Community Intermediate Care Service

1
Community Intermediate Care Service

• Early Stroke Supported Discharge Team

2
Development of the Service

• What used to happen in Croydon?
• Mayday stroke unit
• Community Neuro Rehab Team
• Community Intermediate Care Service
• Social Services
• Stroke Association Family and Carer Support
  Worker / Dyphasia Support Group

3
Options for ESSD Team

• Create a new team
• CNRT to expand
• Shared intervention from CICS and CNRT e.g. CICS
  support workers to provide visits to assist with
  personal care meal prep and CNRT to lead
  rehabilitation
• CICS to become the ESSD team and CNRT to continue
  with longer term rehabilitation
• CNRT to provide rehabilitation supported by
• social services care packages

4
Decision

• CICS to expand and increase specialism to create
  early stroke discharge team within Intermediate
  Care Service
• Increased staffing for CNRT to allow a reduction
  in their waiting list

5
Challenges we faced

• Training competencies
• Setting up a Stroke Discharge Team within an
  already busy Intermediate Care Team
• Data collection
• Setting up a service when not quite sure what the
  demand will be

6
Staffing ESSD Team

• 2 Band 7 OTs
• Band 7 Physio
• Band 6 Physio
• 0.5 Band 7 SLT
• 2 additional GSWs
• Input from CICS DNs
• Input from CICS mental health nurse

• Stroke co-ordinator
• Care manager
• Dyphasia support worker
• Family support worker

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Criteria

• Patient needs assistance with personal activities
  of daily living / mobility due to cognitive or
  physical problems
• Patient has rehabilitation potential
• Patient is medically stable
• Also role with supporting complex discharges e.g.
  oversee high risk discharges for 48 hours to iron
  out potential problems and provide source of
  support

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ESSD Team Service

• Provide service from 7am to 9.30pm 7 days a week
• Provide up to 4 visits per day to a patient in
  their own home or support patient in Intermediate
  Care Bed in NH
• Provide input from nurses physiotherapists
  occupational therapists speech and language
  therapist mental health nurse and generic
  support workers
• Intervention can be for up to 12 weeks

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Intermediate Care Stroke Beds

• 2 3 beds in a designated Nursing Home
• Aim of a minimum of one timetabled visit every
  day from CICS staff
• Access to weekly art group and chaplaincy
• Rehabilitation room and kitchen
• 2 designated HCAs for ESSD patients

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Referral and Assessment

• Patient referred to ESSD team
• Assessment completed by nurse and therapist on
  the ward prior to discharge
• If appropriate joint treatment session / home
  visit between ESSD therapist and ward therapist
• Therapist and Nursing assessments completed on
  the day of discharge from hospital

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• Copy of patient led goals kept in office notes
  and home notes and reviewed with patient weekly
• Weekly Early Supported Stroke Discharge Team
  meeting to discuss patients review goals and
  plan discharge/onward referral with stroke
  co-ordinator and designated stroke care manager
• Once patient can manage PADL, or has an
  appropriate care package in place, their
  rehabilitation is passed onto the CNRT (if
  further rehabilitation goals are identified)

12
CNRTs Role in the Pathway

• MDT rehabilitation in the community / patients
  home / gym / clinic setting for up to 14 weeks
• Neuro-psychology input
• Return to work / education / leisure
• Driving screen

13
Case Study

• Mr T 23/10/09 extensive left MCA infarct.
• Dense right hemiplegia expressive and receptive
  dysphasia
• Discharged home to house with wife. Sliding board
  transfers and bed set up downstairs.
• On warfarin

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ESSD Team Intervention

• 4 visits per day to assist with personal care
  toileting and rehabilitation
• Nursing intervention for INR / Warfarin
• Physiotherapy to progress mobility / educate wife
  regarding transfers / strength / balance
• Speech and Language Therapy for dysphasia
• Occupational Therapy for personal care / upper
  limb management / cognitive assessment
• Mental Health Nurse input for assessment of low
  mood

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• Visits reduced to twice daily for rehabilitation
  as patients mobility progressed and independence
  improved
• Referral made to Stroke Association Family
  Support Worker
• After 12 weeks patient was able to manage ADLs
  with minimal supervision of wife, had returned to
  sleeping upstairs and was walking with a stick.
• Rehabilitation was taken over by the CNRT

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• Rehabilitation continued for 14 weeks by CNRT to
  improve and progress outdoor mobility
• Returned to hobbies e.g.gardening
• Continued SLT input
• Dysphasia support group / ongoing SLT group
• OT completed driving screening

17
Audit and Patient Involvement

• Plan is to audit the ESSD service against the
  Healthcare for London stroke guidelines.
• Patients and their carers are asked to provide
  confidential feedback through a questionnaire.

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Problems

• Demand for beds is greater than what we can
  accommodate
• Some patients are picked up immediately by CNRT
  but there are occasional delays
• Difficulties of being a stroke team within a
  larger Intermediate Care Team
• Additional resource for service provision does
  not meet the demand

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Measuring Success

• Community Stroke Service (ESSD team and CNRT)
  will support acute trusts in achieving 90 of
  stroke patients spending 90 of their time in an
  acute stroke ward target by facilitating timely
  and early discharge.
• There will be no excess bed days within secondary
  care.
• Discharge destination
• Improving independence as demonstrated by the
  Community Dependency Index

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Areas for Improvement

• Communication between teams. New stroke
  co-ordinator will play a large role in
  facilitating transfer of information. Care
  manager will prevent delays in organising care
  packages / benefits.
• Increased number of stroke beds would mean more
  patients can be discharged from the stroke unit
  sooner. This would require more staff.
• Potential to have access to gym space for home
  based patients.
• Improving links with other organisations e.g.
  Active Lifestyles to improve long term management
  of patients

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• The real message is that I still have a number
  of problems but, with your help, Ive been able
  to go out and achieve things anyway