DEVELOPING A COMMUNITY STROKE TEAM

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DEVELOPING A COMMUNITY STROKE TEAM

• Tracy Walker
• Clinical Specialist OT
• Team Leader Community Stroke Team
• NHS Blackburn with Darwen

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SPECIALIST COMMUNITY STROKE REHABILITATION? WHY

• Cochrane review services to reduce hospital
  length of stay 2005 ( early supported discharge
  trialists) provided evidence for
• i) Reduced length of stay (8 days)
• Patients more likely to remain at home long-term
• Regain independence in activities of daily living
• Greatest benefits were seen in the teams which
  were well organised discharge teams and patients
  with mild to moderate dependency (median of 41
  of stroke patients met criteria for ESD, Barthel
  14/20).

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SPECIALIST COMMUNITY STROKE REHABILITATIONCONTD

• RCP Guidelines 2004 Discharge early only to
  specialist coordinated multidisciplinary
  services, when patient able to transfer with one.
• RCP 2008 Domiciliary rehab services should be
  commissioned as part of early supported
  discharge scheme to provide specialist rehab at
  home and as well as in the longer term.
• Patients in care home or house bound should have
  access to specialist rehabilitation post
  discharge.

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STROKE STRATEGY

• New Stroke Strategy
• i) Commissioners should contract for ESD
  teams for stroke patients based using asset to
  determine correct levels.
• ii) Develop ongoing rehab in the community
  provided by stroke skilled staff.
• iii) Expert patient programmes to support
  self care, community based and peer delivered
  activities involving people who had a stroke i.e.
  conversation groups or peer support.

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STROKE STRATEGY GUIDELINES

• Specialist teams maybe more important in the
  early stages of rehabilitation while generic
  teams more appropriate at later stages.
• Configuration of team is less important than
  making sure these teams are multidisciplinary and
  have specialist skills to help rehabilitate
  stroke patients.
• When patients are transferred from stroke unit
  to intermediate care better outcomes can be
  achieved with specialist MDT teams with
  specialist input remaining to oversee management.

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CHALLENGES IN SETTING UP APPROPRIATE SPECIALIST
COMMUNITY STROKE OR ESD TEAMS

• Establishing correct model of service provision
  which meets needs of stroke patients inpatient
  and community
• Establishing correct staffing levels and skill
  mix within the team to ensure patients needs are
  met and adequate rehabilitation provided.
• Ensuring the team can respond quickly to
  coordinate timely discharge whilst balancing
  daily rehabilitation.
• Establishing and developing partnership working
  across other organisations and services to ensure
  all patients need are met in a coordinated timely
  manner.

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DIFFICULTIES SETTING UP APPROPRIATE SPECIALIST
COMMUNITY STROKE OR ESD TEAMS

• Ensuring that patients receive enough community
  stroke team rehabilitation Managing throughput
  effectively.
• Ensuring staff have appropriate stroke specialist
  skills on the team and continued investment in
  development for EBP.
• Ensuring provision of training to other
  organisations staff who may be supporting the
  specialist team
• Using adequate outcome measures to provide
  evidence your service is meeting targets set,
  increasing functional abilities/independence,
  keeping people at home and not causing harm.

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NHS BLACKBURN WITH DARWEN MODEL OF COMMUNITY
STROKE REHABILITATION PROVISIONOUR EXPERIENCE

• Combined early supported discharge and longer
  term rehabilitation with extended upper and lower
  limb clinics.
• Initially a review of patient need was made to
  establish the levels of dependency of stroke
  patients and support needed for early discharge
  which influenced our service structure.
• Flexibility of criteria existed early into the
  team development in order to ensure the service
  was responsive to patient need.
• .
• The team has never limited itself to ESD only and
  has since grown over the last two years in
  response to stroke patients rehabilitation needs.

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COMMUNITY STROKE TEAM PATHWAS OF REHABILITATION

• Established four pathways which form the basis of
  our model
• High functioning patients Home with CST core
  team only for up to 4 months.
• Lower functioning patients Home with CST
  professionals for up to four months, plus
  domiciliary rehab support for up to four times a
  day for six weeks if needed.
• Pt Non-manageable at home Residential
  intermediate care bed for up to six weeks with
  CST daily input until level 2 or 1.
• Residential or nursing home CST visit to ensure
  correct management of patient and provide rehab
  as appropriate.

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CORE ROLES OF TEAM AND PROCESS FOR STEP DOWN
PATIENTS

• Therapist OT or PT attend acute stroke unit twice
  week to screen patients and coordinate discharge
  with MDT team.
• Attend Pendle hospital rehab wards to coordinate
  discharge with staff.
• When patient at one of our four pathway levels
  and medically stable then they are discharged.

• Member of stroke team visit patient on day of
  discharge on set up visit either at home or
  residential intermediate care setting.
• Plan and provide rehab

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STEP UP PROCESS

• Flexible referral process can be from any health
  or social care worker, self referral via GP to
  confirm stroke, patients can re refer back in to
  the service via phone call to team usually.
• Criteria set at patient must have problems
  related to their stroke.
• Patient/referrer screened on phone and then
  assessed at home as soon as convenient for
  patient.
• Appropriate pathway of rehabilitation provided as
  per step down patients.

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EXTENDED UPPER AND LOWER LIMB CLINIC

• Upper limb clinic
• 1.5 days OT or PT a week in a clinic setting
  within a extra housing care facility.
• Provision of further upper limb rehabilitation
  for those patients with residual problems from
  CST.
• Referrals from consultants, GPs etc for community
  patients
• The team are trained to provide FES, Biometrics
  upper limb trainer, Saeboflex/Saebostretch.

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LOWER LIMB CLINIC

• Physiotherapist provides assessment and continued
  follow up for Odstock footdrop stimulator for
  stroke patients who fit criteria.

• Both Odstock footdrop stimulator and Saeboflex
  provision are funded by our commissioners.

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STAFFING LEVELS OF TEAM

• Team Leader/Clinical specialist OT 8A
• Band 7 PT and OT and SALT (full time)
• Band 6 OT and PT (full time)
• Band 4 Ass practitioner for stroke (full time)
• Two band 3 rehab workers (full time)
• Nurse band 6 (new post 2.5 days)
• Social worker (attends our weekly MDT as inputs
  when necessary)
• Admin support
• Access to pool of 15 domiciliary support workers
  to support our team on level 2 pathway/work over
  7days.

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APPROACH TO ADDRESSING STROKE PROBLEMS

• Use both an impairment and function based
  approach to assessment and treatment.
• Neuro approach (physical) Evidence based rather
  than one specific approach, Movement
  science/Motor learning very applicable to the
  community setting and in line with current
  research.
• Cognitive Braintree training Cognitive
  Rehabilitation
• Innovative interventions outside of approaches
  Odstock footdrop stimulator, electrical
  stimulation for upper limb/lower limb, saeboflex
  upper limb splint and saebostretch unit,
  Biometrics upper limb trainer.

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OUTCOMES SO FAR
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OUTCOMES

• 208 referrals between Dec 07- Dec 08
• 30 (14) not accepted 178 (86) accepted
• Changes in Modified Barthel
• Average total change in MBI -11 points
• Count of change in dependency (82 patients)
• Mild mild 9 Severe
  mild 4
• Mild minimal 15 Severe
  Severe 4
• Minimal minimal 36 Total
  Moderate 1
• Moderate minimal 5 Total Total
  2
• Moderate mild 6

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OUTC0MES

• Place of residence of discharged patients Dec
  07-08 (78) (22 still active) from CST
• 73 home
• 2 (8) re admitted due to (health,
  stroke, TIA)
• 3 death
• Step down 67 Step up 33
• Average length of stay CST 67days

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Team involvement in accepted cases as a
percentage of accepted referrals
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CONTACTS PER TEAM AND PROFESSION
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KEY ELEMENTS TO THE DEVELOPMENT OF OUR MODEL OF
COMMUNITY STROKE DELIVERY

• Developing our pathways and service around stroke
  patient/carer need not just early discharge
  target.
• Being part of a wider community rehabilitation
  service
• Partnership working across all sectors to support
  in meeting stroke patients rehabilitation needs
  long term
• Adequate staffing and skill mix
• Investment in the teams training and development
• Flexibility, organisation within the team and
  ability to respond
• Being innovative and evidenced based
• Joint working and support from commissioning

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KEY ELEMENTS TO THE DEVELOPMENT OF OUR MODEL OF
COMMUNITY STROKE DELIVERY

• Support from the NHS Blackburn with Darwen
• Support from manager and Older peoples
  directorate to develop ideas, innovative practice
  from team and funding for training staff members.

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FUTURE DEVELOPMENTS

• Contribute to development of stroke secondary
  prevention and exercise group (8 week programme)
  to follow on after CST.
• Patient Experience/satisfaction
• Develop more evidence base for our interventions
• Involved in research project/Evaluate service
• Develop upper limb clinic to provide saeboflex,
  saebostretch and Odstock footdrop stimulator
  service.
• Further develop the database
• Improve links with other agencies
• Make links with other community stroke teams
  nationally
• Marketing the service

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• THANK YOU TO NETWORK FOR
• INVITATION TO SPEAK