1. Development of a Community Stroke Rehabilitation Team “meeting the need” NHS Blackburn with Darwen Tracy Walker Team Leader

2. AIMS To provide an overview of our model of community stroke rehabilitation. To provide you with some data regarding resource use and outcomes. To highlight some of the key elements which were key to our success and sustainability as a team.

3. Stroke Rehabilitation for all “Meeting the need” Stroke Team support Hospital High function ESD People living At home Nursing/ Residential home Hospital Low function patients Out of area Hospital referrals

4. Our Model “Meeting the Need” Focused on Meeting patient need rather than just early discharge. Four pathways of support from the stroke team: 1. High functioning – Home with core team support only (6 months) 2. Lower functioning but manageable at home – Home with CST therapists and domiciliary rehab team support. 3. Non-manageable at home – Residential intermediate care bed with CST therapist support. 4. Residential/Nursing care – CST core team visit on discharge to check correct pt management.

5. PROCESS FOR STEP DOWN PATIENTS Therapist OT or PT attend acute stroke unit once week to screen patients and coordinate discharge with MDT team. Attend hospital rehab ward meeting to coordinate discharge with staff. When patient at one of our four pathway levels and medically stable then they are discharged. Team visit on day of d/c Plan and provision of rehab

6. 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.

7. 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) Three band 3 rehab workers (full time) Nurse band 6 (new post 2.5 days) Admin support Access to pool of 15 domiciliary support workers to support our team on level 2 pathway/work over 7days.

8. Team contacts per staff group

9. Evidence behind our model Specialist multidisciplinary team of professionals as per ESD articles. Organised & coordinated discharge planning Therapy commenced on day of discharge at home Weekly team MDT to coordinate patient management Management of patients going into residential intermediate care is provided by stroke team. Access for residential and housebound patients. Stroke strategy – return to work, driving, longer term needs Flexible re-referral system

10. The Demand so far Average 4-5 referrals a week. 240 referrals last year. Average length of stay 67 days. Around 70% hospital and 30% community referrals.

11. Impact on patient related outcomes Important to measure change in function and ability in activities of daily living. This ensures quality and impact of team. Figures illustrate the positive impact of rehabilitation post stroke. 11 88 9 0 2 4 6 8 10 12 MBINott ADLMASBerg Balance Changes in Patient Related Outcome Measure Average change post team intervention

12. Impact of reducing dependency levels Reduction in dependency post team intervention reduces help needed. Saving yearly of 12,480 of care hours needed to support stroke survivors in activities of daily living £7.50 hr for carer = £93,600 per year saving.

13. Reducing Length of stay National average length of stay 24 days. Compared to 2006 pre stroke team 6 day average reduction this year Jan – Sept 09. 2008 no stroke unit This year stroke ward identified and pathways more efficient. However still patients on other outlying wds and no dedicated wd at pendle rehab.

14. Readmission rates No sign of early discharge increasing re admissions rates. Trend to lower re admission rates for stroke 05 – 09 compared to other general conditions. Specialist Community stroke support maybe keeping readmission rates down. 5.19% 2.38% 5.73% 2.08% 4.64% 2.09% 5.79% 2.08% 6.99% 1.88% 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 20052006200720082009 Re admission rates within 28 days % readmitted within 28 days - with any diagnosis % readmitted within 28 days - with diagnosis of stroke

15. New Developments to Pathway Upper and Lower limb clinics Community stroke exercise and prevention class Community stroke Exercise and prevention class Stroke specific Exercise class Secondary Prevention and education Links to Leisure activities Stroke specific Community walks Stroke specific Gardening group

16. Summary of Key Elements 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 Training of wider intermediate care rehab support staff. Flexibility, organisation within the team and ability to respond Being innovative and evidenced based Joint working and support from commissioning Measuring and producing clinical outcome reports All team members employed by PCT

17. Thank you