Beyond the Bathboard: Work and Community Participation after Stroke

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Beyond the BathboardWork and Community
Participation after Stroke

• Yashashree Bedekar
• Occupational Therapist, Vocational Rehabilitation
• Tower Hamlets PCT
• Yashashree.bedekar_at_thpct.nhs.uk
• 0208 223 8841

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What are your goals?

• Go shopping with my daughter
• Play cards
• Use my hair straighteners
• Go on e-bay
• Run a marathon
• Go back to work

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Context of stroke

• 25 strokes in those under 65 years
• Most disabling condition with consequences in
  health, social services and benefits sectors
• 1.8 billion in lost productivity and disability
• Top three unmet needs reported by young people
  after stroke provision of information financial
  assistance and lack of intellectual fulfilment
• (The Stroke Association, Kersten et al)

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Work- definitions

• Employment paid work in a formal setting
• Work a range of purposeful activities, which may
  or may not be paid
• Volunteering
• Study
• Extended ADLs
• Participation in community life

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Work matters

• Quality of life and work
• Links between worklessness and poorer health
• Representation of people with disabilities in
  workforce
• DDA
• Incapacity benefits and mortality

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What is Vocational Rehabilitation?

• A process to overcome the barriers an individual
  faces when accessing, remaining or returning to
  work following injury, illness or impairment
  which includes
• The procedures in place to support the sick
  individual and/or employer or others (e.g. family
  and carers),
• Help to access vocational rehabilitation
• Help to practically manage the delivery of
  vocational rehabilitation
• (DWP, 2004, p 14).

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Vocational Rehabilitation for stroke

• Close interplay of
• Core stroke rehabilitation- MDT working
• Rehabilitation for work retraining of skills,
  adaptation to disability, task analysis,
  workplace assessment
• Knowledge and application of employment law/DDA
• Knowledge and application of benefits system
• Interlinked with family/carer needs

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Key Documents User views

• Different Strokes Work After Stroke (2002)
• 74.8 respondents wished to return to work after
  stroke
• 42 were able to return to work
• Barriers for return to work included
• Lack of access to specialist staff
• Pessimistic attitude of healthcare professionals
• Rehabilitation goals aimed at minimal function
• Insufficient scope or duration of rehabilitation
• Enablers for return to work included
• Support and advice re their condition and
  employment
• Liaison between rehabilitation professionals and
  employers
• Occupational therapists

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Key Documents Pensions and Health

• Working for a healthier tomorrow Black, 2008
• Vocational Rehabilitation Inter-agency
  Guidelines BSRM/RCP/DWP, 2004
• National Clinical Guidelines for Stroke, 2008
• National Stroke Strategy, 2008

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Putting guidance to practice NCGS

• 6.49.1 Recommendations
• A Every person should be asked about the
  vocational activities they undertook before the
  stroke.
• B Patients who wish to return to work (paid or
  unpaid employment) should
• have their work requirements established with
  their employer (provided the patient agrees)
• be assessed cognitively, linguistically and
  practically to establish their potential
• be advised on the most suitable time and way
  to return to work, if this is practical
• be referred to a specialist in employment for
  people with disability if extra assistance or
  advice is needed (a disability employment
  advisor, in England).
• C Patients who wish to return to or take up a
  leisure activity should have their cognitive and
  practical skills assessed, and should be given
  advice and help in pursuing their activity if
  appropriate.

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Practical application

• 1 Part of rehabilitation pathway
• NCGS- early identification of work issues
• Occupational therapy core remit
• MDT involvement in assessment process
• Case Study Elaine

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Putting guidance to practice National Stroke
Strategy

• Commissioners will want to consider engaging a
  wide range of provision, including provision from
  the third sector, to meet the needs of the local
  population. Services should also be appropriate
  for all ages one quarter of people who have a
  stroke are under 65 and may have particular
  needs.
• In 6 months post discharge, 50 receive the rehab
  they need at 12 months 20 receive this.

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Practical application

• 2 Intensity of core rehabilitation by
  appropriate professionals, and long-term support
• BSRM/NCGS/Stroke Strategy
• Case study Abdul
• Seen by specialist community team following
  discharge (OT, SLT, Psych)
• Local community centre for resources

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Putting guidance to practice An Inter-agency
Framework
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Practical application

• 3 Interagency links with DWP, non-statutory
  organisations
• Stroke Strategy, Inter-agency guidelines
• Case Study Carl
• Seen by community stroke team
• In-reach and follow-up by specialist voc rehab OT
• Referred to local disability gym- physio
  involvement

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Meeting long-term needs

• Timeliness of intervention
• Intensive rehabilitation as well as long-term
  adaptation
• Sharing of information across agencies
• Understanding of stroke and consequences
• Employers, families, social settings
• Routes back in for review and top-up input
• Retention of roles- not just acquisition
• Opportunity for 3rd sector partnership working

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Vocational Rehabilitation models

• Specialist Vocational Rehabilitation Programs
• Stroke Pathway Teams with extended rehabilitation
• Local/ regional centre for long-term support-
  health and voluntary sectors
• Inclusion into mainstream healthcare
• Intensive, specialist MDT stroke rehabilitation
  in the pathway
• Specialist vocational rehabilitation staff (OT,
  psych)
• Extended therapy input for meeting participation
  goals
• Links with DWP/voluntary sector for long-term
  needs

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Example of Stroke VR THPCT

• Specialist vocational rehabilitation for stroke
  and neurology client groups
• 1 WTE OT, 8a
• 1 WTE TA, 4
• Sessional neuropsychology
• Based with stroke and neuro teams
• Inreach/outreach at acute, inpatient and
  community
• Developing partnerships with local voluntary
  group organisations Volunteer centre, Tower
  Project etc
• Promoting and developing voc rehab skills across
  relevant teams

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Measurement tools/outcomes

• LTC working group/HfL standards for vocational
  rehabilitation- in progress
• LTC/BSRM Implementation guidelines for
  vocational rehabilitation for people with long
  term neurological conditions- in progress
• Audit of casenotes- RCP/NCGS
• Hierarchy of work outcomes
• Retention of outcomes 12, 24 months

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The bottom line

• Vocational rehabilitation should be part of
  mainstream healthcare for stroke
• Assessment and treatment of work issues begin at
  inpatient level OT/psychology staffing levels to
  support this
• Consider links with voluntary organisations for
  long-term social participation needs
• There will be auditable standards for VR
  interventions

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What are our goals??