Stroke rehabilitation in the community: commissioning for improvement


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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

  1. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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