in the community: commissioning for improvement
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Stroke rehabilitation in the community: commissioning for improvement



Stroke rehabilitation in the community: commissioning for improvement ...

Stroke rehabilitation in the community: commissioning for improvement
provides a comprehensive guide to the development of effective community rehabilitation services. Together with detailed examples of good practice and information about early supported discharge (ESD) service models implemented in England, it explores factors which influence local commissioning, and identifies tools to assist with commissioning and funding rehabilitation. This new publication is particularly relevant to the emerging commissioning landscape, the development of a new outcomes framework, and the positioning of stroke within long term conditions. (Published July 2012)



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Stroke rehabilitation in the community: commissioning for improvement Document Transcript

  • 1. NHSCANCER NHS Improvement StrokeDIAGNOSTICSHEARTLUNGSTROKEStroke rehabilitation in the community:commissioning for improvementAn information resource for providers andcommissioners of stroke rehabilitation andearly supported discharge services in thecommunity
  • 2. AcknowledgementsCo-authorsDavid Broomhead, MCSP.SRPPhysiotherapy Service Manager, NorthLincolnshire and Goole NHS Foundation TrustPam Green, BSC (Hons) MSCPSpecialist Physiotherapist and AssistantDirector Contracting N.E. EssexJill Lockhart, MCSP. SRPNational Improvement Lead - Stroke, NHSImprovementTracy Walker, BAOT. MScStroke Lead and Clinical SpecialistOccupational Therapist Community StrokeService, Lancashire Care NHS FoundationTrustAdvice and supportSteve PrunerCommissioning Officer Adults, Health &Community Wellbeing, Essex County CouncilMichael KaiserHealthcare Commissioning Consultant,NHS Improvement – HeartThank youThank you to all the early supporteddischarge (ESD), community stroke andneurology teams who shared informationabout their services with us, andthe cardiac and stroke networks, includingcommissioners, who answered our questionsand shared their knowledge with us.
  • 3. Stroke rehabilitation in the community: commissioning for improvementContents4 Executive summary 6 Chapter 1: Setting the scene for stroke rehabilitation in the community 6 • The current situation 7 • Existing evidence and guidance to support rehabilitation in the community10 • Tariff progress for stroke11 • Commissioning for stroke rehabilitation - guidance12 Chapter 2: Defining and developing a community service for stroke12 • Understanding what good looks like13 • Developing a good service - the process14 • What influences and shapes the selection of a local model for ESD15 • Models of delivery21 • Practical help in understanding your local services22 • Opportunities to realise economic benefits through community rehabilitation24 • Useful tools to help understand the local picture25 • Developing an integrated approach between health and social care27 Chapter 3: Planning for improvement27 • Engaging stakeholders29 • Tools to support the process30 • Measuring for improvement32 • Effective leadership, management and workforce34 Chapter 4: Examples of innovations in stroke rehabilitation34 • Improving access and uptake35 • Using telemedicine35 • Providing stroke services in rural areas37 • Capitalising on pathway redesign38 Chapter 5: Commissioning stroke rehabilitation in the community38 • The practicalities39 • Unbundling the stroke tariff41 • The process for achieving unbundling of the stroke tariff42 • Achieving quality and value through procurement43 Conclusion45 References 3
  • 4. Stroke rehabilitation in the community: commissioning for improvement Executive summary ‘Achieving sustainable The development of community improvement will also mean rehabilitation including early Early supported supported discharged (ESD) services discharge (ESD) can be taking on the challenge of for stroke survivors provides both a the impetus for change service change, to provide challenge and an opportunity. Over to rehabilitation in the services closer to patients the last five years many good community. Identifying wherever appropriate and to community rehabilitation services have existing local services, improve integration between been developed that can demonstrate and joining up specialist positive impact on the experience and services……real change can be outcomes for stroke survivors in their and non-stroke specialist achieved where managers and expertise creates the locality. Sustainable and effective clinicians work together with services put the patient at the heart of foundations of an effective service. courage and skill where change the service, and make year on year is needed in the interest of improvement in outcomes. They bring financial savings across the pathway • Community rehabilitation patients and taxpayers for and for social care, and continue to services should be example to the organisation of develop in line with the aspirations of organised around local care for long term conditions eg the stroke strategy for meaningful life patient need the configuration of stroke after stroke and long term integration • Community services services. As well as truly by embedding their service within should be commissioned their local community. clinically led commissioning and for all stroke survivors not a robust and diverse provider Discussions around ESD offer local just ESD to avoid inequity sector, service change requires communities an opportunity to • Considering the the right environment at local examine and review their existing perspectives of all services and the local pathway of stakeholders can mean level, an environment in which rehabilitation in the community for all taking a flexible approach patients, the public and stroke survivors. Where this is done in • ESD requires a process of communities are highly the context of a whole integrated financial flow to follow engaged.’1 system, ESD can be a catalyst for the patient and clear change and improvements in the budgetary movement to community for all stroke survivors. release and redirect revenue • Identify quality community data and protect resources to sustain the process. 1NHS Outcomes Framework 2012-13. Department of Health, 2011. 4
  • 5. Stroke rehabilitation in the community: commissioning for improvement‘It will be equally importantthat, as more decision makingis taken locally to reflect theneeds of patients and theclinicians who support them,the NHS does more to integrateservice delivery, not only acrossprimary and secondary carebut also with social careorganisations. Each sectorneeds to look at where it canwork better with partners,including voluntaryorganisations, so that servicesare organised around theinterests of patients and serviceusers rather than institutions.’1‘Stroke rehabilitation in the For stroke community services thiscommunity - commissioning for may mean starting off small and aimprovement’ provides key step by step process. It requiresstakeholders with information to stakeholders to look at the wider poolsupport them with the process of of people who impact on the localdeveloping rehabilitation services for stroke survivors’ environment, manystroke survivors in the community. It of whom are not exclusively strokeincludes examples of good practice, skilled, and how this can beand information about service models addressed. With education andimplemented in England. It explores training, support and time, the poolfactors which influence local of stroke skilled people within acommissioning and identifies tools to community across health, social care,assist with the process of the voluntary sector and local supportcommissioning and funding of organisations can be widened. Byrehabilitation for stroke survivors in bringing these people together withthe community. This is particularly clinical communities, patients andimportant at this time of major commissioners, cost effective andchange within the NHS. A different meaningful rehabilitation in thecommissioning landscape is emerging community can be delivered.along with a new outcomesframework and positioning of strokewithin long term conditions.NHS Outcomes Framework 2012-13. Department of Health, 2011.1 5
  • 6. Stroke rehabilitation in the community: commissioning for improvement Chapter 1: Setting the scene for stroke rehabilitation in the community ‘Stroke costs The current situation The Care Quality Commission (CQC, 2011)5 reported across a number of the country £7 Stroke rehabilitation works. Specialist aspects of ESD and community coordinated rehabilitation, started rehabilitation services and concluded: early after stroke and provided with ‘The overall picture is one of billion, with £1.7 sufficient intensity, reduces mortality and long-term disability2. Whilst inconsistency, waits between transfer home and commencing community billion spent on there is robust evidence showing the rehabilitation and lack of specialist benefits of ESD services, and a access. They comment ‘these differences suggest that clearer community consensus3 to guide the implementation of evidence based guidance is required on what ESD service, there is currently a lack of constitutes ESD’. costs, which academic literature that can be easily used to guide service provision after The NHS Improvement - Stroke team includes ESD, or for stroke survivors for whom has developed a clear understanding ESD is not beneficial. This is being of the challenges and rationale behind addressed by work carried out by the local development of stroke nursing home Collaborative Leadership in Applied Health Research and Care rehabilitation services, through working with clinical teams, care for stroke Nottinghamshire, Derbyshire and commissioners, networks and service Lincolnshire. (CLAHRC NDL) and NHS providers. Services range from effectively embedded stroke survivors’ Improvement - Stroke and will be reported on in a separate publication. rehabilitation pathways demonstrating good outcomes and value for money, Consequently the evolution of to virtually non-existent access to even National Audit Office, 2010 rehabilitation services in the generic rehabilitation services. It is community, including ESD is patchy, clear that the term ESD is often variable and inconsistent, reflecting misinterpreted; it is used instead of local attempts to make it work; ‘community rehabilitation’ with the reconciling the evidence, mistaken assumption that the terms recommendations and guidelines with are synonymous and some services local need and local financial context. have adapted ‘early’ into earliest. For clarity in this document community ‘There is a wide variation in the rehabilitation refers to the availability of rehabilitation and rehabilitation patients receive on community services. Some areas have leaving hospital and includes early supported discharge services, rehabilitation for patients both responsive community stroke appropriate for and not eligible for rehabilitation teams and vocational ESD, pertaining to the commissioning rehabilitation services. Other areas process. The services have been have no dedicated community stroke differentiated where necessary service.’4 throughout the document. 2National Stroke Strategy, Department of Health, 2007. 3A Consensus on Stroke; ESD, Fisher et al, Stroke AHA, 2011. 4Stroke Rehabilitation Guide, Health Care for London, 2009. 5Supporting life after stroke, Care Quality Commission, 2011. 6
  • 7. Stroke rehabilitation in the community: commissioning for improvementExisting evidence and They recommend an intensity of ESDguidance to support and state, ‘for the time they would ‘The team went about otherwise have been receivingrehabilitation in the inpatient rehabilitation (usually up to achieving my aims andcommunity two weeks), stroke survivors receive at whilst doing so made it least five sessions per week of fun for me and I lookedEarly supported discharge occupational therapy, physiotherapy,There is research evidence supporting and speech and language therapy. forward to their visits.the implementation of ESD services While initial assessment of the stroke They set about workingincluding work by Langhorne6,7 and survivor is carried out by qualifiedthe ESD consensus work from professionals, some care may be with me and filling meCLAHRC. The latter states that ESD delivered by therapy assistants under with confidence andteams should be stroke specific and the supervision of a qualifiedmultidisciplinary, offering co-ordinated enjoyment and I soon professional. Following this initialand planned discharge from hospital intensive period, the therapy regime made very quickand continued rehabilitation when then reverts to the level of normal progress. While I know Ipatients are settled at home. The community rehabilitation.’intervention is beneficial for a subset had to put in a lot ofof the patient population; those of The Royal College of Physicians8 (RCP) effort, their kind friendlymild-to-moderate stroke severity. guidance around intensity states, ’ESDStrong links are required between the nature I would say is designed to give eligible strokeacute service and the ESD team, with patients rehabilitation in their own played a big part. Theboth hospital staff and ESD team home at the same intensity as greatest pleasure andmembers identifying patients. To inpatient care.’measure effectiveness, ESD teams credit I could give themshould use standardised assessments The National Stoke Strategy2 (2007) was my progress. Ifto monitor stroke severity, comments that, ‘the number ofdependency, activities of daily living anyone wants to know patients suitable for ESD will also varyand satisfaction as well as the impact according to eligibility criteria, but in if the scheme worksof the ESD service on length of stay trials an average of 41% of patients they only have to lookand readmission rates. were found to be suitable.’ at my happy progress.’Healthcare for London (HfL) guidancedescribes ESD as enabling a seamless Taken from a patient’stransfer of care from hospital to thank you letterhome. This gives stroke patients theopportunity to continue rehabilitation,while being supported in their ownsurroundings and with input from aspecialist stroke team.6Langhorne et al, 2005.7Langhorne et al, 2007.8National Clinical Guidelines for Stroke, RCP, 2008. 7
  • 8. Stroke rehabilitation in the community: commissioning for improvement Rehabilitation in the community HfL states, ‘community rehabilitation The National Stroke Strategy focuses The National Stroke Strategy, National should be a simple, coherent service four quality markers, around Institute for Health and Clinical that is easy to navigate. This service rehabilitation in the community, QM Excellence (NICE) quality standards for should have a single point of entry, no 10 rehabilitation; QM 12 seamless stroke, RCP clinical guidelines and HfL waiting lists and be accessible to all transfer of care; QM 15 participation include guidance around the stroke survivors. It should be designed in community life, and QM 16 return commissioning of rehabilitation in the around the needs and goals of the to work. community, to assist with individual, so the stroke survivor is understanding the whole assessed by a specialist stroke multi- b) Shaping of the pathway for rehabilitation pathway. London has disciplinary team who will determine commissioning rehabilitation in additional guidance, Life after Stroke; the best use of the team’s resources. the community commissioning guide. NHS Community rehabilitation teams The National Stroke Strategy Commissioning support for London should also assist appropriate stroke comments that some people may 20109 which focuses on how services survivors to access vocational move into care homes, but can still should be configured to support rehabilitation.’ benefit from rehabilitation, depending stroke survivors in the period of their on individual needs. Depending on lives following their acute The NICE quality standards10 for stroke the model of delivery adopted, rehabilitation. set specific measures for frequency commissioning for care homes may be and intensity of rehabilitation and relevant for community services that a) Pathway configuration access times. They make no distinction include ESD and non ESD and design between ESD and non ESD services. components. The RCP (2008) recommend whole pathway commissioning stating, ‘commissioning organisations should ensure that their commissioning Early Supported Discharge portfolio encompasses the whole ESD team members attend weekly MDT stroke pathway.’ on acute stroke and rehabilitation unit Stroke survivor Does stroke Rationale identified by or survivor fit the NO documented referred to ESD criteria? YES In its guidance on support for Referral to specialist services London, NHS Commissioning Face to face contact if required made with ward, stroke states that, ‘all staff in nursing survivor +/- family/carer homes, care homes and residential Goals agreed by ESD and stroke homes should be familiar with the survivor +/- ESD team member All identified Patient ESD make family/carer common clinical features of stroke establishes level of home equipment discharged contact within 1 week/ rehabilitation needed is in place home within 24 hrs named key worker and the optimal management of assigned within 1 week common impairments and activity limitations. Although this Have all goals been met or YES population has long gone without Rehabilitation potential Onward referrals agreed by ESD ESD discharges once all agreed reached as the access to quality stroke and Weekly MDT agreed by and stroke survivor/family support networks in ESD/stroke social care services that they need meetings survivor +/- All relevant information and made place and contact name family and deserve, local commissioners given to stroke surviovor/family and details given need to organise services to ensure Stroke Association/ and relevant organisations to Onward referrals TSSS attend MDT accepted and that this population can also include ongoing goals/care start dates agreed if receive the care they need’. NO plans applicable 9Life after Stroke; commissioning guide. NHS Commissioning support for London, 2010. NICE Quality Standards for Stroke. National Institute for Clinical Excellence, July 2010. 10 8
  • 9. Stroke rehabilitation in the community: commissioning for improvementc) The use of specialist and non- d) The processspecialist services HfL expresses how this can beThe National Stroke Strategy states, delivered:’specialist teams may be moreimportant in the early stages of • Where effective communityrehabilitation, while generic teams can rehabilitation teams are in place ESDbe appropriate for the later stages. services should be offered. ESDHowever, the configuration of services should have appropriatecommunity teams is less important staffing levels to provide ESD forthan ensuring that these teams are suitable patientsmultidisciplinary and all staff have the • Every PCT should ensure access to aright specialist skills to help specialist stroke communityrehabilitate people who have had a rehabilitation service beforestroke.’ developing an ESD service • An ESD service is an addition toHfL guidance indicates that, ‘every effective community rehabilitation.primary care trust (PCT) should • An ESD service could be provided bycommission a community an appropriately resourcedrehabilitation service for stroke community stroke rehabilitationpatients, delivered by staff with teamspecialist stroke skills. Service • There may be benefits to having theconfiguration should be locally ESD team and communitydetermined. Every PCT should rehabilitation team in one location.commission an early supported If appropriate, this would allow fordischarge service for people who the sharing of resources, such aswould benefit. This service should social workers, speech andinclude staff with specialist stroke language therapists, clinicalskills and must meet all of the psychologists; improvedperformance standards. communication between professionals on the stroke pathway; and a more seamless transition of care for the client between services. 9
  • 10. Stroke rehabilitation in the community: commissioning for improvement Tariff progress for stroke ‘Transforming community services: currency and pricing options for NHS Improvement continues to work community services’12 recognises the with the DH Payment by Results team challenges progressing this work (PbR) on ways to support the flow of nationally and helps the NHS to create funding into the rehabilitation part of new local currencies and better the pathway. pricing. Stroke is part of HRG4, (Health PbR stroke guidance for 2012-13 is Resource Group) a group of tariffs to carry forward existing guidance that can be unbundled ie making it from 2011-12. This includes an possible to separately report, cost and aspiration for local unbundling, local remunerate the different components negotiations and process within a care pathway. Unbundling improvements around managing provides a mechanism for moving tariff so that the flow of funds parts of a care pathway such as follows the patient from acute into rehabilitation away from the the rehabilitation parts of the traditional hospital setting. They do pathway. not receive a separate tariff. It is challenging for stroke because of the More information to understand the difficulties identifying a specific point tariff process13 can be found at: at which acute care ceases and rehabilitation begins. In most cases confirmation-pbr-arrangements there is a degree of overlap. and in relation to unbundling, at Unbundling is useful where it supports changes to care pathways but Stroketariff/Stroketariff1pathways/ excessive unbundling carries risks, tabid/260/Default.aspx such as inadvertently creating a fee- for-service system where every service is commissioned and billed for separately. More detail around local work on unbundling is available in Chapter 5. ‘Equality and Excellence: Liberating the NHS’ (DH 2010)11 also announced plans to accelerate the development of currencies and tariffs for community services. Community services have lacked some of the building blocks such as national data flows that allow the consistent capture of a classification or currency, and this has impeded the move away from block contracts. 11Equality and Excellence; Liberating the NHS. Department of Health, 2010. 12Transforming community services: enabling new patterns of care. Department of Health, 2009. 13A simple guide to Payment by Results .Department of Health, 2011.10
  • 11. Stroke rehabilitation in the community: commissioning for improvementCommissioning for stroke The RCP (2008) set the context,rehabilitation - guidance responsibilities and the challenge for commissioners of stroke services1. National Stroke Strategy stating, ‘rehabilitation services are2. NICE Quality Standards for best delivered as close to the patient’s Stroke own environment as is compatible3. RCP National Clinical Guidelines while ensuring the patient’s care and for Stroke well-being, and taking into account4. Healthcare for London Stroke the cost consequences of the pattern Rehabilitation Guide; of service delivery. Commissioners are Supporting London key in determining the overall commissioners to commission organisation of stroke rehabilitation quality services 2010/11 services, but must exercise this power5. Life after stroke; Commissioning taking into account evidence and guide. NHS Commissioning maintenance of core services.’ support for London Commissioning organisations mustCommissioners may choose to commission a service capable ofestablish key performance indicators delivering specialist rehabilitation atas part of a tendering processor to home in liaison with inpatient services,incentivise provider performance as recommended in the guidelines.through the mechanism ofCommissioning for Quality and • Consider the overall organisation ofInnovation CQUIN payment services delivered to theirframework. population • Specialist services in relation to theMore details are available at: overall population need, rather specifically in relation to stroke.statistics/Publications/PublicationsPolicyAndGuidanceAn example of CQUIN to supportstroke rehabilitation can be foundhere: on commissioning shouldalso take account of the costeffectiveness of the service, plus anyrelated costs, and include attention tostakeholder views, including the viewsof patients. 11
  • 12. Stroke rehabilitation in the community: commissioning for improvement Chapter 2: Defining and developing a community service for stroke Understanding what good Portsmouth and Blackburn looks like community stroke rehabilitation • A stroke focus and services are examples of this ability to provide timely Defining what a good service looks approach. Their definition of early transfer from hospital like can be problematic as there are relates to the earliest possible for all patients with a many different models of community opportunity for every patient. comprehensive range of rehabilitation and stroke rehabilitation and ESD services currently in place England with a More detail about these services can support variety of delivery methods, and a be found at: • Providing an intensity range of outcome metrics and data and frequency of reporting. CommunityStrokeResource/CSR meaningful intervention Rehabilitationservicemodelsincluding that is coordinated and Often the more established ESD ESD/tabid/213/Default.aspx reviewed • Leadership, clear vision, services were set up before the stroke strategy was published, but not However, this is not the case clarity of purpose and branded as such. They were created everywhere. In some areas, especially evidence of efficacy on a foundation of good strategic more rural and remote places, services • Effective throughput of level support, adopting pragmatic are non-existent, or delivered by patients through solutions to local needs and using generic intermediate care teams often integration with local existing local resources available at with a strong admission avoidance providers’ social care, that time. They have been supported focus and limited stroke expertise. leisure services, the voluntary sector and to undergo evolutionary development to become today’s mature ‘Rehabilitation after stroke works’ other community ‘community stroke rehabilitation (National Stroke Strategy, 2007). It is rehabilitation services services’ incorporating ESD. acknowledged that patients who • Good outcomes that access rehabilitation are more likely to are relevant for patients They are not always badged as ESD experience an improved quality of life and offer value for services, but incorporate its key and better functional outcomes; money principles, together with strong however translating this into the • Demonstrable evidence leadership with clear vision, clarity of delivery of a quality community stroke of sustainability and purpose and evidence for efficacy. or ESD service in practice becomes credibility within and They are well integrated with other more complex where the provision of outside of their local providers e.g. social care, leisure the rehabilitation service is shared or organisations. services, the voluntary sector and crosses the pathway between primary, other community rehabilitation secondary care and social care. services, facilitating effective throughput of patients. These holistic services can also demonstrate through their data, successful patient outcomes. They have good staff retention, are flexible in the services that they provide, have proven to be sustainable over time and have credibility within and outside of their organisations.12
  • 13. Stroke rehabilitation in the community: commissioning for improvementDeveloping a good service - The purpose and aims of the Partnership working with secondarythe process community rehabilitation for stroke, care stroke services and social care can including ESD services should be support the design of a pathway andThe process begins with defining and informed by attention to current ensure that the service model selectedagreeing the desired purpose of a evidence, national policies and is relevant and cost effective for all,stroke rehabilitation service within the guidelines. It can be enriched by and meets patient needs. Cardiac andcommunity and how this will be learning about examples of good stroke networks are often ideallymeasured through key performance practice, and practical evidence placed to coordinate this process.measures both clinical and service. available from other sources, such asThis helps with understanding what the NHS Improvement community An example of a service specificationexisting local services provide, where stroke resource at: for community rehabilitation,the gaps are and what might need to including ESD, can be found on thebe done to build a service from CommunityStrokeResource/tabid/204/ South London Cardiac and Strokescratch or to improve or transform Default.aspx and the Department of Network web site at:existing community services to be fit Health publication ‘Transforming supporting stroke survivors and community services (rehabilitation)12delivering ESD. In many instances the enabling new patterns of provision’ More examples can be found on thelocal discussions around how to at: NHS Improvement website at:implement ESD have been the catalyst groups/dh_digitalassets/documents/ change across the community digitalasset/dh_093196.pdf ESDsupportingcommissioning/tabid/rehabilitation pathway for all stroke 168/Default.aspxpatients and have galvanised local A detailed service delivery model cancommunities into delivering be planned and produced based on aimprovement. local service specification. This will vary depending on local A business case should be developed demographics, patient populationin support of securing a properly needs and approach to specialistcommissioned community commissioning. Engagement andrehabilitation service, within contribution from patients and carerswhatever model is agreed locally. is essential as part of the process of building the detail within the model. ItAn example of a business case should also include suitable metrics tocan be found at: Transforming Community Services: Enabling new patterns of provision DH 200911 13
  • 14. Stroke rehabilitation in the community: commissioning for improvement What influences and shapes When the local stakeholder group UNDERSTAND the selection of a local have agreed their local approach and What you have already got and where it is, benchmark existing services the plan for delivery, an action plan model for ESD can then be devised for implementation. It should align with AGREE There are a number of factors that the local key performance indicators Where you want to be - which model e is best for your area? affect the selection of a model for ESD (KPIs), national indicators and four in addition to the evidence base and domains within the NHS Outcomes guidelines: Framework (2011) and should include PLAN What do you need? contingency planning, review, and How will you get there? • Ability to align and contextualise the opportunity for remedial action. Local research and evidence to local need stakeholder groups should ideally • The local perspective and include the providers of community PROGRESS Towards it, step by step Towards interpretation of ESD rehabilitation and ESD services, local • The local impact of shorter length of commissioners and patient service stay in acute care and the demand users and social care, working BRING for more rehabilitation at home together to agree local delivery. Everyone with you • The flavour of exiting community services - skills, content, remit and Examples of KPIs can be found at. their potential for shaping to be KEEP Patient and carer feedback integral to the process arer Measuring effect against aspirations effect able to deliver effective ESD ESDsupportingcommissioning/tabid/ Collecting data and outcomes • Geography - urban, rural or remote 168/Default.aspx • Funding and flow of money • Leadership within the community, presence/absence of a voice at strategic level • Relationship between health and social care within stroke services.14
  • 15. Stroke rehabilitation in the community: commissioning for improvementModels of deliveryA range of models is emerging acrossEngland to deliver the principles ofESD. This includes acute based,community based, and hybrid models,that broadly fall into one of fivecategories.1. Stand-alone/acute outreach ESD only2. ESD with community stroke/neurology team service3. Integrated ESD within community stroke team service4. Integrated ESD within community neurology team service5. ESD hybridThese are detailed in the following The costing model (see ‘Useful toolstables and include cost per case to support the process, (Page 29) willinformation, derived from the skill allow commissioners and providers tomix information and referral detail, cost services more accurately includingprovided by the teams who have the local costs where they are known.shared their service model details with The costs of services used here areNHS Improvement - Stroke. The posts indicative and relate to thehave been costed at the midpoint of configuration and integration of thethe Agenda for Change band in all services as a comparator to the fivecases inclusive of on costs (national groups of services that have beeninsurance, pension etc.). Non pay noted in the community and are realcosts, travel expenses and fixed asset commissioning solutions.costs have not been included in thecalculations as these have not alwaysbeen available, so the staffing costsact as a proxy for the cost of theservice. Where two teams share thepathway, such as models three andfour the costs should be addedtogether to give a pathway cost. 15
  • 16. Stroke rehabilitation in the community: commissioning for improvement Model 1 Stand-alone ESD/outreach ESD from acute providers with follow on rehabilitation available from generic community services if required There are relatively few of these compared with other models. This may reflect challenges with funding additional discrete smaller services. They tend to be more prevalent in denser populated urban cities and where there are large city hospitals. There are examples of services that have started in this model being adapted or merged into models three and four after a period of time. FACTORS FOR CONSIDERATION Timeframe of rehabilitation • Usually six weeks - some teams provide two weeks, or the estimated time of acute rehabilitation, but in the patient’s home Proportion of patients who fit criteria • Up to 40% Number of pathways from acute provider to home • Two – ESD and non ESD Stroke dependency level catered for • Mild to moderate dependency levels Potential patient wait • Yes – to access the service, if the team does not contain a dedicated social worker there may be waits for care package/enablement • Yes - potential waits between cessation of ESD and access to generic rehabilitation depending on capacity of generic services Groups of stroke patients unable to access service • Complex/severe dependency cohorts of patients • Care home based patients • Community based patients who have not been admitted to acute care first (declined) Additional support infrastructure that may be needed. • Follow on access to a community stroke/neuro/generic team for continued rehabilitation • Community stroke/neuro/generic team for patients who do not meet the criteria • Social care enablement/care packages: seven day patient support to enable early discharge and intensive daily rehabilitation Re referral access • Normally one discrete episode of care post discharge without capacity to accept rereferral Stroke skilled management for whole rehabilitation pathway • No - only for duration of service ( two to six weeks) with referral onto generic services COSTS Cost per case range between £2,580 and £1,13216
  • 17. Stroke rehabilitation in the community: commissioning for improvementModel 2ESD services with a pathway into a community stroke team or a community neurology servicesFrequently created before the National Stroke Strategy, these community services are more mature and establishedservices, which have been shaped and developed further. They work alongside ESD teams, (out-reach or in-reach). Manyservices initially of this category have subsequently been developed into model three or four. Typically reasons for thisare insufficient cohort of patients to justify a separate ESD service, perceived expense of the ESD component and wherethe model was deemed to be creating a two tier service for stroke patients locally. The model offers all the componentsof model one with additional opportunities from specialist follow on rehabilitation. FACTORS FOR CONSIDERATION Timeframe of rehabilitation • Typically six weeks ESD then referral on to the community stroke, or neurology team for continued rehabilitation of approximately three months Proportion of patients. who fit the criteria • Up to 100% of rehabilitation patients Number of pathways from acute to home • Two – ESD and non ESD Stroke dependency level catered for • All dependency levels catered for, mild to complex severe Potential patient wait • Yes – potentially to access the service, if the team does not contain a dedicated social worker there may be waits for care package/enablement to access either component from acute care • Yes - potentially between ESD and follow on rehabilitation depending on the capacity of stroke and neurology community teams Groups of stroke patients unable to access service • Usually all groups of patients can access rehabilitation via the ESD and non ESD pathways including ESD/Non ESD from acute care, care home and community based locations Additional support infrastructure that may be needed • Social care enablement/care packages providing seven day patient support to enable early discharge and intensive daily rehabilitation Re referral access • Normally one discrete episode of care post discharge Stroke skilled management for whole rehabilitation pathway • No - only for the length of the service (typically six weeks – three months). Further referral can be made onto generic services COSTS Cost per case range between £1,157 and £1,868.95 17
  • 18. Stroke rehabilitation in the community: commissioning for improvement Model 3 ESD is delivered within an integrated community stroke team Typically these services originated from an existing community stroke team that could demonstrate an ability to deliver ESD elements effectively, or where setting up a separate ESD service might compromise staffing of an existing performing community service. It is more prevalent in urban/rural mix areas with district general hospitals, and in rural areas with higher stroke populations. It is one of the most comprehensive models including all the components of models one and two with additional elements. Most of the teams in this model have re-enablement/health care, domiciliary support workers to support with delivery of seven day rehabilitation including multiple visits a day for up to six weeks. FACTORS FOR CONSIDERATION Timeframe of rehabilitation • Typically goal directed approach, so available for as long as required (range three months to one year) Proportion of patients who fit criteria • Up to 100% Number of pathways from acute provider to home • One pathway for all patients, through a coordinated discharge/rehabilitation process led by the team Stroke dependency level catered for • All dependency levels, from mild to complex severe Potential patient wait • Usually no wait and immediate access to supported discharge/rehabilitation .Typically these services coordinate and lead the transfer from hospital to home Groups of stroke patients unable to access service • All groups of patients can access timely rehabilitation including, ESD/non ESD from acute care, care homes, and community-based patients Additional support infrastructure that may be needed • Social care enablement/Health domiciliary rehabilitation support staff: Seven day patient support to enable early discharge and intensive daily rehabilitation Re referral access • Yes - usually these services accept re referral back into the service post discharge Stroke skilled management for whole rehabilitation pathway • Multidisciplinary stroke skilled therapy for whole pathway, including staff from intermediate and social care Additional components • Examples of managing patients in intermediate care beds • May offer review services • May offer specialist additional services e.g. FES, spasticity clinics COSTS Cost per case range between £1,336 and £2,50218
  • 19. Stroke rehabilitation in the community: commissioning for improvementModel 4ESD delivered within an integrated community neurology serviceThese services have a wider remit to include neurological conditions therefore have experience and skills withmanagement of with very complex presentations. They tend to be more prevalent in rural, less urban areas, or wherethere are issues recruiting (specialist) staff or smaller stroke populations. Some of the services in this model havere-enablement/health care domiciliary support workers to support with seven day rehabilitation, multiple visits a day forup to six weeks. A comprehensive model offering all the components of models one, two and three and additionalelements. FACTORS FOR CONSIDERATION Timeframe of rehabilitation • Typically adopt a goal directed approach, so the services are available for as long as required (range three months to one year) Proportion of patients who fit criteria • Up to 100% of patients Number of pathways from acute provider to home • One pathway for all patients; coordinated discharge/rehabilitation via the team Stroke dependency level catered for • All dependency levels of stroke patients mild – complex severe, and neurological patients Potential patient wait • Usually no wait and immediate access to supported discharge/rehabilitation .Typically these services coordinate and lead the transfer from hospital to home • Where the team does not include a dedicated social worker, there may be delays accessing service from acute care awaiting packages/enablement support • There is an example of wait of up to three weeks for non ESD patients within this group Groups of stroke patients unable to access service • All groups of patients can access the service including, ESD/non ESD from acute care, residential care and community based locations Additional support infrastructure that may be needed • Social care enablement/Health domiciliary rehab support staff, or seven day patient support to enable early discharge and intensive daily rehabilitation Re referral access • Yes- usually these services accept re referral back into the service post discharge Stroke skilled management for whole rehabilitation pathway • Yes - multidisciplinary stroke skilled therapy for whole pathway Other benefits • Examples of managing patients in intermediate care beds • May offer review services • May offer specialist additional services e.g. FES, spasticity clinics • Experience with complex case management COSTS Cost per case £770 19
  • 20. Stroke rehabilitation in the community: commissioning for improvement Model 5 Hybrid ESD – supporting more complex patients This model is emerging from the evolution of established and successful ESD services. Irrespective of their starting model, these ESD services have develop into bigger community stroke teams by widening criteria, demonstrating the ability to safely manage more complex patients and ensuring a comprehensive fit within the community pathway. In many circumstances these are community providers. They frequently operate through an in reach approach and typically offer input from four times a day (ESD phase), seven days week, reducing to weekly visits by the time of exit. FACTORS FOR CONSIDERATION Timeframe of rehabilitation • Usually time limited (range six weeks to 12 weeks) Proportion of patients who fit criteria • Varies depending on individual criteria but usually there are higher percentages of patients than traditional ESD models, but lower than 100% Number of pathways from acute provider to home • Two pathways, ESD and non ESD pathway Stroke dependency level catered for • All dependency levels of stroke patients mild to complex severe Potential patient wait • Yes, potentially a wait for the non ESD patients who do not fit the criteria • Yes, potentially a wait for follow on rehabilitation depending on the capacity of follow on rehabilitation teams in intermediate care services Groups of stroke patients unable to access service • Patients who do not meet the criteria • Community-based patients who have not been admitted to acute care Additional support infrastructure that may be needed • Social care enablement/health domiciliary rehabilitation support staff, to provide seven day patient visits to enable early discharge and intensive daily rehabilitation • Follow on support from community stroke/neurology teams or generic rehabilitation teams Re referral access • Normally one discrete episode of care post discharge Stroke skilled management for whole rehabilitation pathway • Usually time limited for as long as the service is provided. This may cease on transfer into the community, depending on other local services’ availability for example, community stroke/neurology or generic intermediate care services Additional components • May include six month and one year review services COSTS Cost per case £5,16220
  • 21. Stroke rehabilitation in the community: commissioning for improvementPractical help withunderstanding your localservicesThere are many documents andresources to assist with the process ofidentifying what you need to know tounderstand your current services andhelp with any planned improvements.• ESD Toolkit • Equality for all: Delivering safe care Working out how much seven days a week, produced by ‘good’ costs ESD/tabid/160/Default.aspx NHS Improvement15 The evidence suggests ESD is cost effective, however establishing local• Community Stroke Resource SevenDayWorking/tabid/218/ costs and benefits of wider Default.aspx community rehabilitation services is CommunityStrokeResource/tabid/ challenging due to the variability of 204/Default.aspx • Psychological care after stroke, the intervention, the setting, and the produced by NHS Improvement - health care professional delivering the• Tariff Support Stroke16 interventions. Additionally difficulty in establishing the cost per patient and Unbundlingthestroketariff/tabid/ Psychologicalcareafterstroke/tabid/ the corresponding outcome is 259/Default.aspx 177/Default.aspx engendered through the use of block contracts for community services and• DH Tariff Guidance • Care Quality Commission a dearth of accurate measurement. (CQC) report Agreement and understanding of the confirmation-pbr-arrangements costs and the impact of the service are surveys-and-reviews/reviews-and- best developed through discussion• Stroke Association studies/services-people-who-have- involving all key stakeholders which had-stroke-and-their will in turn direct the focus on service our_publications objectives. • Delivering Quality, Innovation,• Different Strokes Productivity, Prevention (QIPP)• Social Care for Stroke • Measurement tools and practical modules stroke/SocialCareforStroke/tabid/ 89/Default.aspx ImprovementSystem/Login.aspx? ReturnUrl=%2fImprovementsystem• Mind the Gap14 %2fdefault.aspx Rehabilitation/tabid/285/ Default.aspx14Mind the Gap: Ways to increase access to therapy and rehabilitation. NHS Improvement, 2011.15Equality for all: delivery of safe care seven days a week. NHS Improvement, 2012.16Psychological care after stroke: Improving stroke services for people with cognitive and mood disorders. NHS Improvement, 2011. 21
  • 22. Stroke rehabilitation in the community: commissioning for improvement Opportunities to realise Investment for future savings economic benefits through The Blackburn community Following the National Audit Office stroke team demonstrated review of stroke services in 201017, community rehabilitation the House of Commons Public savings for social care by reducing the amount and Accounts Committee recognised that Creating well organised services ESD could deliver better outcomes Well organised high quality services frequency of care packages. In 2010 final packages of care and save costs through bed closures, are the most cost efficient. after initial investment to establish the Commissioners have a particularly for patients undergoing community rehabilitation with service. CLAHRC research reports that important role in ensuring that ESD reduces mean hospital length of services are appropriately organised. this team were reduced by 240 hours of care per week, stay by about six days, however the Some of the efficiencies that can be trials were done when average achieved arise from altering where equating to savings of £93,600 per year. hospital length of stay was and how services are delivered (RCP considerably longer. Translating the 2008). In many instances there will be research into practice, the NHS potential costs associated with start Stroke care coordinators from health and social care within Camden - stroke REDS team reduced up or with changes in practice, but the average length of stay by ten days the evidence suggests that well South Tees have developed joint partnership working to for 32% of people with new stroke in organised services generally deliver an Camden in 2009. Five hundred and equal or better outcome at about the review the care needs of stroke survivors in care home eighty acute and inpatient bed days same cost (HfL 2009). were saved, leading to potential settings at around six months to ensure an equitable service savings of £307,161 in acute bed day Effective stroke rehabilitation can costs. The Camden team estimate bring wider economic benefit (HfL provision to all stroke survivors. They were able to savings of more than £200,000 or 2009) in terms of hospital £83,000 per 100,000 population. readmissions, reduction in hospital demonstrate savings of £36,000 by returning two Reducing hospital length of stay length of stay, reduced GP indicates only potential cost savings if consultations and inappropriate patients form care homes to their own home, and a the bed is subsequently used again. further secondary care referrals. More Closure of beds is needed to realise costly interventions such as reduction in nursing resources and medication costs by actual cost savings. management of pressure damage and venous ulcers or surgical treatment of identifying and managing potential complications in Supporting people with stroke back to joint contractures may be engendered work through rehabilitation and joint through a failure to provide timely other patients. working with the Department of rehabilitation. Enabling a greater Work and Pensions, vocational degree of independence at home has More details are available at: rehabilitation schemes and employers an impact on the costs of community is another opportunity to realise support from health and social stroke/CaseStudies/Casestudies QM14/tabid/151/Default.aspx savings for the wider health economy services. as well as the obvious personal benefits to individuals and their families. Where stroke survivors are of working age and with support could return to work, costs result from failure to support this area of rehabilitation. The Confederation of British Industry (CBI) estimates that the cost to the economy of a working day lost to sickness is approximately £77 (2008).18 17 Progress in improving stroke care. National Audit Office, 2010 18 Working for a healthier tomorrow. Dame Carol Black’s review of the health of Britain’s working age population. March 2008.22
  • 23. Stroke rehabilitation in the community: commissioning for improvementWorking for a healthier tomorrow18, A study of 3,000 younger strokeadvised that, ’Healthcare professionals survivors by Different Strokes19 (a The Department of Health’sshould consider a return to stroke charity for younger stroke workstep employment supportappropriate work as an important survivors) found that 75% of the programme for people withoutcome in the treatment and support respondents wanted to return to disabilities is delivered byof patients where possible. The NHS is work, and gave a range of reasons Bootstrap Enterprises incurrently considering patient why this was not possible. These partnership with Blackburnpathways for those with major long- included being forced to retire by their with Darwen Boroughterm conditions. For those of working employer, being unable to drive or use Council. This service isage, this should, where appropriate, public transport, fear of losing accessed by the localinclude a consideration of work- benefits and feeling unable or not fit community stroke team forrelated health and the steps necessary enough to do their previous job. support with return to help the patient to move back intoemployment’. A more recent study also suggests More detail is available at that stroke survivors who have not returned to work, might have been be stroke/CommunityStroke able to do so with more support. Of Resource/CSRLifeafterstroke/ An innovative service led by the 339 people in the study who were CSRLifeafterstrokereturnto occupational therapy in West in employment immediately before work/tabid/246/Default.aspx Park Hospital was able to they had a stroke, only 59 (17%) were demonstrate successfully known to be in employment one year returning 50% of their clients on. Appropriate rehabilitation and to employment in 2010. With longer term support specifically shorter waiting lists and focused on improving stroke survivors’ Reinvesting the funding speedier access clients were fitness for work, had the potential to Review of current commissioning able to retain and return to achieve higher rates of return to arrangements in light of the evidence existing employment. employment. and guidance and assessing whether the right service is being provided in More information can be More information is available from the right place may enable some found at: investment to be redirected towards was.htm commissioning more suitable services stroke/CommunityStroke for the population. The experience in Resource/CSRLifeafterstroke/ some London PCTs suggests there is CSRLifeafterstrokereturn potential for cost savings through towork/tabid/246/ simplification and redesign of existing Default.aspx processes to ensure that only effective and efficient treatment is given (HfL 2009). Consideration to moving resources between providers may enable savings to be made. Working for a healthier tomorrow. Dame Carol Black’s review of the health of Britain’s working age population. March 2008.18 Getting back to work after stroke. Different Strokes and the Stroke Association, 2006.19 23
  • 24. Stroke rehabilitation in the community: commissioning for improvement Useful tools to help improve the provision of stroke The Portsmouth community understand the local picture specific services in the community. As stroke service resulted from a result, a cost modelling tool was the closure of an inpatient fast Estimating the financial benefits of developed that allows providers to stream stroke rehabilitation improved rehabilitation is difficult recognise the interdependencies ward. Pay and non-pay costs because there is little evidence to between staffing, income, bed were redirected to develop a support rigorous cost/benefit analysis. occupancy rate and length of stay. community stroke This can complicate the Using this, it is possible for providers rehabilitation team (CSRT), for commissioning picture for community to understand exactly the cost Portsmouth City and south of services, where funding is tied up in window in which they are operating East Hants. Inpatient stroke block contracts, and where there is an and to identify what funding is rehabilitation was retained in absence of robust data collection or available to follow the patient at any the form of a 20 bedded outcome measurement. point of transfer to another setting slower stream stroke ward. during the episode of care. Around £2,000 per patient The costs of training a generic was saved initially in 2004 team to support stroke patients Details of the cost modelling tool with savings of £3,748 for NHS Improvement - Stroke is working are available at: each patient per year in social with the UK Forum for Stroke Training care costs. The team manage (UKfST) to identify more specific detail Stroketariff/Stroketariff1pathways/ more than half of all stroke around the costs associated with tabid/260/Default.aspx patients discharged from developing a generic community team hospital, contribute to the to meet the aspirations within the Scenario generator tool year on year fall of hospital National Stroke Strategy for stroke Scenario generator is a modelling tool length of stay and patients. The information will be that uses pathway design to map demonstrate positive clinical available on NHS Improvement – against population projections and outcomes. Stroke website. prevalence, together with data entered on duration, capacity and Unpicking block contracts costs, to predict future requirements Anglia Heart and Stroke Network have for services, giving detail year on year undertaken work across their health down to step (or intervention) level. community to unbundle the block contract, to try to understand the distribution of cost of stroke across Stroketariff/Stroketariff1pathways/ the pathway. They wanted to tabid/260/Default.aspx understand the contribution towards stroke care in hospital and in the community from the block contract and to understand the contribution of NHS Northamptonshire used the block contract to support the tariff this method in 2010 to model payment, Therefore they developed different clinical scenarios to an approach for quantifying the best evaluate the impact of amount of funding dedicated to the Stroke Specific stroke in both the hospital and Community Rehabilitation community setting. This has proved Team including an ESD. Excel invaluable when working with was used to do further commissioners and providers to analysis of the results and to create a simpler way to model the data once the pathway had been designed. It was also used to present results.24
  • 25. Stroke rehabilitation in the community: commissioning for improvementBed modelling tool Staff calculator tool To achieve safe and timely dischargesIn Essex, a stroke bed capacity and The UKfST have created a workforce of patients from the acute sector intoESD impact evaluation model has calculator. This electronic tool can ESD/community stroke services it isbeen used by commissioners to assist users to work out staffing and essential that health teams integrateunderstand and support their work skill mix requirements to deliver with social care teams. Ideally strokearound commissioning ESD services. services and support calculations skilled social workers should beIt can be applied to community around amount of clinical time embedded into the ESD with anrehabilitation models. available from varying skill mix inreach role onto the acute stroke combinations. unit, to enable early identification patients needing social care packagesESDsupportingcommissioning/tabid/ More information is available at: and the mitigation of social168/Default.aspx circumstances that may preclude timely discharge.Data gathering More information to supportIt is crucial to gather as much stroke workforce analysis and design can A key role of the social worker shouldspecific data as is available for analysis be found on the NHS Improvement - be to elicit the support of reablementto work out the patient flows in the Stroke website at: teams to work alongside the ESDacute stroke unit and the income that team at the point of discharge forthis currently generates from tariff. Increasingaccesstotherapy/Increasing these patients. Those receiving ESDClinical engagement is essential at this accesstotherapyMeasuring/tabid/ support should not be restricted fromstage so that teams can provide 301/Default.aspx accessing reablement funding andadditional information that cannot be support. ESD teams may workcaptured through Secondary Uses alongside reablement colleagues toService (SUS) data i.e. mimic stroke Developing an integrated ensure the patient is getting thedata and bed consumption for those approach between health therapeutic care they require topatients that do not end up being and social care develop their rehabilitation plan. Thecoded as AA22z or AA23z in the simultaneous benefit of this is thatdata set. Where health and social care services reablement colleagues learn stroke work together to facilitate a smooth specific skills and handling byAssumptions then need to be made return home for patients it can help working alongside the experiencedaround the impact that the ESD people recover quickly, reduce the ESD clinicians and rehabilitationservice will have on the acute bed pressure on the individual and their workers.length of stay. It is advisable as per family and prevent unnecessarythe model tool to establish a best case readmissions to hospital or carescenario, baseline impact and a worst homes (National Stroke Strategy,case scenario in order to reassure the 2007). Involving social workers inacute trust of the impact by cohort the multidisciplinary team at anrather than on a case by case basis; early stage is an effective way tothe benefits of ESD on the acute stay achieve this.will only be realised when it hasimpacted on length of stay. 25
  • 26. Stroke rehabilitation in the community: commissioning for improvement As organisations are required to Care homes facilitate and commission services, The National Stroke Strategy also greater integration of health and recommends that ‘commissioners social care from the centre is essential. should also consider providing training on stroke to a wider range of organisations that come into contact with individuals who have had a stroke, for example care home staff. In North East Essex, social Allied health professionals and stroke work colleagues have been voluntary organisations are particularly part of the ESD team since its well placed to carry out this training.’ inception and commencement, and reablement packages have Where true integration has occurred been successfully put in place team are becoming up-skilled and the for the six week period directly patient receives the progression they after discharge. Social care require through all daily tasks which colleagues reported that by enables higher levels of independence working in this integrated way and reduced impairments. Cost can the size and complexity of be calculated around the reduction in social care packages has size of care packages and carer reduced. The packages have burden, savings would directly benefit become less complex for social care budgets and thus would be stroke patients and are easier sufficient to fund a social worker per and quicker to arrange. ESD team on an invest to save basis. In Stoke on Trent, the city A small scale study carried out council’s adult social services using the Northwick Park team has redesigned the dependency assessment for 71 stroke care pathway from patients in Leeds where there rehabilitation into the is established joint working community. between the community stroke team and the Details of their experiences intermediate care and can be found at: enablement teams produced an average reduction between stroke/CaseStudies/Casestudies start and end care costs of QM15/tabid/152/Default.aspx £271 per person per week.26
  • 27. Stroke rehabilitation in the community: commissioning for improvementChapter 3: Planning for improvementMaking any changes to existing Community stroke services that can There will be an expectation that anycommunity service either to include demonstrate a service model offering additional resources to an existingESD, or to deliver a new pathway for all patients a timely service with community team to support ESD willstroke survivors requires a thorough flexibility to deliver appropriate levels be required to demonstrate maximumunderstanding of where you are now, of frequency and intensity based on effect across a range of qualitywhere you want to be, sign up, and a need (a pathway approach) with standard related metrics and not justrealistic action plan. Adopting a clear robust data measurement of more of the same. Communityand transparent approach can outcomes are more likely to make a services that can offer clear pathwaysencourage all stakeholders to buy in. persuasive case for delivering ESD for patients according to need areThis is especially important where within their service. better able to demonstrate are currently being deliveredby community hospitals, or where a Patients and carersnew service has implications for acute Engaging stakeholders The NHS operating framework (2011)providers, requiring them to ‘let go’ of says, ‘Patients and carers should feelpatients much earlier in their stay. Commissioners that services are integrated and co- The evidence states that ESD can save ordinated. The need for goodAchieving agreement between acute money, although its primary rationale systematic engagement with staff,and community providers around ‘risk’ is around delivering better outcomes patients and the public is essential somay require much discussion and hard for patients. Most services report that that service delivery and change iswork to build professional trust across the major costs are those associated taken forward with the activethe pathway. Anecdotal evidence with managing patients with more involvement of local people.suggests that this is one of the biggest complex needs and disabilities; Organisations should also listen closelyobstacles to improving timely flow patients typically with a longer length to patient feedback and complaints,into ESD and community rehabilitation of stay in hospital and in community using this information to improveservices. Engaging social care in the rehabilitation with more expensive services’.process can be very challenging, but care costs. Greater impact on costswhere services have persevered and may therefore be achieved through Successful services are those thathave achieved joined up working with improved opportunities for these understand their local care within the hospital stroke patients within community Consequently they have selected amultidisciplinary team, it has produced rehabilitation; thereby reducing service model that works because it ispositive effects on patient community hospital length of stay and offering a locally relevant. Within their model arerehabilitation experience. more effective community service that clear exit strategies that are relevant will achieve more in less time – thus to their service users, and activelyIn some instances, it may be necessary delivering an overall shorter total support meaningful social develop confidence within acute pathway length of stay and lower This has been achieved through fullyservice providers and among final package of care costs. including patients and carers in servicecommissioners in the ability of design. These services have embeddedcommunity services to step up to the Clinicians themselves within the localtask of delivering ESD. This can be The question for clinicians is how to community and constantly seekassisted by benchmarking existing deliver the best outcomes for patients opportunities to further consolidatecommunity services and obtaining in their care with the resources that this.relevant performance data. are available. This involves consideration of the research evidence, understanding local resources (both existing and potential), alongside the intended outcomes of the ESD service. Opportunities to identify how to increase access to therapy, intensity and frequency (such as demand and capacity work) should be explored. 27
  • 28. Stroke rehabilitation in the community: commissioning for improvement Social care In Haringey, the stakeholders Local authorities are facing an worked from the back of the unprecedented financial and service pathway, forwards. They demand challenge. They may wish to worked with patients and see evidence that any money they carers to identify and agree spend realises real benefits, either in local priorities for stroke cost savings or reduced demand. This survivors and then developed a is not just about value for money. range of options in the With less to spend and tighter fiscal community. For some, stroke pressures they will want to know clubs offer long term support what will be realised in the short to while for others they are a medium term from an investment, springboard to further groups even if this is jointly with health. A and activities that are less local authority will need to be able to stroke specific and more clearly see benefits for their broadly integrated. organisations in joint working with community rehabilitation services. Opportunities and benefits from integrating health and social care across the stroke pathway COMMUNITY ACUTE CARE AND TRANSFER FROM REVIEW REHABILITATION REHABILITATION HOSPITAL AND INTEGRATION Effective communication to Establishment of clear Effective joint rehabilitation/ Joint review at jointly identify future care joint health and social enablement. six months. and rehabilitation needs. care plans. Promotes access to stroke Increases numbers of May avoid repetition and May reduce frequency and skilled training and patients returning home duplication of effort. quantity of delayed discharges. support for social care staff, from initial placement and enables greater to care homes. Enables more efficient use Enables shared use of competence of care agency of social care time community resources between and care home staff. Enables reduction in on ward. health and social care. number of re-referrals More timely integration into for additional care. Potentially improves patient Potentially improves the community. and carer experience. patient and carer Fewer complications. experience. Facilitates more effective use of intermediate care beds for stroke. Improved carer support to manage the stroke patient’s Enables reduction in levels of transition home. care packages required. May lead to increase in patients returning home from care home beds. Increase in number of patients remaining in own home for longer. Enables reduction in number of re-referrals for additional care. Potentially improves patient and carer experience.28
  • 29. Stroke rehabilitation in the community: commissioning for improvementSome working examples There are no quick fix solutions or In Northampton, they used process• Evidence highlighting benefits of prescriptive answers around securing mapping with a QIPP twist to engage joint training for health and social engagement and commitment from all stakeholders and develop a care staff on the stroke pathway all stakeholders. Successful outcomes pathway for their community stroke• Savings due to a joint in terms of an agreed service rehabilitation service. More commissioning approach, funding a specification and model are derived information is available at: well-resourced ESD team, including from locally agreed definitions and therapy service provision integrated plans, using the evidence as a starting CaseStudies/CasestudiesQM10/tabid/ with an enabling care approach to point. Understanding where you are 147/Default.aspx provide intensive stroke and what already exists may be rehabilitation within the person’s challenging, but can yield benefit. Northumbria have developed a home: £315 per week saving in Many areas have more potential than strategy for including patients and social care packages may be apparent initially, so effort carers throughout their pathway• Evidence of joint working to enable spent finding out what already exists including education of staff. More timely discharge for the more is worthwhile. It may take time to information is available at: complex stroke patients reach agreement locally around the• Improved patient experience and shape and vision for community CaseStudies/CasestudiesQM4/tabid/ quality of life rehabilitation but when it is achieved, 141/Default.aspx• Achieving the aspirations of the clear plans can be developed to move stroke strategy for in-patient the service forward. Further resources are available from intermediate care around delivering the Improvement Leaders’ Guides better outcomes when professionals produced by the NHS Institute for with stroke expertise are part of the Tools to support Innovation and Improvement at: rehabilitation team and specialist the process input remains ImprovementLeadersGuidesBoxSet• Joint working to reduce long term There are many tools and techniques care home placement: Potential five that can assist with analysing services patients per year case studies and to help plan for improvements. (Blackburn/Leeds). These include process and value stream mapping, understandingMore details with supporting evidence capacity and demand, usingfor these examples are available on measurement or improvement andthe NHS Improvement – Stroke web involving patients and at: NHS Camden used demand and capacity work to support the business case for their ESD service model. More information is available at: Increasingaccesstotherapy/Increasing accesstotherapyMeasuring/tabid/301/ Default.aspx#workforce 29
  • 30. Stroke rehabilitation in the community: commissioning for improvement Measuring for improvement Why measure To understand the direction To understand the current state of travel of the service. Regular monitoring and analysis of information will inform the impact of • Establish a baseline - this Establishing a true baseline of current any changes on the service. It can avoids dependence on service delivery is a major part of inform decisions about whether assumptions about service improvement. Unless the pre adjustments to the service are needed. improvement priorities change position is known, it will be • Engage all key difficult to know if changes are an To determine progress stakeholders - including improvement and have had any When data is used as continuous Clinical Commissioning impact on the process or outcomes feedback about the effectiveness of Groups, at the outset for patients. The baseline is a the service and any improvements, it • Measure what matters - measure of how well the pathway is objectively demonstrates what agree meaningful working, in terms of efficiency, progress is being made in terms of measures at the outset effectiveness and patient and carer benefits, return on investment, and include in initial experience. avoiding the need for assumptions. commissioning intentions • Develop reliable systems for data collection Aligning stroke data with the outcome domains including technical solutions Domain 1 Domain 2 Domain 3 Domain 4 Domain 5 • Protect resources to Preventing Enhancing Preventing Ensuring that Treating and collect accurate and people from quality of life people from people have a caring for reliable data. dying for people dying positive people in a prematurely with long prematurely experience of safe term care environment conditions and protecting them from avoidable An effective system for capturing and harm analysing information is essential to understand how well a service is Information Includes Measures Generic No stroke functioning and to establish the about the measure of ‘improving patient related impact of changes and proposed under 75 ‘the recovery from experience indicators improvements. Establishing systems, mortality rates proportion of stroke’ using measures of from people feeling the modified hospital and and then analysing the information, cardiovascular supported to Rankin score primary care can be challenging in a busy clinical disease will manage their at six months are included environment. apply to condition’ and stroke ‘health related quality of life Further information can be found on for carers’ the measuring for local improvement pages of the NHS Improvement – Stroke website at: MeasuringforImprovement/Measuring forlocalimprovement/tabid/188/ Default.aspx30
  • 31. Stroke rehabilitation in the community: commissioning for improvementThe Stroke Sentinel National Audit What are the strategic, regional • Part of the team culture - involveProject (SSNAP) audit indicators? all of the team in the collection,This is the new national stroke audit These indicators currently determined validation or use of the data forintended to be the single source for all by Strategic Health Authorities, will improving the servicenational stroke data, and incorporates subsequently be determined by CCGs • Shared - make the informationNational Institute for Health and and will potentially be based on the openly available for staff andClinical Excellence (NICE) quality COF. These indicators tend to be more patients to understand the level ofstandards for stroke. It will include locally defined and can include: care provided and intentions forcore data about every stroke patient, improvement.mainly about their acute care but • Key performance indicators used toimportantly for community incentivise provider performancerehabilitation teams will include data when used in association withabout joint care planning, incentive payments, such as the Lancashire Healthcare NHSpsychological care after stroke, early CQUIN scheme Trust community stroke teamsupported discharge and six month • The need for commissioners to align in Blackburn have developed areviews. Some patient reported service specifications with NICE community dashboard tomeasures are planned to be included. quality standards. collect and report on key stroke rehabilitation data inMore information is available at: What should local databases order to evaluate and include? their service. Effective local service delivery isThe commissioning outcomes dependent upon accurate information More information on this canframework (COF) about the quality of the service. be found at:This will be an accountability Services with robust data collection for clinical commissioning processes, and regular evaluation stroke/Increasingaccesstogroups (CCGs) to enable the NHS using the information will be able to therapy/IncreasingaccesstoCommissioning Board to identify the demonstrate outcomes and unmet therapyMeasuring/tabid/contribution of CCGs to achieving the needs and understand the clinical and 301/Default.aspxpriorities for health improvement in cost effectiveness of the service.the NHS Outcomes Framework. The Availability of this informationCOF will contain a number of articulates the value of the communityindicators developed from NICE rehabilitation team and supports theevidence-based. future commissioning of the service. Team level The CLAHRC ESD consensus (2011)The measure which has the most Local databases should be: recommends the use of standardisedsignificance for community • Simple - collect only data which is assessments to monitor strokerehabilitation teams is the modified important and will be regularly used severity, dependency, activities of dailyRankin score at six months - a to develop the service where living and satisfaction as well as thefunctional recovery score. This possible be consistent with national impact of the ESD service on length ofmeasure is planned to be collected in stroke data requirements to avoid stay and readmission rates.the SSNAP audit. duplication • Robust - take steps to validate the Some examples of outcome measures data used by individual services are detailed • Patient-focussed - include regular within the community stroke resource, patient and carer feedback about their experience of the service CommunityStrokeResource/tabid/ 204/Default.aspx 31
  • 32. Stroke rehabilitation in the community: commissioning for improvement Effective leadership, However, many of these services Similarly the increasing essential management and workforce demonstrate strong leadership from requirements of data reporting and AHPs who have access and a voice at audit necessitate the provision of Leadership and management the highest strategic level where they adequate and appropriate support. can articulate how their service aligns These requirements should be built ‘Clinicians with leadership with national policy drivers and the into the specifications for stroke skills have the greatest bigger picture. They may not operate rehabilitation services in the within their team as the most expert community in order to make the most ability to deliver better clinician, but have skills in effective effective use of clinical resources, and services for patients and service management and financial meet the administrative demands. foster innovation, quality acumen, and confidence with data management. and safety.’ Workforce Many community services have ’Specialist teams may be National Allied Health Professional evolved from a core group of leadership challenge, DH, 201020 clinicians. They have grown over time more important in the early into bigger services, with senior stages of rehabilitation, clinical staff juggling additional An effective strategic profile for any administrative responsibilities that while generic teams can be rehabilitation service requires that the appropriate for the later could reasonably be carried out by less service is led by an individual who can expensive non-clinicians. Typically stages. However, the influence the decisions of senior vacancies are used as opportunities to managers and commissioners. This revisit the staffing matrix, and improve configuration of impacts positively on service outcomes and the progress of the service locally. the number of unqualified staff rather community teams is less than in improving administrative Anecdotal feedback and learning from support. important than ensuring the national rehabilitation projects that these teams are 2009-1021 and 2010 -1114 showed Community rehabilitation teams multidisciplinary and all that strong leadership within commonly report difficulties in the community rehabilitation is crucial establishment, funding and staff have the right to success. maintenance of administrative specialist skills to help support, yet there is an essential In most places these services are led requirement for any service to run rehabilitate people who by an allied health professional (AHP), have had a stroke.’ smoothly, in managing the transfer of working with business managers at information between secondary and operational level. The absence of a National stroke strategy 2007 primary care, and between health and medical lead may be viewed as a social care. disadvantage. 21 Going up a Gear: Practical steps to improve stroke care. NHS Improvement, 2010. 14 Mind the Gap: Ways to increase access to therapy and rehabilitation. NHS Improvement, 2011.32
  • 33. Stroke rehabilitation in the community: commissioning for improvementAnecdotally, some stroke services Establishing the current pathway In turn, staff time can be difficulties in reconciling this and associated costs will help By integrating provision, patients withwith their commissioner focus on commissioners understand how their needs that can be met by less highlystrategic implementation programmes current resource is used, and provide skilled staff can access thesefor transforming community services. an opportunity to refocus this individuals, freeing the time of more resource in stroke skilled care. highly skilled clinicians to attend toCommissioners may have invested patients with more complex in developing their Rural workforceintermediate care services and can In more rural and remote areas the Education and training are essential toneed persuasion that these generic emphasis has been on developing underpin the roles of the whole teamintermediate care services cannot, services that can deliver the best and staff should hold appropriatewith some training deliver the bulk of outcomes for patient care within the competencies for the delivery of caresupportive rehabilitation within the resources that are available. In some, for which they are responsible,community, for both ESD and non but not all areas, a modest additional particularly in rural areas.ESD services. Stroke services and investment to support ESD may beproviders will need to be able to available. Their preference may be on Useful information is available at:articulate clearly the evidence base for identifying and developing skills and how this can align with within any part of their existing statistics/Publications/Publicationslocal services cost effectively. It is resources to support an equitable PolicyAndGuidance/DH_098352crucial to gain agreement among all service for all stroke patients. This canstakeholders about how the include social care staff. http://ukfst.orgopportunities from existingcommunity and intermediate care Agenda for Change22 allows for the can be realised, without creation of new job roles, Increasingaccesstotherapy/Increasingcompromising the need for ESD or multi-skilling of staff outside of accesstotherapyMeasuring/tabid/community services to comprise stroke traditional professional boundaries, 301/Default.aspx#workforceskilled staff, including stroke the devising of new ways of workingspecialists. and the redefining of the skills and knowledge of staff to meet patientFurther discussions between all needs rather than focusing on thestakeholders may be needed in these grades of staff. This alters the balancesituations, to agree the pathway for around content and structure ofrehabilitation in the community, and teams, allowing teams to behow ESD fits with this. Teams, specialised and skilled beyondincluding commissioners, may find it traditional professional boundaries,useful to talk with, or visit other according to local needs, and alsoservices who have resolved this, and leads to a greater mix and overlapusing resources such as workforce with non-health providers of care,pathway analysers and the stroke with greater emphasis on partnershipspecific education framework can also working between differentinform the process. It may then be agencies.23,24possible to agree the local definitionsaround stroke specific, stroke exclusiveand stroke skilled and develop aspecification to deliver an appropriate,safe service.22 How Agenda for Change Works, NHS Employers. January 2011.23 Rural Proofing For Health. Swindlehurst, 2005.24 Department for Communities and Local Government. 2006. 33
  • 34. Stroke rehabilitation in the community: commissioning for improvement Chapter 4: Examples of innovations in stroke rehabilitation in the community Buy in and ownership of a service • These services have found it may play a significant part in difficult to identify a cohort of Haringey initially had two access to and uptake of ESD patients suitable for an additional rehabilitation teams in the services. ESD service. This is typically resolved community for stroke; the ESD through merging ESD with the (seven day team) for eligible Improving access existing community patients and stroke (five day and uptake stroke/neurology service. team) for patients with less intensive needs. The teams Therapist anxiety around perceptions have now merged into one Some ESD services, predominantly of of role loss and a changing job model type one and two, report service that can see all patients emphasis in the hospital setting. leaving hospital through an difficulty achieving the 40% uptake of ESD. Anecdotally a number of factors approach that includes • In some areas where whole pathway working with an enablement are thought to be relevant to this. reconfiguration has been team for support with the undertaken these staff have been intensive rehabilitation work. Acute provider confidence in the encouraged to recognise that this ability of community teams to Analysis of their data had work is more relevant in a shown them that there was ensure patient safety so early in the community setting, and have been process. not a need for two separate supported to move into services teams due to insufficient where rehabilitation is the priority. patient numbers for ESD (less • This can occur where acute therapy teams have limited than 40%) requiring seven There are instances of ESD services days intensive rehabilitation. community experience and the ESD having been commissioned initially as service is community provider based By reconfiguring the service model type one or two that have model into one team over five and when the selected model evolved into models type three and requires hospital based therapy days, supported by enabling four. These models allow a greater care over seven days, they are teams to identify suitable patients cohort of patients to access earlier and the community team to provide able to see all patients. This supported discharge within the model is more effective, the service. It may be due to principles of ESD from within a historical perceptions of community exceeds the 40% standard community rehabilitation team with and has delivered cost savings. services associated with long stroke skills. waiting times for access, and traditionally providing a ‘supportive’ rather than ‘rehabilitative’ function creating reluctance or hesitation within the acute providers. Possible solutions One ESD service within Greater Manchester found that that their include closer joint working and criteria only enabled them to recruit 20% of stroke patients. The rest of rotation of therapy staff between the patients had long waits for the other community rehabilitation services. services (either generic or neurology single profession services) which they felt was not equitable or acceptable. They reorganised the services When the service is delivered by an so that all patients could access the same team, but via two streams, acute outreach service in a trust that one for ESD and the other, a stroke specific hospital to home. Patients already has a short length of stay can have six weeks ESD over five days or both depending on need. The and where there is already a team are currently working on a closer working partnership with the responsive community stroke local authority re enablement team. All patients can now access timely service. stroke skilled community rehabilitation with the result that referral rates have increased and the service is delivering more with no change in funding.34
  • 35. Stroke rehabilitation in the community: commissioning for improvementUsing telemedicine Additionally, they may have more For most, a stroke excusive challenges around the recruitment of community and ESD service is costThe use of telemedicine to support staff, especially those from the allied prohibitive, and in the very rural andrehabilitation is in its infancy, so there health professions, although staff that remote areas, a community neurologyhas been little time to establish a are recruited do tend to stay for service is not viable. In these situationsreliable evidence base to support its longer spells. looking at how to best enable existinguse. However, there is some evidence generic teams has to be considered.that occupational therapy, The national picture is of most ruralphysiotherapy and speech and and remote areas struggling to find High quality care and services forlanguage therapy assessments can be solutions to delivering the aspirations people with stroke or at risk of strokeundertaken reliably using telemedicine of the national stroke strategy. A need to be delivered by staff withtechnologies25. Telerehabilitation, pragmatic approach adopting the stroke specialist knowledge. Theincluding telephone follow up care principles of ESD, within an equitable challenge is how to ensure capability,and teleconferencing and may provide service, delivered by stroke skilled capacity, and collaborative workingan alternative when direct follow up is people offers a positive way forward. both within stroke teams and acrossimpractical.26 Other studies have providers and commissioners so thatdemonstrated using gaming The principles of planning the service there is an overall focus on delivery oftechnologies as an adjunct to are no different from those previously high quality stroke care and servicesrehabilitation.27 The inspiration for described. The difference lies in how for stroke survivors.much of the work is taken from rurally delivery can be achieved from within achallenged areas such as Australia smaller number of qualified This requires an identified person towho are adopting telemedicine within practitioners, across a wider be responsible for leading servicerehabilitation; much can be applicable geography. delivery and development, includingto remote rural services in England. development of staff as well as developing mechanisms for, and an ethos of, shared responsibility. (National Stroke Strategy, 2007).Providing stroke services in Education, training and support withrural areas • Services must be well oversight from a stroke lead can coordinated facilitate the delivery of appropriateRural areas account for approximately • Integration with existing rehabilitation for stroke patients in9.5 million residents or 35.6% of the services promotes these circumstances. They canUK population28 and present their sustainability coordinate the pathway andown challenges to providers of • Planning of services opportunities for stroke patients, andcommunity rehabilitation services. should include provision provide the specialist expertise.They have a higher proportion of for all patients, includingelderly residents than urban areas and the support and Partnership working with social caretherefore a higher proportion of rehabilitation of non ESD and integration with all existingstroke patients. They tend to have patients in primary care services is essential for long termpoorer transport infrastructures, and settings sustainability. Building relationshipsare less densely populated, resulting in • New services should not with the local hospital- based strokegreater travel times from work base to destabilise existing team can facilitate peer support,patient homes and between patients. provision or stroke expertise and improved disadvantage another coordination. patient group.25A review of the evidence of use of telemedicine. Schwamm et al, 2009.26 Tele-rehabilitation a new model for community based stroke rehabilitation. Lai et al, 2009.27 Effectiveness of virtual reality using Wii gaming technology in stroke. Saposnik, 2010.28 Office of National Statistics, 2009. 35
  • 36. Stroke rehabilitation in the community: commissioning for improvement Key considerations within a rural Information about the models of They have adopted pragmatic community service for stroke provision can be found at: solutions and their experiences can Planning and coordination of staff offer useful lessons to services activity is therefore essential to ensure struggling to deliver stroke skilled effective utilisation of resources, when u/modelsofcare/docs/Stroke_Model_of services in some of the remote rural delivering any rural community _Care.pdf areas of England. This includes services to allow for: identifying the key principles for effective ESD within community • Inreach and liaison with acute documents/initiatives/rural_stroke/ rehabilitation and establishing how providers Evaluation_of_NSW_Rural_Stroke_ this may be achieved by better • Attendance at multidisciplinary Services_2006_Phase_1_of_the_NSW_ utilisation of existing resources, and team meetings (MDTs) Rural_Stroke_Program_Gill,_Cadilhac, through more extensive and specialist • Journey planning and timetabling _Pollack__and__Levi.pdf on page 49 education and training. visits • Clustering of workload around The Australian view is that community localities rehabilitation can be equally effective • Flexible working patterns to support if delivered in the hospital via home working for data inputting, outpatients, or day hospital, or note writing and other activities. in the community. Possible models Some very rural and remote areas are considering adopting the hub and In Cumbria work has been undertaken to implement ESD in a very rural spoke model approach, through area through an existing generic community team. Through limited several small hubs of highly skilled resources of the stroke supported discharge service to support the generalists with additional stroke existing generic community team they are managing the more complex training aligned very closely with local stroke patients outside the criteria for ESD. To achieve this they have community services with a defined focussed on cross training and providing specialist support to the stroke lead and overseen by strong existing community generic team and outpatient neurology services. This leadership with a strategic voice. has been achieved through a certified education programme of up- skilling for all of the rehabilitation support workers. Consequently there Examples of provision of follow up is an increase in referrals to the generic community team, which they rehabilitation in truly remote areas can feel is due to more local confidence in the service, and the appreciation be found in New South Wales, of the support from the stroke supported discharge service. These staff specifically and more widely across in reach to provide assessment and make the decision about which Australia. pathway is suitable. Those patients appropriate for slow stream rehabilitation are referred to the neurology therapists who also support the generic community team. This creative and pragmatic approach makes good use of local resources, demonstrates effective team work, communication and a cost effective use of education.36
  • 37. Stroke rehabilitation in the community: commissioning for improvement Capitalising on pathway redesign Some successful ESD and community stroke services have developed on the back of bigger local changes associated with local pathway redesign or service reconfiguration, turning potential threats into opportunities and successes. Major changes in the location and configuration of stroke rehabilitation were planned across Northumbria. This afforded an opportunity to develop an ESD service in the community to support the new pathway. The service wasIn rural Dorset, community rehabilitation services are piloting a strategy designed by a wideto deliver ESD across a huge geographical area, covered by ten small, stakeholder group includingcommunity rehabilitation teams. Their data shows that each week one patients to include a range ofor two new patients could be transferred from the acute hospital to any bespoke support, - providedof these teams, therefore each team needs to be prepared to “catch’ the by stroke skilled staff - thatESD patient. They have adopted an integrated approach with the local could be supported to enrichstroke unit to jointly identify suitable patients, and share the transfer the rehabilitation opportunityprocess. The stroke unit specialist staff are available during the two for patients in their home. Theweek ESD period for additional support as required. The ESD pilot Lead service reduced length of stayneeded to identify therapists who had sufficient stroke or neurology in acute care by seven daystraining and experience within each of these generic teams to devise a and contributed significantlyprogramme of education and a mechanism of support for them. To to a release of £500,000 backsupport the service requirement for 45 minutes of therapy, they had to to commissioners.devise a similar approach to developing their support for staff to deliverstroke therapy and care, including competency based online packages. Itis envisaged that qualified therapists will visit the patient as often asrequired for assessment and therapeutic intervention. They will devisesufficiently detailed intervention plans and goals to allow the supportstaff to deliver functional activities and therapy up to four times per day,with availability seven days a week. The ESD Lead oversees the processof the pilot implementation, coordinating activity and measuring theimpact on patients, acute providers and the community teams, across arange of metrics, and data gathered during the first six weeks of thepilot shows very favourable results. 37
  • 38. Stroke rehabilitation in the community: commissioning for improvement Chapter 5: Commissioning stoke rehabilitation in the community The practicalities The acute tariff for stroke (AA22z and The tariff splitting process is designed AA23z HRG) is driven by the collection to reflect the localised approach to a While studies have concluded that the of reference costs and mandatory pathway of care. opportunity savings from hospital bed data. Reference costs capture the days released is greater than the cost value of the resources (cost) in the There is no simple answer resolving of the ESD service, releasing these acute setting that provides support for where a tariff should be split but it savings can be difficult. Many areas a patient with a particular health should be determined by the localised are undertaking this work, but it is problem. For stroke this is divided into arrangement of services and financial complex and requires recognition of an infarct related stroke (AA22z) or a analysis of health care systems. Work the many potential implications for haemorrhagic stroke (AA23z). Tariffs between commissioners and providers acute services beyond those for include staffing costs, overheads, to analyse the commissioner spend stroke. investigations and hotel costs. and provider costs, and capacity and demand work within the acute stroke For many community services, the cost The collection and statistical analysis pathway, should be completed before of rehabilitation is tied up within block of all associated data across acute any local discussions about splitting contracts. For others, costs can be hospitals in England is a major task. It the tariff are instigated. specifically identified. Some services is compounded by the variance in collect data showing the allocation of returns that reflect different pathways A potential starting point is the tariff resources within the different of care and access to local services. for the first three days of the stroke complexity groups, for example Therefore, tariffs are derived from the pathway; where patients may or may services in Camden and Blackburn. costs associated within the financial not receive thrombolysis. In regions Such services have the potential to year, three years prior to the year of where stroke services have shared cost their service interventions refresh/release of the tariff. So, 24/7 thrombolysis that crosses PCT based on severity of disability (see 2009/10 costs inform the 2012/13 boarders, financial flows have been ’Measuring for improvement, page tariffs. agreed to support repatriation of 30). However, for most community patients to step down facilities, when rehabilitation teams, it is not possible Three years ago a substantial amount medically fit. Details around how this to identify costs, or cost the value of of rehabilitation was being delivered has been achieved in Anglia are the service due to an absence of in the acute setting because lengths available at: metrics, or the sensitivity of data of stay were significantly longer than collected. now. The National Stroke Strategy Stroketariff/Stroketariff1pathways/ (2007) raised the profile for stroke but tabid/260/Default.aspx Traditionally stroke patients have had few ESD services were established and long lengths of stay in an acute the medical model of care, rather than setting and in community therapy or rehabilitation prevailed. rehabilitation beds. Evidence now shows that stroke patients benefit The rehabilitation costs were included from a less institutionalised approach within the acute tariff. However, to care and that delivering where ESD services or stroke skilled rehabilitation in the patient’s own community teams exist, patients are home (an enriched environment) leaving the acute environment much improves outcomes. The principle of earlier resulting in some tension splitting the stroke tariff is designed to around allocation of the resources allow the financial flows to follow the currently contained within the tariff. patient through their patient journey and associated pathway of care, supporting this.38
  • 39. Stroke rehabilitation in the community: commissioning for improvementUnbundling the stroke tariff Therefore percentages may vary as in the following worked examples.There are three approaches tounbundling tariffs that are applicable 1.Unbundling the tariff based onand have been used with stroke: the cohort that are suitable for and access ESD only• Unbundling the acute tariff based on the cohort that are This is based on a tariff that is suitable for and access ESD only unbundled with a percentage ratio of• Unbundling the acute tariff 48 : 52, where 48% of the tariff is based on overall average length retained by the provider and 52% of of stay on the acute stroke unit the tariff is retained by the• Splitting the acute tariff on a commissioner in order to fund patient by patient basis. rehabilitation including an ESD service. NB. 100% of eligible patients hereAnother alternative is to agree a relates to patients that meet the ESDnominal percentage split that reflects criteria, therefore approximately 40%the first three days of care that is of all stroke patients.accurately costed toreflect theinterventions that need Tariff unbundling: Example 1to take place duringthat time. This relates ESD team staffed to see 100% eligible patientsto the repatriation Including Social Worker LA Funding Social Workerwork done in the East No. of eligible 414 414 414 414 414 414of England and in the patientsEast Midlands. PbRguidance in 2008/09 No. of patients 414 165.6 327 414 165.6 327indicated that a accessing the servicepercentage tariff split Percentage of eligible 100% 40% 79% 100% 40% 79%to 55:45 would be patients accessingappropriate to reflect the servicethe acute care of Total cost of service £520,396.12 £520,396.12 £520,396.12 £475,492.90 £475,492.90 £475,492.90stroke patients and the required for eligiblesub-acute patientsrehabilitation phase(time and motion Unbundled from £2,113.80 £2,113.80 £2,113.80 £2,113.80 £2,113.80 £2,113.80 tariff (per patient)studies should beconducted to evidence Per patient cost £1,257.00 £3,142.49 £1,591.43 £1,148.53 £2,871.33 £1,454.11this split if reference of servicecosts are not collected Per patient saving £856.80 -£1,028.69 £522.37 £965.27 -£757.53 £659.69to specifically capturerehabilitation in the Full service/full year £354,717.08 -£170,350.84 £170,816.48 £399,620.30 -£125,447.62 £215,719.70VC04 Group 3 savingdefinition). 39
  • 40. Stroke rehabilitation in the community: commissioning for improvement 2.Unbundling the acute tariff based on Tariff unbundling:Tariff unbundling: Example 2 - Pessimist/Realist Example 2 - Pessimist/Realist overall average length ESD team staffed to see 100% eligible patients of stay on the acute stroke unit Including Social Worker LA Funding Social Worker No. of eligible 414 414 414 414 414 414 This approach takes into patients account the short stay No. of patients 414 165.6 327 414 165.6 327 tariff referenced in accessing the service HRG4 and applies the national tariff to those Percentage of eligible 100% 40% 79% 100% 40% 79% patients with the patients accessing the service national average length of stay. It is based on a Total cost of service £520,396.12 £520,396.12 £520,396.12 £475,492.90 £475,492.90 £475,492.90 population where the required for eligible average length of stay patients for eligible patients is 16 Unbundled from £1,789.77 £1,789.77 £1,789.77 £1,789.77 £1,789.77 £1,789.77 days and the average tariff (per patient) reduced length of stay for eligible patients is Per patient cost £1,257.00 £3,142.49 £1,148.53 £1,148.53 £2,871.33 £1,454.11 of service eight days. The example has therefore been Per patient saving £532.77 -£1,352.72 £641.24 £641.24 -£1,081.56 £335.66 calculated assuming the average resulting length Full service/full year £220,568.66 -£224,010.21 £265,471.86 £265,471.88 -£179,106.99 £109,761.89 saving of stay for eligible patients is eight days. NB. 100% of eligible patients here Tariff unbundling: Example 2 relates to patients that meet the ESD criteria, therefore approximately 40% 5,000 of all stroke patients. 4,500 A letter template has been created to 4,000 support the process of retrieval and 3,500 redistribution of the tariff following 3,000 PRICE adoption of this method. It is based 2,500 on a practical example that has been 2,000 used by commissioners with their local acute provider. It may be a useful start 1,500 point for commissioners considering 1,000 how to begin this process. 500 0 Stroketariff/Stroketariff4create 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 56 58 61 implement/tabid/263/ LENGTH OF STAY Default.aspx40
  • 41. Stroke rehabilitation in the community: commissioning for improvement3. Splitting the tariff on a patient Time period Tariff % paid at each range Cumulative % tariffby patient basis <1 day 0% (funded by A&E tariff 0%Through this approach the tariff is with high cost investigation)split on a patient by patient basis.Costs are derived proportional to the 0-3 days (fixed tariff) 20% 20%length of stay for the individualthrough all pathway options 4-7 days (bed day) Up to 32% 52%developing multiple trim points withinthe pathway. This includes staged Post 7 days (bed day) Up to 48% 100%commencement of excess bed days todisincentivise patients being held Post 18 days XBDlonger in the acute setting than needsbe. This is a pragmatic approach,through developing a proportionalcost in line with the reduction ofaverage length for the unit, and has The process for achieving unbundling of the stroke tariffbeen used successfully. The short staytariff would be paid in line with PbRguidance. Step 1 Ensure Clinical Commissioning Group (CCG) executive sign up and support for the intention to split the stroke tariff. The process of splitting the tariff is challenging and strong negotiation is required. Step 2 Express the intention to split the stroke tariff to the acute trust and to the wider health economy via the process of commissioning intentions by 1st October in order to effect the commencement of the next contractual year 1st April as this constitutes the required six months’ notice to change to commissioning and financial arrangements. It is advisable to split the tariff in advance of commissioning local ESD or stroke specific community service. Step 3 Work closely and in partnership with the acute trust to amicably achieve a tariff split. The principle of this process should be to ensure sustainability in the acute stroke unit but a financial contribution to the ESD service. Step 4 Evaluate and understand the local stroke pathway fully in terms of data, financial flows (block contracts or unit prices cost per case payment structure), resource allocation, contractual framework and provider performance along with patient experience. Step 5 Split the tariff locally and ensure this is added to the acute hospital contract by variation to an existing contract or captured in Section B. 41
  • 42. Stroke rehabilitation in the community: commissioning for improvement Ensure that there is: Procurement is an integral part of the Where service redesign is not possible commissioning cycle. It must be and procurement is required, fully 1. A clear strategy to monitor the transparent (open and fair) executed and successful procurement effect of ESD and the stroke demonstrate proportionality documentation may help to guide community service on acute (procurement proportionate to the commissioners through the stroke length of stay and the value, complexity and risk of the procurement process. rehabilitation service outcomes. service being procured), demonstrate A minimum data set is required non-discrimination and equality i.e. An example of procurement for both services. open to all appropriate providers to documentation, to support compete on an equal opportunity commissioning where service redesign 2. A method of flagging up in basis, with due diligence checks is not possible, can be found here: SUS* the patients that have accordingly. The provision of health qualified for a tariff split, if the care must be compliant with ESDsupportingcommissioning/tabid/ chosen approach is that of an European procurement laws and open 168/Default.aspx individualised patient approach and competitive tender is deemed to financial flows. Otherwise appropriate following a thorough More information can be found at: acute average length of stay contestability assessment. analysis will drive financial movements. An effective procurement process can A new strategy for NHS procurement help to improve quality and ensure is being developed and will be 3. Key performance indicators that value for money. This is particularly published at the end of March 2012. are clearly articulated to pertinent in times of austerity, when monitor quality in acute and there is a need to deliver savings, to community services. preserve stroke specificity and *Secondary Uses Service. A national simultaneously deliver improvements data warehouse managed by NHS 4. A process of financial flow with and increase productivity. Whatever Connecting for Health. It provides clear budgetary movement, to the local rationale for procurement, anonymous patient based data for release and redirect revenue. it can also be an effective tool for purposes other than direct opening up the market to a wider clinical care. range of providers. A more Achieving quality and value competitive market is seen to increase through procurement choice for patients, as well as encouraging improvements in service Commissioners secure services to quality and innovation.29 meet the health needs of their local populations, seeking to deliver the best combination of quality to patients and value for taxpayers. Procurement enables this by securing services through transparent engagement with providers, normally culminating in the award of a new contract to a new provider or the award of a new contract to an existing provider. 29 NHS Confederation Briefing, February 2011, Issue 215.42
  • 43. Stroke rehabilitation in the community: commissioning for improvementConclusion Different models are emerging to fit in with local need and existing quality • ESD can be the impetus for change to rehabilitation in the services. Identifying those existing community local services, and joining up specialist • Agreeing a local definition of ESD is prerequisite to developing and non- stroke specialist knowledge a service are the foundations of an effective • Identifying existing local services and joining up specialist and ESD service. Achieving an agreed local non-stroke specialist expertise creates the foundations of an definition of ESD is prerequisite to effective service agreeing the local pathway and how • Community rehabilitation services should be organised around ESD will fit and improve it. local patient need These processes can be challenging • Considering the perspectives of all stakeholders can mean but also enlightening, as they may taking a flexible approach result in the identification of a much • Community services should be commissioned for all stroke greater potential pool of resources survivors not just ESD to avoid inequity that can be realised and harnessed to • Identify quality community data and protect resources to support improvements to the pathway sustain the process for all stroke patients, and the • ESD requires a process of financial flow to follow the patient evolution of a service that is more and clear budgetary movement to release and redirect revenue. relevant to local needs. This in turn enhances buy in, uptake of the service, cost effective use of resources, value for money and therefore, theDeveloping an ESD service can be continue to be developed. As a result, sustainability of the service.complex. It supports patients to move more stroke patients are experiencingfrom a hospital setting back into their an improved pathway of rehabilitation This process is important in resolvinghomes, and therefore means building in the community, reduced time in the the tensions between the need toeffective relationships with colleagues pathway and better outcomes. minimise costs for commissioners andacross the pathway between acute local authorities, and the aspirationscare and the community and The creation of an ESD service can be for achieving clinical excellence andbetween health and social care the impetus for change to stroke ownership of the service amongservices. Early on, care needs to be rehabilitation in the community. clinicians and providers. Attention totaken to ensure that all stakeholders Irrespective of the model selected, the evidence and guidance canhave a common understanding of simply having discussions around provide the framework and awhat the service can achieve and how implementing ESD and including all willingness to adapt this to localit interacts with existing services. This potential stakeholders can be a means needs, can help to align and realisebuy in is crucial to success and of focussing attention on the existing local resources. Successful servicessustainability. pathway for community rehabilitation have typically required some degree of services for stroke, and how ESD can pragmatism by all stakeholders, butThere is no one size fits all model, or improve this. ESD can be the catalyst without any compromise of patientoff the peg solutions to each for change and improvements in outcomes and safety.challenge, and despite the existence community services for all strokeof an evidence base, agreeing a patients. In some localities it hascommissioning model and establishing provided the missing link joining upthe funding mechanisms can be far acute and community providers, andfrom straightforward. Despite these health and social care.challenges, ESD services have and 43
  • 44. Stroke rehabilitation in the community: commissioning for improvement Local finances and perspective on ‘Achieving sustainable improvement will also mean managing the tariff can influence the process significantly. Organisations taking on the challenge of service change, to provide have tackled this challenge in various ways, and some are now beginning to services closer to patients wherever appropriate and to split the tariff. But understanding the improve integration between services.... real change can full impact of this on services, the pathway, or how monies released be achieved where managers and clinicians work have been used to fund ESD, is still in its infancy. together with courage and skill where change is needed in the interest of patients and taxpayersfor example to Good quality data is crucial for all stages of the process. The value of the organisation of care for long term conditions eg the reliable data, to inform the process of commissioning ESD should not be configuration of stroke services. As well as truly clinically underestimated. Access to baseline led commissioning and a robust and diverse provider data, can facilitate the planning, selection and costing of a model for sector, service change requires the right environment at ESD and support the mechanisms for evaluation. Where services have local level, an environment in which patients, the public undertaken work to collect this and communities are highly engaged.’ information, it has provided clarity and facilitated the process of NHS Outcomes Framework, 2012 -13. Department of Health, 2011 developing and framing their ESD services. Although the challenges are many, they can be resolved through a mixture of engagement, discussion, transparency, pragmatism and determination. In this way successful ESD services can be commissioned and delivered offering stroke survivors better outcomes in the community.44
  • 45. Stroke rehabilitation in the community: commissioning for improvementReferences1. NHS Outcomes Framework 2012 -13. Department of 17. National Audit Office. Progress in improving stroke care.Health, 2011. Department of Health, 2010.2. The National Stroke strategy – Department of Health, 18. Working for a healthier tomorrow. Dame Carol Black’s2007. review of the health of Britain’s working age population. March 2008.3. Fisher R et al. A Consensus on Stroke: ESD. Stroke. AHA110.606285, published on line before print, March 2011. 19. Getting Back to Work after Stroke. Stroke Association and Different Strokes, 2008.4. Stroke Rehabilitation Guide: Supporting LondonCommissioners to commission quality services in 2012 -11. 20. National Allied Health Professional Leadership Challenge.Healthcare for London, 2005. A Toolkit. Department of Health, 2010.5. Supporting life after stroke. Review of services for people 21. Going Up A Gear; practical steps to improve stroke care.who have had a stroke and their carers. Care Quality NHS Improvement, 2010.Commission, January 2011. 22. How Agenda for Change Works [Homepage of NHS6. Langhorne al. For the ESD Trialists. Services for Employers], NHS Employers, 31 January 2011, 2011 - lastreducing duration of hospital care for acute stroke patients update [Online]. Available at:(review).Cochrane database of systematic reviews. Stroke issue 2. 23. Rural Proofing For Health: A Guide for Primary Care7. Langhorne P et al. For the ESD Trialists. ESD after stroke. Organisations. Swindlehurst H.: Institute of Rural Health.Journal of rehabilitation Medicine. 2007;39:103 -8 Wales, 2005.8. National clinical guidelines for stroke, 3rd Edition. Royal 24. Supporting People for Better Health: A Guide toCollege of Physicians, July 2008. Partnership Working. Department for Communities and Local Government, 2006.9. Life after Stroke: commissioning guide. NHSCommissioning support for London, 2010. 25. Schwamm L, et al. A Review of the Evidence for the Use of Telemedicine within Stroke Systems of Care. Stroke.2009.10. NICE Quality Standards for Stroke. National Institute for Volume 40 pages 2616-2634.Clinical Excellence, July 2010 26. Lai J, et al. Telerehabilitation - a new model for11. Equality and Excellence. Liberating the NHS. Department community-based stroke rehabilitation. Journal ofof Health, July 2010. Telemedicine and Telecare. Vol.10, no.4, pages 199-205.12. Transforming community services: enabling new patterns 27. Saposnik G, et al. Effectiveness of Virtual Reality Usingof care. Department of Health, 2009 Wii Gaming Technology in Stroke Rehabilitation. (2010) Stroke 41, pages 1477-1484.13. A simple guide to Payment by Results .Department ofHealth, 2011. 28. Rural and Urban Statistics Notes. [Homepage of Office of National Statistics] ,Office of National Statistics., 17 April14. Mind the Gap. Ways to increase access to therapy and 2011, 2009 - last update, [Online]. Available at:rehabilitation. NHS Improvement, 2011. Stroke_Model_of_Care.pdf15. Equality for All: delivery of safe care seven days a week.NHS Improvement, 2012. 29. NHS Confederation Briefing. Feb 2011, Issue 21516. Psychological care after stroke. Improving stroke servicesfor people with cognitive and mood disorders. NHSImprovement, 2011. 45
  • 46. Stroke rehabilitation in the community: commissioning for improvement46
  • 47. NHS NHS ImprovementCANCERDIAGNOSTICSHEARTLUNGSTROKENHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lungand stroke and demonstrates some of the most leading edge improvement work in Englandwhich supports improved patient experience and outcomes.Working closely with the Department of Health, trusts, clinical networks, other health sectorpartners, professional bodies and charities, over the past year it has tested, implemented,sustained and spread quantifiable improvements with over 250 sites across the country aswell as providing an improvement tool to over 2,000 GP practices.NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NBTelephone: 0116 222 5184 | Fax: 0116 222 Publication Ref: NHSIMP/Stroke0001 - July 2012 ©NHS Improvement 2012 | All Rights ReservedDelivering tomorrow’simprovement agendafor the NHS