2. Severe & persistent – clinical psych intervention Mild/moderate impaired mood. May be addressed by non-psychology stroke specialist staff supervised by clinical psychologists Problems common to many/most people with stroke. Support provided by peers, & stroke specialist staff. 2 In accordance with the stepped care model (Psychological Care after Stroke, DoH, 2011)

3. Level 3 Assessment – Clinical Psychology Level 2 Assessment – additional competence in psychological care Level 1 Assessment – MDT members at this level should be competent in psychological screening and the provision of low level psychological care

4. Level 3 Assessment – severe symptoms require onward referral to clin. Psych. Level 2 Assessment – mild/moderate need further Ax, e.g. Onset/duration, history, family.... Consider carers Level 1 Assessment – simple brief standardised measures with follow up interview to check for unreliability, distress not covered, & patient’s view of distress

5. Level 3 Intervention – Psychology Level 2 Intervention – additional competence in psychological care Level 1 Intervention – low level psychological care

6.  Project Leads: J Morris OT-ASU / M O’Mara OT- ESD  Dr L Roberts –Clinical Psychologist  L Sillito – Stroke Rehab OT  B Lewis – Neuro Rehab OT  J Barnes / P Wells – H&S Network  J Rhodes – ASU Nurse  G Millward / M Edwards – Stroke Association  Objective:  To design and implement robust / standardised mood pathway within stroke  Reduce inappropriate referrals to Clinical Psychology

7.  1 pathway with 3 separate components to suit ASU, Rehab Unit & ESD (Community)  YALE – short screen completed within each stage of stroke pathway  Repeated as aware of discharge as potential trigger point / allows for review  Identified suitable screens for further assessment at each stage  Embed MDT emphasis / focus on mood within stroke care  Simple pathway / documentation  Decrease staff wariness re: mood / suicide risk

8. Commence mood pathway: Yale screen before discharge -Clinical presentation - Monitoring / Observation Question: Does mood appear appropriate to diagnosis? Level 1 Psychological support Level 2 Psychological support Further assessment appropriate to area Regular reviews : *Standard on discharge letter from all stroke services / checklist completed - Clear identification of mood status - Recommendations / ongoing management 6-8/52 Stroke Consultant GP review 6/12 month & annual review Strand 1 (L1) Low or no risk / minimal potential for mood disturbance at time of assessment Strand 2 (L1/2) At risk / potential for mood disturbance at time of assessment Referral to Clinical Psychology / IAPT / support agencies Ongoing monitoring Clear management programme established Goal setting

9. Completed at all stages:  YALE  Observation / clinical presentation  Watchful waiting / monitoring  Further questions re: anxiety / mood if needed  BASDEC risk / suicide question if needed & intent noted Further assessment:  ASU:  DISCS, SADQH-10 (Hospital version), ? Signs of Depression Scale (SDSS)  ESD:  HADS, DISCS, SADQH-10 (Community version), BASDEC, Visual Analogue scale (VAS), Stroke Impact Scale  REHAB UNITS:  HADS, DISCS, SADQH-10 (Hospital version), BASDEC, Visual Analogue Scale (VAS), Distress Thermometer, Signs of Depression Scale (SDSS)

10.  Mood leaflet  Audit –  Patient / carer perspective  Staff perspective  Level 1 /2 psychological training for all staff  MDT engagement  Community links / education  Mood screen within 6/12 and annual reviews  Engagement with IAPT / other agencies  Cognitive pathway

11.  Providing structure to previously informal service  Inclusion within ASU standardised 72 hour monitoring paperwork  ASU exceeding ASI target 40% significantly  ESD / rehab unit screening 100% of patients  Improved handover re: mood issues / management between services / links with Clinical Psychology  Established training package  Increased MDT engagement / changes to MDT perception  Increased patient / carer involvement & self management plans – positive feedback!!!! No negative feedback!!!!!  Increased management plans / goals & confidence of therapy staff with complex case management  Developed links with H & S Network  Improved links with support services  Reduced inappropriate referrals to Clinical Psychology

12.  Clinical Psychology an asset!  Evolving process / review ongoing  Need to engage MDT as can fall on therapy staff – Identify key champions!!!!  Establish Training!  Patients / carers welcome opportunity to discuss at ANY stage!!!! HYPERACUTE / ACUTE not too early!!!!!!  Need to change MDT misconceptions re: mood screening  Use targets as levers to stimulate / maintain momentum  Utilise H & S Network  Don’t reinvent the wheel! Utilise SIP website  Provide patients / carers with screens to complete independently  Access voluntary agencies / support services  Review at different stages

13.  Political and clinical context drawing on basic psychological theory  Pro’s and con’s of formal mood screens  L.2 – suicide screen  Validating L.1 and L. 2 psychological care

14.  L.1 training as mandatory for all staff involved in stroke care, e.g. Housekeepers, HCA’s, domestics, nursing staff....  L.2.training for OT’s, physio’s, nursing staff, social workers, rehab practitioners, Dr’s, Stroke Association - group supervision offered to therapy staff on rehab ward and ESD

15.  Any questions? Contact details:  Lorna.Roberts@northstaffs.nhs.uk Lorna.Roberts@northstaffs.nhs.uk  Margurita.OMara@uhns.nhs.uk Margurita.OMara@uhns.nhs.uk  Josephine.Morris@uhns.nhs.uk Josephine.Morris@uhns.nhs.uk  Laura.Silitto@uhns.nhs.uk Laura.Silitto@uhns.nhs.uk  j.barnes@nhs.net j.barnes@nhs.net