1. Community stroke rehabilitation and data
Sarah Rickard, Network Manager & Tracy Walker, Community Clinical Lead
@GMStrokeODN

3. Our “postcode lottery”
Greater Manchester has 11 CCGs:
17 specialist community neuro rehabilitation teams
1-3 teams per CCG and two had no service
4 different models of care:
Inequitable access to services
Inadequate staffing (#s and professionals groups)
Inefficient, often with waits
Longer hospital LoS

4. Access to medical support Access to suitable exercise services
Stroke survivors in community needing ICST assessment (re-referral or had stroke out of area)
· Contact patient/carer by phone within 48 hours of referral and assess within 7 days
· If ICST intervention needed, apply appropriate pathway and enable life after stroke support as early as possible
Integrated Community Stroke Team (ICST) - Core MDT
OT, PT, SaLT Nurse, Clinical Psychologist/Neuro psychology, Physician, Rehabilitation Support Worker/Assistant Practitioner & Social Worker
IAPT
Crisis intervention/rapid assessment service
Access to medical support
Family & carer support service
Communication support service
Access to suitable exercise services
Stroke survivors discharged from hospital
· In reach/triage by ICST to support pathway decision
· Determine and apply appropriate pathway of care following full holistic assessment with family and patient
· Enable appropriate life after stroke support as early as possible
Support services
· Return to work/vocational support
· Long term conditions services
· Orthotics, orthoptics, wheelchair services
· Spasticity clinics
· Consultant review
· Specialist inpatient neuro rehabilitation centre
Pathway 1
Therapy at home with ICST support
· Telephone call to patient/carer for support within 24hrs if appropriate
· Assess at home within hours depending on clinical reasoning and patient need
· Treatment begins within 24 hours of assessment for ESD patients and within 7 days for non ESD patients
· Therapy intensity provided daily across 6 days a week as per guidelines with clinical reasoning/patient choice
· Intervention provided by ICST for up to 6 months
Pathway 2
Therapy at home with joint ICST & re-ablement rehabilitation support package
· Joint assessment at home by ICST and re-ablement team within 24 hours of discharge (or prior to discharge if local practice) to develop joint management plan
· ICST provide treatment and management plans with therapy practice via re-ablement workers
· Therapy provided within 7 days with up to 3 therapy/care visits a day provided by re-ablement service/ICST daily across 6 days a week as per guidelines with clinical reasoning/patient choice
· ICST review goals/visits weekly with max 6 weeks re-ablement support available
· Step down to pathway 1 if needed
Pathway 3
Discharged to residential/nursing home
· Telephone call to care home within 24hours for triage and management planning
· Assess within 72 hours of discharge depending on clinical reasoning and patient need.
· Treatment begins within 7 days of assessment
· Therapy intensity provided daily across 6 days week as per guidelines with clinical reasoning/patient choice
· Management plan/reintegration if needed to include seating, mobility, swallow & spasticity
· Prevention of contractures and shoulder pain
COMMUNITY REHABILITATION POST DISCAHRGE PHASE
Discharge
· When goals met, maximum 6 months
· When generic pathways or other life after stroke services are deemed appropriate by the ICST
· Self-referral back to ICST if needed in future
Life after stroke services encouraging self-management and use of community assets
· Family & carer support (liaise closely with ICST, may attend MDT)
· Communication & information support
· Exercise, health & fitness
· Social groups, peer support, befriending & respite care
LONGER TERM SUPPORT
6, 12 month and annual review thereafter using GMSAT. Referral back to ICST if needed in future

5. Use data to drive change
Win hearts and minds - best acute care but benefits lost as poor community
Highlight the problem and offer a solution (the model)
Use STP to lever at executive level
Use data to drive change
Strong, credible Clinical Leadership (AHP not medical!)
Identify key decision makers and lobby repeatedly
Broaden to neurological, not just stroke
Make it a commissioning priority – CCGs do have money
Persistence – never give up but be realistic about time frames
Network oversight /leadership is critical

6. What can we use data for? Support the case for change across a region

7. Understanding our teams, their current model of delivery and transformation progress1
Team name
Team A 2
Population (NHSE 2016 unweighted registered populations)
200,000 3
Model of delivery (1-5) - see tab 7 key A 4
Progress of service transformation - see tab 7key B E 5
Number of records discharged or transferred from team in reporting period (4 months) (SSNAP Aug-Nov 17) 57 6
Annual number of referrals including acute, self and community (Local data 2017/18)
142 7
Range of mRS scores seen by team (local data Aug-Nov 17)
1-4 8
Average length of stay in days (SSNAP Aug-Nov 17) 32

8. Measuring current compliance with proposed model across the region#
Key elements of integrated model
Team A
Team B 1
All core professionals in team N 2
Staffing levels met 3
Service provided for 6 days a week Y 4
Service provided for up to 6 months 5
Pathway 1.Therapy at home with ICST support 6
Pathway 2.Therapy at home with joint ICST & re-ablement 7
Pathway 3.Residential/nursing home patients 8
Service accepts 40% ESD cohort 9
Service accepts 60% non ESD cohort 10
Patients seen within 72 hours 11
Wait of 7 days or less from assessment to treatment 12
In reach into acute setting 13
Self referral permitted 14
Life after stroke services available 15
6 month review for all residents 16
Inputting into SSNAP in timely way
% compliance with model 63 75

9. Understanding the impacts of current models on patient access for assessment and treatment (i.e. waits) and highlighting problems in areas with ESD models 1
Average time from referral to triage (i.e. telephone) in days 2
Average time from referral to initial assessment (i.e. face to face) in days 3
Average wait in days between ESD referral and CNRT/CST continuing treatment after 6 weeks of ESD? 4
Average time from assessment to professional treatment by OT in days 5
Average time from assessment to professional treatment by PT in days 6
Average time from assessment to professional treatment by SLT in days 7
Average time from assessment to professional treatment by Nurse in days 8
Average time from assessment to professional treatment by Psychologist in days

10. Auditing team performance and outcomes using SSNAP Section 9
Measure description
Comment
% of adults having stroke rehabilitation in hospital or in the community offered at least 45 minutes of each relevant therapy for a minimum of 5 days a week for up to 6 weeks
NICE Standard 2
% of patients reporting positive experience on friends and family test or patient experience survey
% of adults who have had a stroke have their rehabilitation goals reviewed at regular intervals (weekly)
NICE Standard 6
% of patients who demonstrate positive improvement following Community Stroke Team intervention
% of adults who have had a stroke who can be referred to a clinical psychologist with expertise in stroke rehabilitation who is part of the core multidisciplinary stroke rehabilitation team
NICE Standard 3
% of adults who have had a stroke are offered active management to return to work and advice on driving if they wish to do so
NICE Standard 5 (RTW only)
% of patients who were screened on admission to the Community Stroke Team for mood disturbance and cognitive impairment
Previous NICE Standard
% of patients referred seen within 72 hours for an assessment by Community Stroke Team

11. Key steps: using data to drive our change (2016-current)
Collaboratively developed and agreed a model to benchmark across region
Agreed team measures – involved community
Developed custom fields (Section 9 SSNAP) to collect data - only includes transferred inpatient records currently
Worked with Trust audit departments to support SSNAP download process
Carried out snapshot audits for staffing and waits
Developed community dashboard for teams and CCGs
Provided training for teams on data and outcomes and encouraged data compliance - most teams at 75-90%
Using dashboard to inform commissioners/providers/STP of performance to influence and drive change

12. Business case in development
New investment
New investment
Business case in development
Business case in development
New investment
New investment
Business case in development
New investment
New service being procured

13. sarah.rickard@srft.nhs.uk tracy.walker@pat.nhs.uk
@GMStrokeODN