Knowsley Community. Stroke Team.

Transcription

1 Knowsley Community Stroke Team

2 Knowsley Cardiovascular Disease Service

3 Community Cardiovascular Service Rehabilitation services One stop diagnostic and treatment clinics -Halewood -Huyton -Kirkby (current provision) Admin Hub Heart Failure Service Cardiac Rehabilitation team Knowsley Community Stroke Team

4 All newly diagnosed stroke patients are accepted by the team if: Resident of Knowsley or Registered with Knowsley GP

5 Secondary Care GP s Other HCP s New diagnosis of Stroke Referral made to Community Stroke Service (via admin hub/ proactive case finding) No Rehabilitation needs Referral to appropriate service Community Stroke Team triage patient into appropriate service. Details entered onto stroke register Rehabilitation needs identified Early Supported Discharge Community Stroke Rehabilitation Community Stroke Support Other health/ social care needs Regular Health and social care Reviews Referral to appropriate service

6 Team structure Band 7 Physio 1 WTE Band 7 OT 1 WTE Band 6 SLT 1WTE Social Worker 1 WTE Rehab assistant (Band 4) 2 WTE Band 5 Nurse 0.2 WTE Admin support Support from CVD manager (Band 8a)

7 Service pathway Notification from ward to identify Knowsley patient (GP or resident) or patient identified from pro-active case finding on main referring units. Referral form completed by ward and sent to team highlighting needs. Section 2 sent (if social worker input needed). Team initiate screen as appropriate and triage. Communication with staff re- discharge date. Team to visit within 48 hours post discharge (for ESD) or 2 weeks (community stroke rehab)

8 Early Supported Discharge Community Stroke Rehabilitation Community stroke support Intensive specialist rehab Specialist stroke rehab Dependent patient requiring support to manage long term needs Supporting earlier discharge home. Primarily impairment based with emphasis on function Care package reviewed and adjusted to meet the changing need of the patient. Focus on function, activity and participation in community life, including return to work. Rehab places within day rehab centres, and cardiovascular rehab programme utilised with support provided by community stroke team. Education and advice for: Positioning and seating Splinting Transfers and mobility Communication Swallow function Education and support for carers.

9 Early Supported Discharge Criteria: 2 or more disciplines required Able to tolerate 5 or more therapy sessions a week Able to transfer with 1

10 Rehab provided by specialist team for as long as needed (no fixed length of input): Average length of rehab stay (not just ESD) from April April 2012 = 106 days (range days)

11 Total number of referrals (for all aspects of service) April April 2012 = 237

12 KPI s: 1.100% of patients who are admitted with a confirmed diagnosis of stroke are known to the service and recorded on the stroke register. Year % 90% 100% % of all stroke patients at the three main acute Trusts listed above who may be eligible for early supported discharge referred to the ESD team will be assessed within 48 hours of the referral being received. 3. Patients who survive a stroke and are discharged from hospital will have a multi-disciplinary assessment and agreed care plan/package for onward community care prior to discharge to include carer assessment. This will include social care, housing and benefits etc. The Community Stroke Rehabilitation Service will be proactively involved in discharge planning. 4. In line with the National Stroke Strategy (QM 14) patients will have a health & social care assessment (including carers) performed and documented at the following times; 6 weeks post discharge, again at 6 months post discharge and 1 year post discharge. 5. Patients who survive a stroke, do not meet the threshold for ESD and who are discharged from hospital should have access to community based stroke rehabilitation within 2 weeks of discharge. 75% 85% 100% 50% 75% 100% 50% 75% 98% 50% 75% 100%

13 Health and social care reviews As stated in National Stroke Strategy QM 14, a review of individuals health and social care status is completed at: 6 weeks, 6 months and 12 months. Follow up completed and report sent to GP and Consultant. After 12 months, patient discharged from service

14 CVD Nurse Post 0.4 WTE cardiac rehab 0.2 WTE stroke 0.4 WTE heart failure.

15 Access to Cardiovascular Rehabilitation 6-8 week programme of individualised exercise and education. Appropriate patients identified by stroke team and referred to CVD rehab following end of specialist stroke rehab. 46 patients referred since April % positive feedback received from all. Improvements in Quality of Life, increased uptake in physical activity, reduction in anxiety and depression.

16 Average Barthel on d/c from hospital Barthel on d/c from community stroke team Nottingham Extended Activity of Daily Living Scale on d/c from hospital Nottingham Extended Activity of Daily Living Scale on d/c from community stroke team 15.5 (Range 1-20) 17 (Range 1-20) 7.5 (Range 1-20) 12 (Range 1-20) Changes in Score range of 0-10 Changes in Score range of 0-15 Formal Care packages on discharge from hospital hour care - 1 Care package 1 call / 1 carer 2 calls 3 calls 3 calls 4 calls 4 calls / 2 carers (number of calls/ day) / 1 carer / 1 carer / 2 carers / 1 carer Number of patients Formal Care packages on discharge from community stroke team hour care - 3 Care package (number of calls/ day 0 care input 1 call / 1 carer 2 calls / 1 carer 3 calls / 1 carer 4 calls / 1 carer Number of patients Care packages eliminated = 15 Care packages reduced = 4 4 calls / 2 carers

17 Length of hospital stay has been informally reported to team as 5.5 days less than another area with a less established ESD team (information from Whiston Hospital) Number of referrals to Social Worker = 51 Other SS input Day centre 4 Direct payments 7 Respite 2 Carers Assessment 28 Referral to SW but input declined 3 Assessment completed but pt RIP in hospital 4