Stroke Rehabilitation 1 – Assessment for Rehabilitation / ESD Mark Smith Consultant Physiotherapist March 2008 Apologies Minutes of 1 October 2004 Actions from last minutes Patient carer partnership leaflets – these have been distributed to WGH and RIE - still to be printed for GP surgeries.

This presentation… Assessment for stroke rehabilitation? Community-based rehabilitation strategies The way forward…

Rehabilitation A process aiming to restore personal autonomy to those aspects of daily life considered most relevant by patients or service users, and their family carers. King’s Fund 1998

The Cochrane Library Systematic Reviews Trials Register Plus Numerous electronic databases online

Promising Physical Interventions Treadmill Training, Moseley 2005 Constraint Therapy, Sirtori et al, 2003 Electrical Stimulation, Price et al, 2000 EMG Biofeedback, Woodford et al, 2004 Force Platform, Barclay-Goddard, 2004 Orthotics, Kent et al, 2002 Physical Training, Saunders et al, 2004 PT – Strengthening/Repetition, Pollock et al, 2003 Shoulder Supports, Ada et al, 2005 Therapy at home, OPT, 2003/2006 Early Supported Discharge, ESDT, 2004

Multidisciplinary Team Working Rehabilitation is most effectively carried out by a multidisciplinary team. (Turner-Stokes, Williams and Abraham, 2001). Several studies, including one carried out by Turner-Stokes, Williams and Abraham, have found that rehabilitation is most effectively carried out by a multidisciplinary team. However, there has been little research focussing on the effectiveness of the individual components and it remains a research challenge to determine the value-added contribution that each component makes. Furthermore, several systematic reviews have found that there is a lack of high quality trials, which would be useful to assess the effectiveness and cost effectiveness of comprehensive multidisciplinary rehabilitation programmes.

Assessment for stroke rehabilitation Should we assess for access? Streaming patients – cherry picking? Prognosis Stroke Subtype – TACS? Physical +/- cognitive issues? Age? Previous impairment / activation issues? Social issues?

Assessment for stroke management Best case management strategy Patient-centred Meeting individual needs Best place – hospital/home Stroke Unit – acute/rehab

The Strategies National Framework - Kerr Delivering for Health Changing Lives Better Lives, Better Care: Action Plan / WFP CHD & Stroke Adult Rehabilitation Framework Pan Lothian Review of Older Peoples’ Services Joint Physical & Complex Disability in Lothian

Adult Rehabilitation Framework - Target Groups Older People People with Long Term Conditions People returning from work absence and/or aiming to stay in employment (vocational rehabilitation)

Adult Rehabilitation Framework - Aims and Objectives Access to services Local Service Provision – community based Enablement and Self-Managed Care Comprehensive and Evidence-based Services Sustainable Multi-professional Teams Capacity

Better Health, Better Care 2007 Improve long term condition management Locally involve service users and their carers in primary care and community settings Best use of clinical skills to maximise outcomes for patients Meet highest standards Improve transport infrastructure

Move From Acute to Primary Care Intermediate care Early supported discharge Day Hospital / Centre Private nursing homes in older persons rehabilitation One of the main issues arising from the “Delivering for Health Document” was that more healthcare should be delivered locally, in Primary rather than Acute care. This review of the literature identified 3 themes that can be combined under this heading, namely. Intermediate care Early supported discharge Private nursing homes in older persons rehabilitation I will now look at these sub themes in more detail.

Intermediate Care “ Those services which help to divert admission to an acute care setting through timely therapeutic interventions which aim to divert a physiological crisis or offer recuperative services at or near a person’s own home” Commonly: Community Rehabilitation Rapid Response Crisis Care The development of Intermediate care services is a key element of current policy for older people in England and features in the National Service Framework for older people. The main objective of intermediate care is to reduce hospital and long term care use. Intermediate care is defined by Steiner (1997) as “Those services which help to divert admission to an acute care setting through timely therapeutic interventions which aim to divert a physiological crisis or offer recuperative services at or near a person’s own home” However, the term intermediate care is not a universally recognised term in health services and therefore studies evaluating effectiveness and cost effectiveness of intermediate care services in general are limited.

Early Supported Discharge Overlaps considerably with Intermediate care and community rehabilitation Much of the literature has focussed on patients recovering from a stroke or hip fracture. Recent emphasis on primary care it is feasible that rehabilitation will become increasingly community based. Can make savings to hospital costs, however this is often offset by increased community costs. Much of the literature surrounding early supported discharge has focussed on patients recovering from a stroke or hip fracture. With the recent emphasis on primary health care it is feasible that the rehabilitation of stroke patients will become increasingly community based. Community based stroke rehabilitation has primarily been evaluated within the context of the early discharge team and I have provided examples of this

Evidence for Therapy-based Community Stroke Rehabilitation Early Supported Discharge 2005 Cochrane – 11 trials, 1597 patients, 8 days Therapy-based Stroke Rehabilitation Services for Patients at Home 2003 Cochrane – 14 trials, 1617 patients, sig* OT Services after Stroke 2006 Cochrane - 64 trials, 1258 patients, sig*

Examples Early supported discharge Conventional Bristol £2516 £3292 Average costs up to 3 months £2516 £3292 Newcastle Average costs up to 6 months £7115 £7480 London Average costs up to 1 year £6800 £7432 Several studies have found that early supported discharge rehabilitation services for stroke patients can result in reduced hospital costs. While the underlying costs and assumptions were different for each analysis all concluded that the opportunity savings from hospital bed days released tended to be greater than the cost of the Early Supported Discharge service. Realising such cost savings in practice can be difficult as more patients are found to fill the beds, but it does lead to greater efficiency for the stroke unit. The study carried out in Bristol found that for every £10,000 spent, routine hospital care could be provided for 3 patients while early discharge to care in the hospital at home scheme could be provided for 4 patients. Coast, J., et al (1998) Hospital at home or acute hospital care? A cost minimisation analysis British Medical Journal 316 (7147) 1802-1806 McNamee, A., et al (1998) Cost analysis of early supported hospital discharge after stroke Age and Ageing 27 345-351 Beech, R., et al (1999) Economic costs of early inpatient discharge to community-based rehabilitation for stroke in an inner London teaching hospital Stroke 30 729-735

For whom? Highly selected patients Mild to moderate disability No difference to carers’ mood

Day Hospital / Day Centre Best use of existing resources Expert MDT Evidence-based practice Stroke specific? Social Carers Transport

Private Nursing Homes Increase emphasis on a primary care-led NHS and reduction in hospital rehabilitation. Interest in nursing homes as a potential rehabilitation facility for older people Need for increased input from Allied Health Professionals into nursing home facilities. The recent emphasis on a primary care led NHS and the reduction in hospital rehabilitation has created interest in nursing homes as a potential rehabilitation facility for older people. The number of nursing homes has increased to cope with the increasing age of the population and the increase in long term conditions this brings with it. Nursing homes in the UK are being increasingly regarded as potential rehabilitation facilities for disabled people. However a survey of physiotherapy and occupational therapy provision in UK nursing homes has found that older people in nursing homes appear to be particularly isolated from NHS services. The survey also highlighted marked inequalities in access to physiotherapy services in different nursing homes. It should be noted however that this survey was carried out in 2001, and therefore However several studies have identified the need for increased input from Allied health Professionals and that there is considerable scope to improve rehabilitation provision to older people in UK nursing homes.

Self Management and Self Care Importance of chronic disease self-management Patients as partners The delivering for Health document emphasises the importance of chronic disease self-management. Patients are changing from taking a passive role to a more active role in their care and it is argued that patients are now seen as partners in their care. A systematic review looking at self-management education programmes in Asthma found that 8 out of the 15 studies identified found reduced hospital or emergency department use. However, while self-management programmes are on the increase, little research has been identified relating to the role and the impact of the role of the Allied Health Professional in self management.

Person Centred Care “Treating older people as individuals and enabling them to make choices about their care” (DoH 2001) Patient centred care is essential for effective rehabilitation “Organisation of rehabilitation should match the needs of the people likely to benefit from it”. (Audit Commission, 1997) Patient-centred goal-setting The national service framework for older people defines person centred care as “treating older people as individuals and enabling them to make choices about their care”. They argue that rehabilitation services should address the needs of the sufferer and their carers so that they feel supported at all stages of their care pathway. The Audit Commission support this assertion arguing that patient centred care is essential for effective rehabilitation and that the organisation of rehabilitation services should match the needs of the people likely to benefit from it.

Integrated Services and “Joined up Care” Need for a comprehensive range of integrated services designed to meet the needs of each individual person (Audit Commission 2002) Ouwens, et al (2005): integrated care programmes had a positive effect on the quality of care. Managing the transitions The Audit Commission in their report identified the need for a comprehensive range of integrated services designed to meet the needs of each individual person. A review of systematic reviews Ouwens et al found that integrated care programmes seemed to have a positive effect on the quality of care. However, they suggest that to compare the effectiveness and cost effectiveness of integrated care programmes, consistent definitions need to be used and the component interventions need to be fully described.