1. Tracy Walker Community Stroke Team NHS Blackburn with Darwen DEVELOPING A COMMUNITY STROKE TEAM Our Journey

2. AIMS To provide an overview of our model of community stroke rehabilitation. To highlight some of the key elements which were key to our success and sustainability as a team. To provide you with some data regarding the resource use of our stroke patients in Blackburn with Darwen. To give you an insight into some of the hurdles along the way.

3. Our Model “Meeting the Need” Focused on Meeting patient need rather than just early discharge. Four pathways of support from team: 1. 1. High functioning – Home with core team support only 2. 2. Lower functioning but manageable at home – Home with CST therapists and domiciliary rehab team support. 3. 3. Non-manageable at home – Residential intermediate care bed with CST therapist support. 4. 4. Residential/Nursing care – CST core team visit on discharge to check correct pt management.

4. Extended Upper & Lower limb clinic New developments which added to our model of stroke rehab. Arose from need for extended upper limb rehab and use of novel interventions traditionally used in private practice (saeboflex/odstock foot drop stimulator). Need commissioning support for funding. Need clinic space and therapy staff extra to original CST plan. Advantages/Disadvantages: Continued specialist upper limb training, equity of treatment/can be a strain on team. Just secured funding for expert programme type follow on group for stroke!

5. Development phases “Key elements of our progress and sustainability” First few months – 1 st year Defining your service First few months – 1 st year Defining your service Developed a project plan in a gant chart: Made a list of all the tasks that I needed to do under section headings and highlighted priorities. Developed a project plan in a gant chart: Made a list of all the tasks that I needed to do under section headings and highlighted priorities. Initial Priorities: service spec, recruitment, documentation, resources, developed pathways, admin/team systems. Initial Priorities: service spec, recruitment, documentation, resources, developed pathways, admin/team systems. Mapped out all local services which would complement our team to meet patient need i.e rehab services, supported employment, health & wellness, primary care nursing/GP, community transport. Mapped out all local services which would complement our team to meet patient need i.e rehab services, supported employment, health & wellness, primary care nursing/GP, community transport. Relationship building to support our pathways of care: Social services, acute stroke unit and rehab, outlying wards, therapy staff across area, Primary care staff. Relationship building to support our pathways of care: Social services, acute stroke unit and rehab, outlying wards, therapy staff across area, Primary care staff.

6. Sustainability Making sure the team systems and rehab process run efficiently to cope with demand. Making sure the team systems and rehab process run efficiently to cope with demand. Patient active in rehab process and timely discharge. Patient active in rehab process and timely discharge. The use of outcome measures as core practice. The use of outcome measures as core practice. Database development and IT support for length of stay figures. Database development and IT support for length of stay figures. Produce reports of outcomes and patient need to commissioners yearly. Produce reports of outcomes and patient need to commissioners yearly. Team leader involvement in wider stakeholder initiatives for stroke. Team leader involvement in wider stakeholder initiatives for stroke. Training of wider intermediate care rehab support staff to develop. staff with skills to support our team and stroke patients. Training of wider intermediate care rehab support staff to develop. staff with skills to support our team and stroke patients. Continual investment in joint working with stakeholders (dynamic process). Continual investment in joint working with stakeholders (dynamic process). Evidence based practice to develop staff skills to treat patients. Evidence based practice to develop staff skills to treat patients.

7. What is the demand? Population 162.000 people. Population 162.000 people. Average 4 referrals a week. Average 4 referrals a week. Accepted and provided rehab to 178 stroke patients last year. Accepted and provided rehab to 178 stroke patients last year. Around 25 percent needed pathway 2 and similar for pathway 3. Around 25 percent needed pathway 2 and similar for pathway 3. Average length of stay 63 days. Average length of stay 63 days. Around 30% have SALT needs. Around 30% have SALT needs. OT involved in more cases than physio ? Due to cognitive rehab need ! OT involved in more cases than physio ? Due to cognitive rehab need ! Lessens learnt Having correct staffing levels and skill mix is essential to cope with constant demand! Having correct staffing levels and skill mix is essential to cope with constant demand! You need equal OT/PT and full time Band 7 SALT. You need equal OT/PT and full time Band 7 SALT.

8. Hurdles along the way Taking patients before team developed adequately Taking patients before team developed adequately Resistance to new ways of working. Resistance to new ways of working. Influx of referrals or ignorance to service Influx of referrals or ignorance to service Coordination of stroke patients on other wards in acute setting Coordination of stroke patients on other wards in acute setting Balancing therapy input Balancing therapy input Solutions Staff and systems in place first is a must! Positive approach/persistence Set your criteria and send out Provide your discharge protocol at start to outline responsibilities of acute. Set limits to reduce staff stress and patient overload.

9. Hurdles along the way Sustaining CST team coordination and joint goal planning with bigger team. Sustaining CST team coordination and joint goal planning with bigger team. Managing throughput effectively. Managing throughput effectively. Implementing outcome measures in the team. Implementing outcome measures in the team. Split therapists into two pods: senior OT/junior PT & Senior PT/junior OT. Split therapists into two pods: senior OT/junior PT & Senior PT/junior OT. Stick to criteria and discharge on to other services Stick to criteria and discharge on to other services Team leader persistence in educating on importance of measuring outcomes. Team leader persistence in educating on importance of measuring outcomes.

10. Key elements to the development of a community stroke rehabilitation service Developing our pathways and service around stroke patient/carer need not just early discharge target. Developing our pathways and service around stroke patient/carer need not just early discharge target. Being part of a wider community rehabilitation service Being part of a wider community rehabilitation service Partnership working across all sectors to support in meeting stroke patients rehabilitation needs long term Partnership working across all sectors to support in meeting stroke patients rehabilitation needs long term Adequate staffing and skill mix Adequate staffing and skill mix Investment in the teams training and development Investment in the teams training and development Flexibility, organisation within the team and ability to respond Flexibility, organisation within the team and ability to respond Being innovative and evidenced based Being innovative and evidenced based Joint working and support from commissioning Joint working and support from commissioning Measuring and producing clinical outcome reports Measuring and producing clinical outcome reports Effective team management of throughput Effective team management of throughput

11. Finally “Create a team vision” “To provide a stroke rehabilitation service which has quality and equity at its heart and driven by highly skilled clinicians who feel valued and empowered to make a positive change in the quality of life of our BWD stroke survivors.”