1. Michelle Graham
EARLY REHABILITATION

2. Session Aim New Driver Diagram Highlight Changes Definitions
Minimum data set
Process Measures

3. . “Early rehabilitation is effective when provided in specialist stroke units, or as part of properly organised early supported discharge and longer-term support in the community, according to need.” Department of Health (2007) National Stroke Strategy. London. Department of Health.
Devised after meeting with the Welsh Stoke Alliance rehabilitation group as clinicians working in a rehabilitation setting to develop the original bundles into an Intelligent target.
The group met on several occasions and as well as their expertise and
(The National Collaborating Centre for Chronic Conditions (2008) Stroke- National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) (CG68). London. Royal College of Physicians
Welsh Assembly Government (2006) National Service Framework for Older People..
(2007) National Stroke Strategy. London. Department of Health.
Scottish Intercollegiate Guidelines Network (2010) Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning: A national clinical guideline. Scottish Intercollegiate Guidelines Network
RCP (2008) National Clinical Guideline on the Management of People with Stroke (3rd Edition)..
We also used the feedback from yourselves via visits, web ex’s and telephone conferences
It was agreed that although this has been designed to commence on day 8 of the patients care that it is a 6 week snapshot of the patients specialist rehabilitation and therefore when patients who are not on combined units are transferred to either stroke rehab units or ESD teams they can commence 6 weeks of data collection on arrival to that unit or team. The data base will pick up delays in transfer of care as before
The changes are not huge and the principle of reliability of care remains and the .
The main changes are:
As you can see we now have 4 bundles as opposed to 2 HAVING SPLIT BUNDLE 1 INTO 1 AND 2 EFFECTIVELY SEPARATING THE DATA INTO TRANSFER IN AND TRANSFER OUT
Aproriate rehab in approriate setting has been split into bundles 2 and 3
Intial patient centered rehab planning interventions take place within the first 2 weeks
3 of the bundles are only recorded once
We have developed a new minimum data set with additional optional process measures
Over the following slides I’ll give the definitions for the individual interventions within the bundles

4. Bundle One
This bundle will not be used to measure your service but will give an indication to the health board that communication and continuity from other wards needs to be improved
Reliable point of contact for patient and relatives
Were the patients and/or their relatives given a point of contact- either a ward name or a person, and a telephone number for the place they are being transferred to?
Robust MDT transfer of care documentation sent at time of transfer
Was a multidisciplinary transfer of care document provided at time of transfer which included:
Patients expectations- e.g. where they are going to be discharged to, how long they are likely to be in hospital
Medical information (tertiary prevention)
Initial assessments
Patients goals
Outcome Measures
Treatment Plans
Patient has written information on rehab service they are going to
Have the patient and/or carer been given written information about the rehab unit they are being transferred to?

5. Bundle Two Allocation of link/key person/contact
Do the patient and carer have a link person or stroke liaison worker or key worker with whom they can discuss goals, aims of treatment, issues relating to their rehabilitation and discharge?
The key worker should be responsible for organising and attending the initial rehab planning meeting.
Initial rehabilitation planning meeting with patient and/ or family
Was there a meeting within the first 2 weeks of rehabilitation between the patient and/or carers and- as a minimum, a nurse and a therapist, one of whom should be the key worker, for discussion of:
Process of rehabilitation
Realistic prospects of recovery
Options for discharge
Process for communication between the MDT, the patient and their carers
The patients/carers wishes for discharge
Availability of all relevant/appropriate specialist assessments and interventions
Did the patient have access to the specialist assessment they required, for example:
Cognition
Mood/adjustment
Vision
Seating
Continence
Communication
Specialist equipment

6. Bundle Three In most appropriate setting for rehab
Is this patient in the most appropriate setting based on their rehabilitation needs and wishes?
Weekly review of progress
Is the patient continuing to make functional improvements and benefiting from rehabilitation? This can be measured by goal attainment or using functional outcome measures.
Appropriate intensity of rehabilitation from multidisciplinary / professional / agency team with relevant competencies
Did the patient receive all the rehabilitation contacts from the core team they required in this week?
The core team includes;
Clinical Psychology
Dietician
Nursing
Occupational Therapy
Physiotherapy
Social Worker
Speech and Language Therapy
Contacts may be direct or indirect where the contact is related to the patient’s goals. Definitions of what can be included in indirect contacts should be agreed locally so all professional groups are doing the same.
This is the only bundle which is repeated weekly for 6 weeks

7. Bundle Four Reliable point of contact for patient and relatives
Was the patient (and/or relative) given a reliable point of contact?
Patient receives a copy of MDT transfer of care documentation at time of transfer
Did the patient (and/or relative) receive a copy of the MDT transfer of care documentation?
Patient has written information on all follow-up services
Did the patient receive (and/or relative) written information on the follow-up services on discharge?

8. Minimum Dataset
The minimum dataset enables the same health information to be generated, independent of the system that captures it.
It enables healthcare professionals to measure and compare the delivery and quality of care provided
So we have our driver diagram and we have our locally agreed protocols how do you measure the reliability of your care
This is the minimum you need to do and can be expanded on. The process measures behind it aid you in looking at demand and capacity
As ever this data is not to compare sites competitively against one another this is about HOW YOU DELIVER AND EFFECTIVELY IMPROVE YOUR SERVICE LOCALLY
During the development of the minimum dataset, some data items were identified as process measures and are therefore not needed as part of the minimum dataset. However, they may provide valuable information on local processes and inform audit of services so they have been include separately as process measures
The dataset collected by the multidisciplinary clinical teams will provide the data for the following outcome measures. The data collection tool will display these outcome measures as a run chart:
Change in average functional outcome (Barthel) score on discharge
Percentage of people who return to their usual place of residence
Average Length of Stay
Additional Process Measures
The data collection tool will also produce run charts for additional process measures on a patient level for:
Time from stroke to commencing rehabilitation
Change in Barthel Score
Length of Stay The following slides will show the data name within each bundle and give the rational for collecting this data

9. Minimum dataset Bundle 1
ID Number
Date of transfer
Reliable point of contact
Robust MDT documentation
Patient has written information
Seamless transition of care from acute to rehab setting
To identify patients uniquely
This is the date when rehabilitation commences. This is needed to be able to calculate compliance with the transfer bundle on a weekly basis to track changes over time.
This is to be used if they have any queries about the transfer of care, such as when it is going to happen, what form of transport has been arranged
If a patient is transferred form an acute setting to a rehab setting in an evening or at a weekend, the transfer documentation should contain enough information to enable staff on the rehab ward/unit to continue rehabilitation without the need for additional assessments.
Patient and their carers will have a better understanding of the rehabilitation process if they have written information on the unit such as:
Address
Telephone numbers and times to ring
visiting times
the rehabilitation process such as meetings, specialist services available

10. Minimum dataset Bundle 2
Allocation of link person
Initial rehabilitation planning meeting
Availability of all relevant appropriate specialist interventions
Initial patient centred rehabilitation planning within 2 weeks of rehab commencing
The first 2 are self explanatory
This intervention follows on from the screening of all impairments that occurs within 7 days as part of the acute bundles. If screening shows a patient requires a specialist assessment then this referral should be made and available within the relevant timeline based on clinical presentation.

11. Minimum dataset Bundle 3
Functional assessment
In most appropriate setting for rehab
Weekly review of progress
Appropriate intensity of rehab provided
Barthel on discharge
Appropriate ongoing rehabilitation in most appropriate setting for first 6 weeks
Initial Barthel Outcome measure needed to calculate change in functional outcome
Patients discharge may be delayed for a variety of reasons, for example, availability of:
Medically fit for rehab
Lack of community rehabilitation services
Social care package
CHC funding
Care home bed
Aids and adaptations
Availability of rehab beds closer to home
Patients should only continue to receive rehabilitation while they continue to improve.
Contacts recorded as per agreed local guidelines
Required to obtain outcome measure

12. Minimum dataset Bundle 4
Date of discharge
Reliable point of contact
Patient receives a copy of the MDT transfer documentation
Patient has written information on follow up services
Seamless Transition of care from Rehab setting
This allows the database to look at reliability of discharge processes on a week to week setting
Patients and their relatives should have a person or place they can contact if they have any issues or concern following discharge.
There is evidence that patient-held records may enhance the patient’s understanding and involvement in their care. There is also evidence to show that discharge planning increases patient satisfaction. Patients should be given written information on support services available locally post discharge such as:
Support groups
Expert Patient Programmes
National Exercise on Referral Schemes
Vocational training opportunities
As per Life after Stroke Driver Diagram

13. Process Measures Measure LOS Monitor discharge destinations
Monitor unmet demand for specialist assessment and intervention
Monitor demand for professions to provide adequate levels of rehab for all patients on the ward on a weekly basis
Monitor capacity for professions to provide adequate levels of rehab on the ward each week
In addition to the minimum dataset process measures will enable the teams to look behind the data and start to understand the demands on their service as well as their capacity to deliver, enabling them to improve and develop their service.

14. Finally Reliability of Care Not for comparison of sites
How can you deliver and improve your service most effectively
This is already included in the 2011/2012 Annual Quality Framework
As of yet no decision has be made about compliance levels

15. ANY QUESTIONS?