1. Proactive Care- Stroke Physiotherapy Outreach - Home Based Care
Claire Richards
Clinical Lead Physiotherapist for Stroke

2. Setting the scene
new stroke patients per annum in Carmarthenshire area of Hywel Dda University Health Board
Stroke is the single leading cause for chronic disability and is a long term/ chronic condition
Physiotherapy criteria prior to outreach
Stroke patients discharged from the hospital setting were referred to the Generalist community physiotherapy teams by written referrals
The physiotherapy service prioritised care alongside other pathologies
The generalist community physiotherapy teams would provide all community care for stroke patients
Skill mix of physiotherapist providing the care varied (Band 6 to Band 3)
Multiple re-referrals via GP/other profession during the ‘wait’ for community therapy

3. Snap shot Audit: Old ways of working
Snap shot audit of patients discharged from hospital, with ongoing physiotherapy needs, between January – May 2015 (Carmarthen only)
ITEM
DATA
Number of new stroke patients discharge from hospital with ongoing needs 48
The average time taken for initial community assessment after discharge from hospital
48.3 days
Patients seen within 14 days of discharge from hospital
10%
Patients seen within 72 hours of discharge 7%
Patient experience
Isolated
‘Chasing’ follow up care
Abandoned
No data on POC or equipment needs

4. The need for change….Steered to stroke patients
Poor compliance with national guidelines
Patient dissatisfaction in the delay in receiving specialist therapy care
Extended time on physiotherapy caseload owing to ‘un-doing’ bad habits developed by patient during delay in follow-up physiotherapy care
Physiotherapy often the first contact for stroke patients after discharge from hospital
The transition of care for stroke patients was not a preventative approach & this group are high risk

5. Change in Practice: What we did
Proactive care (ICF) monies was utilised to facilitate a service delivery change in the Carmarthenshire stroke physiotherapy teams
Recruitment of 4wte- 1 band 7, 1 band 5 and 2 band 4 physiotherapy staff
Goal
Redesign physiotherapy stroke services to provide stroke specific physiotherapy outreach for new stroke patients within Carmarthenshire
Supporting recovery and transition of care between hospital and community by early community intervention- intermediate care.

6. Change in Practice: What we did
AIMS:
Improve the transition of care for stroke patients from the acute setting into the community setting through timely intervention in home/ community
Deliver evidenced based stroke rehabilitation by physiotherapists specialising in stroke care in the community setting as early as possible post discharge from hospital
Reduce long term need for commissioned care hours and equipment needs
Reduced demand on the generalist community teams, increase availability for other pathologies
Promote self-management strategies in the community setting
Strive to adhere to local and national guidelines for stroke community care
Improve patients functional outcomes and well-being and help them to achieve their goals sooner
Prevent duplicate referrals to services and prevent readmission

7. Data for April 2017 to May 2018 across Carmarthenshire
Outcomes/Data
Data for April 2017 to May 2018 across Carmarthenshire
DATA
Figure
Number of new patients
200
% seen within 72 hours of discharge
84.4%
% seen within 2 weeks of discharge
100%
Average time to follow up
2.8 days
Reason not seen within 72 hours
Initial teething problems
Bank holiday weekend cover
Staffing (leave/capacity/rotation)
Number of physiotherapy contacts
1006
% of patients showing improvement of 4 Outcome Measures
% of patients discharged from stroke community outreach
81.5%
(163 out of 200)
What ongoing input required
Generalist physiotherapy, NERS

8. Total data continued…. Data Figure Example
% of patients requiring ongoing NEW social care at point of discharge from hospital
25%
(51/200)
Of those patients, % of patients with a reduction in ongoing care needs on discharge from physiotherapy
37%
(19/51)
1 carer x 2 daily to no care needs
1 carer x 1 daily to no care needs
1 carer x 3 daily to 1 carer daily
2 carers x 4 daily to no care needs
2 carers x 4 daily to 1 carer x 4 daily
% of patients with NEW equipment needs on discharge from hospital
61%
(122/200)
Of those patients, % of patients improvement in equipment need on discharge from proactive care physiotherapy
60%
(74/122)
Hoist to RZF
Hoist to stedy
Stedy to RZF
Stick to no equipment needs
RZF to stick
Tripod to stick
Commode to no equipment needs
RZF to crutch
RZF to no care needs
2 x sticks to 1 stick

9. What does this mean?
Reduced waiting time for patients to receive community follow-up care
Increased capacity/availability for the generalist community team to treat other pathologies (1006 less appointments/163 less patients)
Improved patient function and achieving this goals sooner- promote well being and independence
Preventative approach
Reduced long term care need in the community setting
Reduced long term need for equipment
Improved compliance with national targets and guidelines

10. I don’t know why they had to stop after what was it…6 weeks, wish they could’ve carried on seeing me
It was nice not to worry about starting all over again with people I don’t know, they made me laugh in hospital and they made me laugh at home
Its obvious they know what they are doing, they helped me walk again
PATIENT FEEDBACK
The girls (physio staff) are amazing and having them come to see me at home makes going home less frightening.
They helped me get the confidence to try new things that I was scared to try for myself, they helped me get my wife to see it was ok to mow my lawn!!
Physiotherapy vital to my recovery, I was so glad you can see us at home straight away
Its obvious they know what they are doing, they helped me walk again
Its more than them just seeing me, they gave me the reassurance to live at home. They are the only people I have seen since going home. If they didn’t know the answer they would find out and get back to me
A friendly face was all I needed to start off with and that’s what they gave me

11. Further Developments: Integrated Group Work
Why?
A lot of travel time spent across the counties
Patients with similar needs over 2 hours apart
Chronic PT staffing deficits across the whole stroke pathway therefore limited PT availability
Integrated Group Work - Carmarthen
Integrated group work for Stroke patients across the whole stroke pathway (includes other pathologies)
Staffing: 1 PT from stroke team, 1 PT from community team. OT once a month for UL group
3 classes at present: Upper limb, low level balance, high level balance

12. Summary
Proactive care investment has enabled the stroke physiotherapy team to transform stroke community outreach across Carmarthenshire for up to 6 weeks after discharge from hospital
Patient benefits include:
Reduced wait to physiotherapy contact within the community
Decreased LOS
Improved functional outcomes & maximise independence
Reduced reliance on carers and equipment
Access to specialist stroke physiotherapist for 6 weeks on discharge from hospital
Improved well being
Increased self management of this chronic condition
Strategic benefits:
Preventative approach
Reduced demand for ongoing care needs
Reduced patient demand for equipment needs
Improved compliance with national guidelines
Improved availability of the generalist community teams to treat other pathologies
Value for money
Integrated groups have proved crucial in delivering sustainability
Further considerations need to adopt a multidisciplinary approach to community care for this cohort at high risk of chronic disability.