Stroke rehabilitation in the community: commissioning for improvement

NHS
CANCER
NHS Improvement
Stroke

DIAGNOSTICS

HEART

LUNG

STROKE

Stroke rehabilitation in the community:
commissioning for improvement
An information resource for providers and
commissioners of stroke rehabilitation and
early supported discharge services in the
community

Acknowledgements
Co-authors

David Broomhead, MCSP.SRP
Physiotherapy Service Manager, North
Lincolnshire and Goole NHS Foundation Trust

Pam Green, BSC (Hons) MSCP
Specialist Physiotherapist and Assistant
Director Contracting N.E. Essex

Jill Lockhart, MCSP. SRP
National Improvement Lead - Stroke, NHS
Improvement

Tracy Walker, BAOT. MSc
Stroke Lead and Clinical Specialist
Occupational Therapist Community Stroke
Service, Lancashire Care NHS Foundation
Trust

Advice and support

Steve Pruner
Commissioning Officer Adults, Health &
Community Wellbeing, Essex County Council

Michael Kaiser
Healthcare Commissioning Consultant,
NHS Improvement – Heart

Thank you

Thank you to all the early supported
discharge (ESD), community stroke and
neurology teams who shared information
about their services with us, and
the cardiac and stroke networks, including
commissioners, who answered our questions
and shared their knowledge with us.

Stroke rehabilitation in the community: commissioning for improvement

Contents
4 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 community
10 • Tariff progress for stroke
11 • Commissioning for stroke rehabilitation - guidance

12 Chapter 2: Defining and developing a community service for stroke
12 • Understanding what good looks like
13 • Developing a good service - the process
14 • What influences and shapes the selection of a local model for ESD
15 • Models of delivery
21 • Practical help in understanding your local services
22 • Opportunities to realise economic benefits through community rehabilitation
24 • Useful tools to help understand the local picture
25 • Developing an integrated approach between health and social care

27 Chapter 3: Planning for improvement
27 • Engaging stakeholders
29 • Tools to support the process
30 • Measuring for improvement
32 • Effective leadership, management and workforce

34 Chapter 4: Examples of innovations in stroke rehabilitation
34 • Improving access and uptake
35 • Using telemedicine
35 • Providing stroke services in rural areas
37 • Capitalising on pathway redesign

38 Chapter 5: Commissioning stroke rehabilitation in the community
38 • The practicalities
39 • Unbundling the stroke tariff
41 • The process for achieving unbundling of the stroke tariff
42 • Achieving quality and value through procurement

43 Conclusion

45 References

3


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


‘It will be equally important
that, as more decision making
is taken locally to reflect the
needs of patients and the
clinicians who support them,
the NHS does more to integrate
service delivery, not only across
primary and secondary care
but also with social care
organisations. Each sector
needs to look at where it can
work better with partners,
including voluntary
organisations, so that services
are organised around the
interests of patients and service
users rather than institutions.’1

‘Stroke rehabilitation in the For stroke community services this
community - commissioning for may mean starting off small and a
improvement’ provides key step by step process. It requires
stakeholders with information to stakeholders to look at the wider pool
support them with the process of of people who impact on the local
developing rehabilitation services for stroke survivors’ environment, many
stroke survivors in the community. It of whom are not exclusively stroke
includes examples of good practice, skilled, and how this can be
and information about service models addressed. With education and
implemented in England. It explores training, support and time, the pool
factors which influence local of stroke skilled people within a
commissioning and identifies tools to community across health, social care,
assist with the process of the voluntary sector and local support
commissioning and funding of organisations can be widened. By
rehabilitation for stroke survivors in bringing these people together with
the community. This is particularly clinical communities, patients and
important at this time of major commissioners, cost effective and
change within the NHS. A different meaningful rehabilitation in the
commissioning landscape is emerging community can be delivered.
along with a new outcomes
framework and positioning of stroke
within long term conditions.

NHS Outcomes Framework 2012-13. Department of Health, 2011.
1

5


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


Existing evidence and They recommend an intensity of ESD
guidance to support and state, ‘for the time they would ‘The team went about
otherwise have been receiving
rehabilitation in the inpatient rehabilitation (usually up to achieving my aims and
community two weeks), stroke survivors receive at whilst doing so made it
least five sessions per week of fun for me and I looked
Early 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 working
including work by Langhorne6,7 and survivor is carried out by qualified
the ESD consensus work from professionals, some care may be with me and filling me
CLAHRC. The latter states that ESD delivered by therapy assistants under with confidence and
teams should be stroke specific and the supervision of a qualified
multidisciplinary, offering co-ordinated enjoyment and I soon
professional. Following this initial
and planned discharge from hospital intensive period, the therapy regime made very quick
and continued rehabilitation when then reverts to the level of normal progress. While I know I
patients are settled at home. The community rehabilitation.’
intervention is beneficial for a subset had to put in a lot of
of the patient population; those of The Royal College of Physicians8 (RCP) effort, their kind friendly
mild-to-moderate stroke severity. guidance around intensity states, ’ESD
Strong links are required between the nature I would say
is designed to give eligible stroke
acute service and the ESD team, with patients rehabilitation in their own played a big part. The
both hospital staff and ESD team home at the same intensity as greatest pleasure and
members identifying patients. To inpatient care.’
measure effectiveness, ESD teams credit I could give them
should use standardised assessments The National Stoke Strategy2 (2007) was my progress. If
to monitor stroke severity, comments that, ‘the number of
dependency, activities of daily living anyone wants to know
patients suitable for ESD will also vary
and satisfaction as well as the impact according to eligibility criteria, but in if the scheme works
of the ESD service on length of stay trials an average of 41% of patients they only have to look
and readmission rates. were found to be suitable.’
at my happy progress.’
Healthcare for London (HfL) guidance
describes ESD as enabling a seamless Taken from a patient’s
transfer of care from hospital to thank you letter
home. This gives stroke patients the
opportunity to continue rehabilitation,
while being supported in their own
surroundings and with input from a
specialist stroke team.

6Langhorne et al, 2005.
7Langhorne et al, 2007.
8National Clinical Guidelines for Stroke, RCP, 2008.

7


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


c) The use of specialist and non- d) The process
specialist services HfL expresses how this can be
The National Stroke Strategy states, delivered:
’specialist teams may be more
important in the early stages of • Where effective community
rehabilitation, while generic teams can rehabilitation teams are in place ESD
be appropriate for the later stages. services should be offered. ESD
However, the configuration of services should have appropriate
community teams is less important staffing levels to provide ESD for
than ensuring that these teams are suitable patients
multidisciplinary and all staff have the • Every PCT should ensure access to a
right specialist skills to help specialist stroke community
rehabilitate people who have had a rehabilitation service before
stroke.’ developing an ESD service
• An ESD service is an addition to
HfL guidance indicates that, ‘every effective community rehabilitation.
primary care trust (PCT) should • An ESD service could be provided by
commission a community an appropriately resourced
rehabilitation service for stroke community stroke rehabilitation
patients, delivered by staff with team
specialist stroke skills. Service • There may be benefits to having the
configuration should be locally ESD team and community
determined. Every PCT should rehabilitation team in one location.
commission an early supported If appropriate, this would allow for
discharge service for people who the sharing of resources, such as
would benefit. This service should social workers, speech and
include staff with specialist stroke language therapists, clinical
skills and must meet all of the psychologists; improved
performance standards. communication between
professionals on the stroke
pathway; and a more seamless
transition of care for the client
between services.

9


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 www.dh.gov.uk/health/2012/02/
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 www.improvement.nhs.uk/stroke/
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


Commissioning for stroke The RCP (2008) set the context,
rehabilitation - guidance responsibilities and the challenge for
commissioners of stroke services
1. National Stroke Strategy stating, ‘rehabilitation services are
2. NICE Quality Standards for best delivered as close to the patient’s
Stroke own environment as is compatible
3. RCP National Clinical Guidelines while ensuring the patient’s care and
for Stroke well-being, and taking into account
4. 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 power
5. Life after stroke; Commissioning taking into account evidence and
guide. NHS Commissioning maintenance of core services.’
support for London
Commissioning organisations must
Commissioners may choose to commission a service capable of
establish key performance indicators delivering specialist rehabilitation at
as part of a tendering processor to home in liaison with inpatient services,
incentivise provider performance as recommended in the guidelines.
through the mechanism of
Commissioning for Quality and • Consider the overall organisation of
Innovation CQUIN payment services delivered to their
framework. population
• Specialist services in relation to the
More details are available at: overall population need, rather than
www.dh.gov.uk/en/Publicationsand specifically in relation to stroke.
statistics/Publications/Publications
PolicyAndGuidance

An example of CQUIN to support
stroke rehabilitation can be found
here: www.improvement.nhs.uk/
stroke/ESD/ESDsupporting
commissioning/tabid/168/
Default.aspx

Decisions on commissioning should
also take account of the cost
effectiveness of the service, plus any
related costs, and include attention to
stakeholder views, including the views
of patients.

11


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 www.improvement.nhs.uk/stroke/
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


Developing a good service - The purpose and aims of the Partnership working with secondary
the process community rehabilitation for stroke, care stroke services and social care can
including ESD services should be support the design of a pathway and
The process begins with defining and informed by attention to current ensure that the service model selected
agreeing 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 and
community and how this will be learning about examples of good stroke networks are often ideally
measured through key performance practice, and practical evidence placed to coordinate this process.
measures both clinical and service. available from other sources, such as
This helps with understanding what the NHS Improvement community An example of a service specification
existing local services provide, where stroke resource at: for community rehabilitation,
the gaps are and what might need to www.improvement.nhs.uk/stroke/ including ESD, can be found on the
be done to build a service from CommunityStrokeResource/tabid/204/ South London Cardiac and Stroke
scratch or to improve or transform Default.aspx and the Department of Network web site at:
existing community services to be fit Health publication ‘Transforming www.slcsn.nhs.uk/research.html
for supporting stroke survivors and community services (rehabilitation)12
delivering ESD. In many instances the enabling new patterns of provision’ More examples can be found on the
local discussions around how to at: www.dh.gov.uk/prod_consum_dh/ NHS Improvement website at:
implement ESD have been the catalyst groups/dh_digitalassets/documents/ www.improvement.nhs.uk/stroke/ESD/
for change across the community digitalasset/dh_093196.pdf ESDsupportingcommissioning/tabid/
rehabilitation pathway for all stroke 168/Default.aspx
patients and have galvanised local A detailed service delivery model can
communities into delivering be planned and produced based on a
improvement. local service specification. This will
vary depending on local
A business case should be developed demographics, patient population
in support of securing a properly needs and approach to specialist
commissioned community commissioning. Engagement and
rehabilitation service, within contribution from patients and carers
whatever model is agreed locally. is essential as part of the process of
building the detail within the model. It
An example of a business case should also include suitable metrics to
can be found at: collect.
www.improvement.nhs.uk/stroke/
Stroketariff/Stroketariff1pathways/
tabid/260/Default.aspx

Transforming Community Services: Enabling new patterns of provision DH 2009
11

13


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 www.improvement.nhs.uk/stroke/ESD/
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


Models of delivery

A range of models is emerging across
England to deliver the principles of
ESD. This includes acute based,
community based, and hybrid models,
that broadly fall into one of five
categories.

1. Stand-alone/acute outreach
ESD only
2. ESD with community
stroke/neurology team service
3. Integrated ESD within
community stroke team service
4. Integrated ESD within
community neurology team
service
5. ESD hybrid

These are detailed in the following The costing model (see ‘Useful tools
tables and include cost per case to support the process, (Page 29) will
information, derived from the skill allow commissioners and providers to
mix information and referral detail, cost services more accurately including
provided by the teams who have the local costs where they are known.
shared their service model details with The costs of services used here are
NHS Improvement - Stroke. The posts indicative and relate to the
have been costed at the midpoint of configuration and integration of the
the Agenda for Change band in all services as a comparator to the five
cases inclusive of on costs (national groups of services that have been
insurance, pension etc.). Non pay noted in the community and are real
costs, travel expenses and fixed asset commissioning solutions.
costs have not been included in the
calculations as these have not always
been available, so the staffing costs
act as a proxy for the cost of the
service. Where two teams share the
pathway, such as models three and
four the costs should be added
together to give a pathway cost.

15


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 £1,132

16


Model 2
ESD services with a pathway into a community stroke team or a community neurology services

Frequently created before the National Stroke Strategy, these community services are more mature and established
services, which have been shaped and developed further. They work alongside ESD teams, (out-reach or in-reach). Many
services initially of this category have subsequently been developed into model three or four. Typically reasons for this
are insufficient cohort of patients to justify a separate ESD service, perceived expense of the ESD component and where
the model was deemed to be creating a two tier service for stroke patients locally. The model offers all the components
of model one with additional opportunities from specialist follow on 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

• All dependency levels catered for, mild to complex severe

• 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

• 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

• 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


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.


• Typically goal directed approach, so available for as long as required (range three months to one year)

• Up to 100%

• One pathway for all patients, through a coordinated discharge/rehabilitation process led by the team

• All dependency levels, from mild to complex severe

• Usually no wait and immediate access to supported discharge/rehabilitation .Typically these services coordinate and lead the
transfer from hospital to home

• All groups of patients can access timely rehabilitation including, ESD/non ESD from acute care, care homes, and
community-based patients

• 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

• 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 £2,502

18


Model 4
ESD delivered within an integrated community neurology service

These services have a wider remit to include neurological conditions therefore have experience and skills with
management of with very complex presentations. They tend to be more prevalent in rural, less urban areas, or where
there are issues recruiting (specialist) staff or smaller stroke populations. Some of the services in this model have
re-enablement/health care domiciliary support workers to support with seven day rehabilitation, multiple visits a day for
up to six weeks. A comprehensive model offering all the components of models one, two and three and additional
elements.


• Typically adopt a goal directed approach, so the services are available for as long as required (range three months to one year)

• Up to 100% of patients

• One pathway for all patients; coordinated discharge/rehabilitation via the team

• All dependency levels of stroke patients mild – complex severe, and neurological patients

• 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

• All groups of patients can access the service including, ESD/non ESD from acute care, residential care and community based locations

• 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

• 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


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.


• Usually time limited (range six weeks to 12 weeks)

• Varies depending on individual criteria but usually there are higher percentages of patients than traditional ESD models, but
lower than 100%

• Two pathways, ESD and non ESD pathway

• All dependency levels of stroke patients mild to complex severe

• 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

• Patients who do not meet the criteria
• Community-based patients who have not been admitted to acute care

• 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

• 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 £5,162

20


Practical help with
understanding your local
services

There are many documents and
resources to assist with the process of
identifying what you need to know to
understand your current services and
help with any planned improvements.

• ESD Toolkit • Equality for all: Delivering safe care Working out how much
www.improvement.nhs.uk/stroke/ seven days a week, produced by ‘good’ costs
ESD/tabid/160/Default.aspx NHS Improvement15 The evidence suggests ESD is cost
www.improvement.nhs.uk/ effective, however establishing local
• Community Stroke Resource SevenDayWorking/tabid/218/ costs and benefits of wider
www.improvement.nhs.uk/stroke/ 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
www.improvement.nhs.uk/stroke/ www.improvement.nhs.uk/stroke/ 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.
www.dh.gov.uk/health/2012/02/ (CQC) report Agreement and understanding of the
confirmation-pbr-arrangements www.cqc.org.uk/public/reports- 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
www.stroke.org.uk/information/ had-stroke-and-their will in turn direct the focus on service
our_publications objectives.
• Delivering Quality, Innovation,
• Different Strokes Productivity, Prevention (QIPP)
www.differentstrokes.co.uk www.improvement.nhs.uk/qipp

• Social Care for Stroke • Measurement tools and
www.improvement.nhs.uk/ practical modules
stroke/SocialCareforStroke/tabid/ http://system.improvement.nhs.uk/
89/Default.aspx ImprovementSystem/Login.aspx?
ReturnUrl=%2fImprovementsystem
• Mind the Gap14 %2fdefault.aspx
www.improvement.nhs.uk/stroke/
Rehabilitation/tabid/285/
Default.aspx

14Mind 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


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:
www.improvement.nhs.uk/ 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


Working for a healthier tomorrow18, A study of 3,000 younger stroke
advised that, ’Healthcare professionals survivors by Different Strokes19 (a
The Department of Health’s
should consider a return to stroke charity for younger stroke
workstep employment support
appropriate work as an important survivors) found that 75% of the
programme for people with
outcome in the treatment and support respondents wanted to return to
disabilities is delivered by
of patients where possible. The NHS is work, and gave a range of reasons
Bootstrap Enterprises in
currently considering patient why this was not possible. These
partnership with Blackburn
pathways for those with major long- included being forced to retire by their
with Darwen Borough
term conditions. For those of working employer, being unable to drive or use
Council. This service is
age, this should, where appropriate, public transport, fear of losing
accessed by the local
include a consideration of work- benefits and feeling unable or not fit
community stroke team for
related health and the steps necessary enough to do their previous job.
support with return to work.
to help the patient to move back into
employment’. A more recent study also suggests
More detail is available at
that stroke survivors who have not
www.improvement.nhs.uk/
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: www.differentstrokes.co.uk/research/ investment to be redirected towards
www.improvement.nhs.uk/ 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


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 www.improvement.nhs.uk/stroke/
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 www.improvement.nhs.uk/stroke/
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


Bed modelling tool Staff calculator tool To achieve safe and timely discharges
In Essex, a stroke bed capacity and The UKfST have created a workforce of patients from the acute sector into
ESD impact evaluation model has calculator. This electronic tool can ESD/community stroke services it is
been used by commissioners to assist users to work out staffing and essential that health teams integrate
understand and support their work skill mix requirements to deliver with social care teams. Ideally stroke
around commissioning ESD services. services and support calculations skilled social workers should be
It can be applied to community around amount of clinical time embedded into the ESD with an
rehabilitation models. available from varying skill mix inreach role onto the acute stroke
combinations. unit, to enable early identification of
www.improvement.nhs.uk/stroke/ESD/ patients needing social care packages
ESDsupportingcommissioning/tabid/ More information is available at: and the mitigation of social
168/Default.aspx http://breeze01.uclan.ac.uk/SSEF/ circumstances that may preclude
timely discharge.
Data gathering More information to support
It is crucial to gather as much stroke workforce analysis and design can A key role of the social worker should
specific data as is available for analysis be found on the NHS Improvement - be to elicit the support of reablement
to work out the patient flows in the Stroke website at: teams to work alongside the ESD
acute stroke unit and the income that www.improvement.nhs.uk/stroke/ team at the point of discharge for
this currently generates from tariff. Increasingaccesstotherapy/Increasing these patients. Those receiving ESD
Clinical engagement is essential at this accesstotherapyMeasuring/tabid/ support should not be restricted from
stage so that teams can provide 301/Default.aspx accessing reablement funding and
additional information that cannot be support. ESD teams may work
captured through Secondary Uses alongside reablement colleagues to
Service (SUS) data i.e. mimic stroke
Developing an integrated ensure the patient is getting the
data and bed consumption for those approach between health therapeutic care they require to
patients that do not end up being and social care develop their rehabilitation plan. The
coded as AA22z or AA23z in the simultaneous benefit of this is that
data set. Where health and social care services reablement colleagues learn stroke
work together to facilitate a smooth specific skills and handling by
Assumptions then need to be made return home for patients it can help working alongside the experienced
around the impact that the ESD people recover quickly, reduce the ESD clinicians and rehabilitation
service will have on the acute bed pressure on the individual and their workers.
length of stay. It is advisable as per family and prevent unnecessary
the model tool to establish a best case readmissions to hospital or care
scenario, baseline impact and a worst homes (National Stroke Strategy,
case scenario in order to reassure the 2007). Involving social workers in
acute trust of the impact by cohort the multidisciplinary team at an
rather than on a case by case basis; early stage is an effective way to
the benefits of ESD on the acute stay achieve this.
will only be realised when it has
impacted on length of stay.

25

Stroke rehabilitation in the community: commissioning for improvement

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