1. Dorset Improving Psychological Support after Stroke Project Sara Leonard Lead Manager Dorset Cardiac and Stroke Network Dorset Improving Psychological Support after Stroke in the Community Project

2.  The scale of the problem  Summary of original pilot project  Issues and sustainability  Progress since pilot  Ongoing challenges and next steps Today I will cover…….

3. A significant proportion of stroke patients with depression remain undiagnosed or inadequately treated (Hackett et al 2005). Up to 75% experience cognitive impairment (RCP 2009) Prevalence of post stroke depression independent of disability is approx 33% (Hackett et al, 2005) Anxiety rates of 30- 49% up to 12 years post stroke (South London Stroke Register) The scale of the problem

4. National Stroke Strategy (2007) Central importance of a psychological pathway of rehabilitation RCP National Clinical Guidelines for Stroke (2009) Patients with stroke should be routinely screened for depression anxiety and cognition NICE Quality Standard for Stroke (2010) Screen within 6 weeks of diagnosis … to identify mood disturbance and cognitive impairment NICE Quality Standard for Depression in Adults (2011) People with depression should receive appropriate psychosocial interventions or collaborative care according to the degree of depression, associated chronic health problems and its impact on function National Guidance

5. Collaborative Care  Close collaboration between primary and secondary physical health services and specialist mental health services  Case management supported from senior mental health professionals  A range of interventions including patient education, psychological and pharmacological interventions  Long term coordination of care and follow up. Collaborative Care

6. Mental Health Strategy 2011

7. The National ambition for psychological care after stroke

8.  Little had been done.  STRONG support from local people.  Pilot Site – North and South West Dorset.  Collaborative working  New Pathway  Training – developed and provided  Monitored  Accreditation & Oscar Summary of original pilot project

10. Step 1 Under Step 1 DIPSS trained staff are able to: Ask initial screening questions Employ nationally validated screening assessment tools as appropriate (e.g. PHQ9, GAD-7, SADQ-10) Risk Assess. Provide initial support and information. (Including for sub-threshold scores). Progress to Step 2 (persistent sub-threshold, mild to moderate) Refer on as appropriate.

11. Step 2 Initial Management Under Step 2 DIPSS trained staff are able to: Offer Sleep Hygiene Advice Undertake Active Monitoring (discussing problems, providing information on depression and arranging a further assessment) Provide information on self-referral/refer to local IAPT services for Step 2 low intensity psychosocial interventions and/or drug treatment.

12. PPI Involvement Patient & carer representatives on steering group Patient & Carer easy-read feedback forms Dorset Stroke Network PPI Forums – ongoing and specific Stroke Network PPI Members with aphasia PPI Involvement

13. BandCosts per hour with on costs (mid point) HoursTotal cost Clinical Neuropsychologist 8D£46.9415.0£704.10 Service Improvement Manager 7£22.0215.0£330.30 UK Forum for Stroke Training accreditation£300.00 DEVELOPMENT & ACCREDITATION OF TRAINING£1,334.40* *One off cost – funded by Network Cost of Psychology Training - DEVELOPMENT

14. BandCost per hour HoursCost per course* Number of courses Total cost Clinical Neuropsychologist 8D£46.9 4 7.5£352.053£1,056.15 Assistant7£22.0 2 7.5£165.153£495.45 COST TO DELIVER TRAINING (3 x courses @ £517.20 each)£1,551.60* *plus: –administrative support for booking venue/confirming places –catering costs Funded by Network Cost of Psychology Training - DELIVERY

15. BandCost per hour HoursCost per course PlacesTotal cost Community Rehab Team Leader 7£22.027.5£165.15 Community Senior Physio/OT/SALT 6£18.387.5£137.8520£2757.00 Physiotherapist5£15.267.5£114.45 COST TO ATTEND TRAINING£2757.00* *Cost to provider Does not include travel expenses Cost of Psychology Training - ATTENDANCE

16. Not including accreditation process: Delivery: £517.20 per course Attendance: £2,757.00 per course = £3,274.20 per course (20 delegates) Total cost of psychology training

17. *One off cost Both costs funded by Network Cost of Communication Training – DEVELOPMENT & DELIVERY UK Forum for Stroke Training accreditation (existing training package) £300.00* Delivery of 3 day course by Speech & Language Therapist£750.00

18. Band equivalent Cost per hour HoursCost per person PlacesTotal cost Psychological wellbeing practitioners 6£18.3822.5£413.5512£4,962.60 COST TO ATTEND TRAINING£4,962.60* *Cost to provider Does not include travel expenses Cost of Communication Training – ATTENDANCE

19. Not including accreditation process: Delivery: £750.00 per course Attendance: £4,962.60 per course = £5,712.60 per 3 day course (12 delegates) Total cost of Communication Training

20. Training delivered end of January Proportion of stroke patients receiving formal screening for psychological issues after stroke during contact with community teams

21. Training delivered end of January Proportion of stroke patients receiving support for psychological issues after stroke during contact with community teams

22. Number of stroke survivors and carers each month supported by PCMH

23. Community rehabilitation/stroke staff are well placed to screen for psychological issues after stroke in the community. With support and training they are able to provide low level support for psychological issues as an integrated part of holistic care, referring those with persistent or more significant levels of distress to specialist primary mental health and clinical neuropsychology services. It was decided to roll the project out across Dorset! Following evaluation it was concluded…

24. Issues and sustainability IssueAction Data Collection Forms redesigned Seeking national advice – ongoing! Need for refresher training Now being provided! People not seen by Communication Trained staff New pathway - to ensure happens. Physical barriers to access Looking into – home visits? Including Carers? Included in Pilot Re ongoing practice – responsibility lies with social care. Carers assessments. Possible to review in future? Huge demands on community rehab teams Building relations / open communication Make process as easy as possible. Ongoing issue!

25. Progress since pilot. We will now look at…. Communication Training Psychology Training Ongoing challenges & next steps

26. 2 additional 3 day training courses 18 additional CMHT/IAPT staff Total now trained = 26 Process to ensure stroke patients are seen by communication trained staff Reflective practice/refresher training – to be provided Communication Training

27. Better Communication Training

28. Did the Communication Training meet your needs? Yes, completely17 (94.5%) Yes, partly 1 (5.5%) No, not at all 0 (0.0%) ” ”Very good balance between “Theory based” and practical knowledge. I think the course enabled me to enhance my ability to communicate better with, and understand the difficulties faced by, people who have had a stroke.”

29. Better Communication Training What was the most useful aspect of the training? 72% specified meeting and talking to people with aphasia “All of it! Understanding how a stroke affects a person mentally as well as physically. Meeting and talking to stroke patients” “The conversations with the aphasic people. This exercise was very important – to experience these conversations and for my own confidence.”

30. 3 training sessions in rollout area Jan-Mar 2012 46 new rehabilitation/stroke staff trained. Including new areas/stages of pathway Total trained to date = 92 1 more training session – April 2012. 13 staff signed up. Total trainees by end April 2012 = 105 Refresher training April (for pilot) & Aug/Oct 2012 (for recent training) Psychology Training

32. Knowledge Gained – top 5 areas DIPSS Knowledge AreaKnowledge Gained What can be done to improve coping and well being after stroke 22% Normal adjustment process after stroke19% Signs of anxiety and depression and how to screen using formal screening tools 17% Simple strategies which can support services users who are distressed 17% Situations when referral on for more formal or intensive input might be needed 16%

35. Distribution of DIPSS psychology trained staff 2011 2012

36. Feedback from 18 people so far in rollout period 88% said a member of the stroke team had discussed how they were coping emotionally since they came home. Of these people: –100% ‘Helpful’ or ‘Very Helpful” –100% member of staff understood their concerns “A great deal” or “quite a lot” 2 people didn’t discuss how they were coping emotionally - 1 would have liked to. Qualitative Feedback

37. I enjoyed our chat and I felt quite reassured to be told I appeared to be coping well with my disability. Comforted Relieved to have someone to discuss my problems with Very pleased for their advice I found it very reassuring to discuss my problems It was important to be asked about ones emotions it helps towards coping Relieved to have some support - someone who understands what is happening How people felt ….

38. Ongoing challenges & next steps IssueAction Data Collection Physical barriers to accessing IAPT Capacity of rehab/stroke teams Ongoing issues! New screening tools DISCS (Aphasia) & BASDEC (older people) Sustainability – training & funding To be discussed IAPT/Talking Therapies going out to “Any Qualified Provider” Ensure AQP sign up to pathway Communicate referral changes to all staff Provision of Step 2 psychosocial interventions Explore possibilities for clinical supervision to enable additional Step 2 support Review new innovative ways of providing support e.g. i-pod apps, tele-support etc. Patient and Carer Feedback Further work planned Roll out to all Long Term Conditions Work has started

39. Frances Aviss Patient and Public Involvement Lead & Service Improvement Manager Dorset Cardiac and Stroke Network Tel: 07736 245 266 e-mail: frances.aviss@bp-pct.nhs.ukfrances.aviss@bp-pct.nhs.uk For further information…..