1. Life After Stroke Michelle Graham Improvement Unit Public Health Wales

2. Michelle Graham LIFE AFTER STROKE

3. The Stroke Population 6000 new strokes per year 2.7% of over 18 population (TIA and Stroke) 50% of all stroke survivors significant level of physical, psychological or social need

4. Evidence RCP Stroke Guidelines (4 th Ed, 2012) National Stroke Strategy (2007) Scottish Intercollegiate Guidelines Network (2010) Stroke Delivery Plan (2012) Care Quality Commission Stroke Care review (2011) Stroke Association Life after Stroke

7. Why be different? WHC 058 & 082 Intelligent Targets LAS structurally different Cross organisations Multi Agency Person Centred

8. Change of Approach Move away from “check lists” Policy context Person centred listening

9. Consultation Events Stroke survivors, their families and carers are the actual experts in this field. Ensure we are placing people at the centre of their own health and healthcare Two events: North and South Wales

10. Key Themes Services aren’t designed for individuals Carers GP services Equity and fairness Social Access Dignity Specialist services Access to information Fears for the future

11. What was the outcome? For survivors and their families and carers? –They were heard –Shaping future provision For staff? –Key information to help development of services For NHS Wales? –Developing a person and patient driven NHS

12. Person centred and joint working progress Multi Agency Steering group Expanded on the listening events Developed driver diagram capturing key drivers and changes

13. The Aim To empower stroke survivors to reintegrate into community and enable optimum quality of life

15. Person Centred Goal Plan Individually tailored SDP: “services need to be planned and delivered around the patient and their individual needs rather than the needs of the organisation”

16. Person Centred Goal Plan Regular Reviews Access to Facilitator Individual Stroke Survivor Passport

17. Have responsive Access to services The right services on offer Match Capacity to demand

18. The Passport: What has happened to me? Risk Factors What matters to me on my journey –things about my illness, my recovery, goals I want to achieve Things I need to remember and record –Medication prescriptions (what and when), appointments to attend My review dates My Progress –Patient to reflect on the goals that they have achieved and what may have helped or hindered this process Information regarding local services

19. Bridgend Pilot Feasibility test of Passport and Facillitator role 16 stroke survivors (post discharge) PDSA Twofold use: supported information and measurement function

20. Where are we now? Focused Timeline Launched Feb 2013 Measurement day and data leads LS1 April 2013 All Health Boards participating 10 teams Engagement, engagement, engagement!!!!

21. ANY QUESTIONS