Stroke review

1
Stroke review follow up

• Sue Winnall Marisa Rose
• 2009

2
6 months post stroke

• What do you think a person who had a stroke 6
  months ago needs?
• Would it be different depending on the deficits
  following the stroke?

3
What are the national directives?

• National stroke strategy 2007 Quality Marker 14
• Recommendations
• Offer regular reviews i.e. 6 weeks 6 months
• Develop a protocol or mechanism to ensure care
  plans cross the health/social care boundary
  consider carer needs
• Enable support self assessment

4
National directives guidelines

• RCP guidelines 2008 point 7.1.1. and take into
  consideration point 7.2.1. and 7.3.1.
• Recommendations
• Any patient whose situation changes should be
  offered further Ax by specialist stroke rehab
  service
• Any patient with residual impairment after
  initial rehab should be offered a formal review,
  at least every six months, to consider if further
  Rx is warranted i.e. new problems are present or
  patients physical or social environment has
  changed

5
Effective 6 month follow up

• Patients with no residual impairments
• Patients with residual impairments but no obvious
  change in circumstance
• Patients with residual impairments with obvious
  changing to current circumstances

6
Tower Hamlets Stroke pathway follow up clinic
pilot project

• Pathway currently acute unit -gt stroke
  specialist rehab unit in community hospital -gt up
  to 12 weeks of specialised community
  rehabilitation in the home
• Pilot carried out May/June 2008
• Multi disciplinary assessment to determine what
  are patient/carers needs at follow up

7
Pilot recommendations

• Review all patients at 6 months by a stroke
  specialist (this could be a therapist or nurse)
  with experience of the patients in the pathway
• Has well developed links with social care,
  voluntary statutory organisations to sign post
  patients most effectively
• Be able to refer back into rehabilitation
  services or have access to the MDT for further
  consultation

8
Findings

• Majority of clients identified changes in
  function or new goals since discharge generally
  of an activity engagement or social participation
  nature
• Assessment generally highlighted need for further
  input, advice or referral to statutory or
  voluntary services
• Many issues highlighted by patient carer had
  been previously identified by therapists during
  their rehabilitation but patients had not
  identified them as relevant at that stage

9
Think for a moment
10
Summary of recommendations

• Focus is on
• Activity engagement social participation
• Meeting the psychosocial needs of the patients
  carers
• The link between health, social care the
  voluntary sector

11
Things to consider

• What do the stroke services in your borough
  currently offer? Length of rehabilitation
  specialism of rehabilitation? Referral to other
  services? Vocational rehabilitation?
• What links do you have with your stroke service?
• What are the links currently in your borough or
  from your practice with statutory or voluntary
  sector organisations?

12
Things to consider

• Is the GP surgery the best place for the review?
  Patients home?
• Who would be the best person to do this review
  for your patients?
• How can their non-medical needs be met?

13
Questions to think about

• What rehabilitation do your patients currently
  have access to?
• What third sector, social care long term
  rehabilitation services are currently available
  in your borough?
• How could you, as the key health care link,
  ensure that your patients have the most
  appropriate 6 month follow up review link into
  these services?
• What are you going to do to meet this requirement
  effectively?