Psychological care after stroke: A national update Dr Ian Kneebone Associate, NHS Improvement – Stroke http://www.improvement.nhs.uk/stroke/Psychologicalcareafterstroke/tabid/177/Default.aspx

ASI 6: Timely access to psychological support Proportion of patients who have received psychological support for mood, behaviour or cognitive disturbance by six months after stroke. Target: 40 % by April 2011 Could use Peninsula as an example of an area which is making real changes in their services which is not reflected in the data. This also applies to parts of London, the Midlands and Dorset. Make the point that Mids and East is ¼ of the country so this approach is fairly significant 2

ASI 6 Psychological care within 6 months of stroke Increase in numbers able to measure their service and report the information In Quarter 1 (April-June) 2010- 36 providers submitted ASI6 data (of around 153) provided data on ASI6. Of 1,755 patients 600 received psychological care (34%). In Quarter 2 (July- Sept) 2012- 51 providers submitted ASI6 data. Of 2,734 patients 1,453 received psychological care (53%) This only tells about unit which submit data, in reality more will have access to psychological care but will either not be measuring it, or measuring but not sharing. Or possibly have some form of psychological care which doesn’t meet the definition.

National Update Multiple examples of good practice on the SI website: Evidence paper: Kneebone & Lincoln (2010) Stroke Improvement programme. Psychological support: State of knowledge. Could use Peninsula as an example of an area which is making real changes in their services which is not reflected in the data. This also applies to parts of London, the Midlands and Dorset. Make the point that Mids and East is ¼ of the country so this approach is fairly significant 4

National Update Specific guidance: Screening for emotional disorder Screening for cognitive deficits Could use Peninsula as an example of an area which is making real changes in their services which is not reflected in the data. This also applies to parts of London, the Midlands and Dorset. Make the point that Mids and East is ¼ of the country so this approach is fairly significant 5

Does the patient have a communication difficulty? Yes No Flow chart for people under 65 years Administer the DISCs Administer the HADS Scored 2 or more? Staff concerns? Score 9 or more on D scale? Yes invalid No Yes Yes No Administer SADQ H10 Administer suicide question from BASDEC 6 or more? No Yes Respond with true? Report to nurse in charge. Non-depressed range No Yes Suicide question from BASDEC Respond with true? Depressed range Report to nurse in charge No Yes Non-depressed range

Informs team of results – rehab planning Weeks 1-3 (or before discharge if <3weeks) OT to administer MOCA or ACE-R + Star Cancellation Informs team of results – rehab planning Week 4 Does patient have communication problems? Yes No OT to administer RCPM OT to administer RBANS Scores less than 19? What cognitive domains are affected? Informs team of results No Yes Assess cognitive problems further using functional assessment. Interfering with rehab? Week 6 onwards. Review. If impaired, discuss treatment options with psychologist Interfering with rehab? No No Yes Yes Review further assessment /treatment options with psychologist Review further assessment /treatment options with SALT and psychologist. 6 month review. Any cognitive problems reported? Yes No Is patient going back to work or do they have cognitively demanding lifestyle or responsibilities (e.g. childcare) Monitored by GP, refer for Stroke Association support etc Comprehensive neuropsychological assessment by clinical neuropsychologist No Yes

National Update Screening for emotional disorder 2006 55% (RCP 2007): 2012 88% (RCP 2013) Screening for cognitive deficits 2006 71% (RCP 2007) for whom it was applicable? 2012 81% (RCP 2013) Could use Peninsula as an example of an area which is making real changes in their services which is not reflected in the data. This also applies to parts of London, the Midlands and Dorset. Make the point that Mids and East is ¼ of the country so this approach is fairly significant 8

ASI 6 Psychological care within 6 months of stroke Increase in numbers able to measure their service and report the information In Quarter 1 (April-June) 2010- 36 providers submitted ASI6 data (of around 153) provided data on ASI6. Of 1,755 patients 600 received psychological care (34%). In Quarter 2 (July- Sept) 2012- 51 providers submitted ASI6 data. Of 2,734 patients 1,453 received psychological care (53%) This only tells about unit which submit data, in reality more will have access to psychological care but will either not be measuring it, or measuring but not sharing. Or possibly have some form of psychological care which doesn’t meet the definition. 10

From around the nation Progress is better than that measured. Many teams not yet submitting data, have undergone major service reorganisation to improve psychological care Midlands and East stroke review Clinical psychology posts being built into specs for ESD and community rehab teams Widespread use of economic case to support bids for clinical psychology Could use Peninsula as an example of an area which is making real changes in their services which is not reflected in the data. This also applies to parts of London, the Midlands and Dorset. Make the point that Mids and East is ¼ of the country so this approach is fairly significant

From around the nation Progress is better than that measured. Dorset: -Trained IAPT in communication skills after stroke (SALT led) -IAPT trained stroke practitioners in recognising mental health problems -Established a clear referral pathway (IAPT level 3) Could use Peninsula as an example of an area which is making real changes in their services which is not reflected in the data. This also applies to parts of London, the Midlands and Dorset. Make the point that Mids and East is ¼ of the country so this approach is fairly significant

Befriending: Connect Reassure – You are not alone – ‘normalising’ Listening ear Give Time Empathise – Shared experience Encourage and Support Tips and Ideas – Signposting (McVicker & Eustice, underway)

Befriending: Connect Information – Link to ongoing support A chance to discuss opportunities ‘A role model’ ‘A inspiration for a positive future and what ‘me with aphasia’ could look like’ (McVicker & Eustice, underway)

Motivational Interviewing “to support and build a patient’s motivation to adjust and adapt” “working with patient’s dilemmas and ambivalence…supporting and reinforcing optimism and self-efficacy”

Motivational Interviewing Elicit person’s own solutions Elicit person’s usual coping style that was successfully used in the past Explore application in the present & the future

Motivational Interviewing An RCT, has shown Motivational Interviewing can improve mood after stroke (Watkins et al., 2007) Administered by nurses with specific training and supervision

SSNAP Organisational audit 2012 the last point reveals itself if you look at it in full screen mode and click once. There has been a welcome 15% improvement in access to psychology services on stroke units from 31% in 2006 to 46% now. But still over half of units have no access at all. At this rate of change it will not be until 2034 until we achieve 100%!

Sentinel Stroke National Audit Programme (SSNAP) Six month (post admission) follow up 8.2.1 Was the patient screened for mood, behaviour or cognition since their stroke using a validated tool? Yes No No but 8.2.2 If yes, was the patient identified as needing support? Yes No 8.2.3 If yes, has this patient received support for mood, behaviour or cognition since their stroke Yes No No but The focus of attention on psychological care after stroke will be continued as the RCP have included the ASI 6 question about psychological support at 6 months in their continuous audit. This question will need to be answered for all patients with stroke.

RCP National Clinical guidelines for stroke 2012 Stroke services should adopt a ‘stepped care’ approach to delivering psychological care. All patients after stroke should be screened within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment (NICE guidance) Recommendations for management of depression, anxiety, fatigue, cognition, emotionalism clear guidance in the newest RCP guidelines are based on the NHS Improvement and NICE recommendations

CCG Outcomes Indicator Set People who have had a stroke who: • are admitted to an acute stroke unit within four hours of arrival to hospital • receive thrombolysis following an acute stroke • are discharged from hospital with a joint health and social care plan • receive a follow-up assessment between 4-8 months after initial admission Mortality within 30 days of hospital admission for stroke Opportunities for psychological care come with the CCG outcomes indicator set. The NHS Commissioning Board will hold CCGs to account on the basis of achievement of these indicators so they will be important in this first year. The follow up assessment is and opportunity to get 6 month reviews in place and to incorporate a psychological screen at the time

CCG Outcomes Indicator Set Ensuring people feel supported to manage their condition • People feel supported to manage their condition Enhancing quality of life for people with mental illness • Access to community mental health services by people from BME groups • Access to psychological therapy services by people from BME groups • Recovery following talking therapies (all ages and older than 65)   these indicators focus on mental health, also demonstrating the increased commitment to addressing mental as well as physical health needs. provides an opportunity to increase use of talking therapies (probably mainly IAPT)

The economic case for a clinical psychology led service

NHS savings from provision of psychological care over two years 68,969

Savings around £98,000 year 1 Savings around £59,000 year 1 Predicted heath and social care savings of around £59,000 in year 1, but effect of psychological interventions anticipated to have a positive effect over 2 years so combined heath and social care savings predicted to be around £98,000 over 2 years. More than the cost of the intervention. This may be enough weight to persuade commissioners to jointly fund a service.

Services which expose patients to risk prevented from continuing Potentially a renewed interest in compassionate care for patients and development of culture where this is possible Legal responsibility for staff to be open about incidences of harm (including neglect) Services which expose patients to risk prevented from continuing Regulate and legislate for compassionate care! Patients must come first with care delivered by caring, committed and compassionate staff working within a common culture. It should be a criminal offence, for a patient to be harmed by a breach of regulatory requirements. There should be an aptitude test for nurses entering training and three months compulsory experience in the direct care of patients. There should be a new registered status for the older person's nurse. There should be a national code of conduct and a registration system for healthcare support workers. There should be an accreditation scheme for leaders of all disciplines and a national leadership staff College. Patient involvement must be increased.