1. 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.

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

3. 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

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

5. 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

6. 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.

7. 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?

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

9. 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

10. 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)

11. 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

12. 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

13. 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.

14. 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.

15. 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

16. 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*

17. 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)
McNamee, A., et al (1998) Cost analysis of early supported hospital discharge after stroke Age and Ageing
Beech, R., et al (1999) Economic costs of early inpatient discharge to community-based rehabilitation for stroke in an inner London teaching hospital Stroke

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

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

20. 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.

21. 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.

22. 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.

23. 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.