Dorset
Improving
Psychological
Support
after
Dorset
Improving
Psychological
Support
Project
after Stroke Stroke
in the Community
Project
Sara Leonard
Lead Manager
Dorset Cardiac and Stroke Network
Today I will cover…….
 The scale of the problem
 Summary of original pilot project
 Issues and sustainability
 Progress since pilot
 Ongoing challenges and next steps
The scale of the problem
100
90
80
70
60
50
40
30
20
10
0
Up to 75% experience
cognitive impairment
(RCP 2009)
Anxiety rates of 30- 49%
up to 12 years post
stroke
(South London Stroke Register)
Prevalence of post
stroke depression
independent of
disability is approx
33%
(Hackett et al, 2005)
Cognition
Anxiety
Depression
A significant proportion of stroke patients with depression
remain undiagnosed or inadequately treated (Hackett et al 2005).
National Guidance
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
CollaborativeCare
Care
Collaborative
 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.
Mental Health Strategy 2011
The National ambition for
psychological care after stroke
Summary of original pilot project
 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
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.
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
arranging a further assessment)
and
Provide information on self-referral/refer to local IAPT services for Step 2
low intensity psychosocial interventions and/or drug treatment.
PPI
Involvement
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
Cost of Psychology Training - DEVELOPMENT
Band
Costs per
hour with on
costs (mid
point)
Hours
Total cost
Clinical
Neuropsychologist
8D
£46.94
15.0
£704.10
Service Improvement
Manager
7
£22.02
15.0
£330.30
UK Forum for Stroke Training accreditation
DEVELOPMENT & ACCREDITATION OF TRAINING
*One off cost – funded by Network
£300.00
£1,334.40*
Cost of Psychology Training - DELIVERY
Band
Cost
per
hour
Hours
Cost per
course*
Number
of
courses
Total cost
Clinical
Neuropsychologist
8D
£46.9
4
7.5
£352.05
3
£1,056.15
Assistant
7
£22.0
2
7.5
£165.15
3
£495.45
COST TO DELIVER TRAINING (3 x courses @ £517.20 each)
*plus:
– administrative support for booking venue/confirming places
– catering costs
•
Funded by Network
£1,551.60*
Cost of Psychology Training - ATTENDANCE
Band
Cost
per
hour
Hours
Cost per
course
Community Rehab
Team Leader
7
£22.02
7.5
£165.15
Community Senior
Physio/OT/SALT
6
£18.38
7.5
£137.85
Physiotherapist
5
£15.26
7.5
£114.45
COST TO ATTEND TRAINING
*Cost to provider
• Does not include travel expenses
Places
Total cost
20
£2757.00
£2757.00*
Total cost of psychology training
• Not including accreditation process:
• Delivery: £517.20 per course
• Attendance: £2,757.00 per course
= £3,274.20 per course
(20 delegates)
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
*One off cost
Both costs funded by Network
Cost of Communication Training – ATTENDANCE
Psychological
wellbeing
practitioners
Band
equivalent
Cost
per
hour
Hours
Cost per
person
Places
Total cost
6
£18.38
22.5
£413.55
12
£4,962.60
COST TO ATTEND TRAINING
*Cost to provider
• Does not include travel expenses
£4,962.60*
Total cost of Communication Training
• Not including accreditation process:
• Delivery: £750.00 per course
• Attendance: £4,962.60 per course
= £5,712.60 per 3 day course
(12 delegates)
Proportion of stroke patients receiving formal screening for
psychological issues after stroke during contact with community teams
Proportion of clients formally screened
72
Training
delivered
Training
end of January
%
45
35
32
27
7
3
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Proportion of stroke patients receiving support for psychological issues
after stroke during contact with community teams
Proporportion of clients receiving psychological support
93
93
89
76
68
%
Training
48
46
Training
delivered
end of January
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Number of stroke survivors and carers each
month supported by PCMH
6
5
5
4
3
2
2
Jan-11
Feb-11
2
2
Apr-11
May-11
2
1
1
0
Dec-10
Mar-11
month
Following evaluation it was concluded…
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!
Issues and sustainability
Issue
Action
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 • Building relations / open communication
rehab teams
• Make process as easy as possible.
• Ongoing issue!
Progress since pilot. We will now look at….
• Communication Training
• Psychology Training
• Ongoing challenges & next steps
Communication Training
• 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
Better Communication Training
Better Communication Training
Pre and Post Training Knowledge Scores
Knowledge scores (Max
possible score = 16)
Pre-Score
Post-Score
18
16
14
12
10
8
6
4
2
0
1
2
3
4
5
6
7
8
9
Individual trainees
10
11
12
13
Better Communication Training
Did the Communication Training meet your needs?
Yes, completely
Yes, partly
No, not at all
””Very
17
1
0
(94.5%)
(5.5%)
(0.0%)
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.”
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.”
Psychology Training
• 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)
Knowledge gained in 9 DIPSS Training Areas
Knowledge before training
Knowledge gained
9
Knowledge score (Max 10)
8
7
6
5
4
3
2
1
0
1
2
3
4
5
6
9 different knowledge areas
7
8
9
Knowledge Gained – top 5 areas
DIPSS Knowledge Area
Knowledge Gained
What can be done to improve coping and well
being after stroke
22%
Normal adjustment process after stroke
19%
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%
Self evaluated learning achieved by profession
Previous Knowledge
90%
80%
70%
9%
Knowledge Gained
9%
13%
13%
16%
19%
60%
50%
40%
30%
65%
72%
81%
81%
71%
56%
20%
Overall
Other
Stroke
Coordinator
SALT
OT
0%
Physio
10%
Self evaluated learning achieved by profession 2011 & 2012
14%
12%
9%
21%
20%
72%
75%
72%
Other
Stroke
Coordinator
SALT
60%
OT
60%
Physio
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Knowledge Gained
16%
66%
Overall
Previous Knowledge
Distribution of DIPSS psychology trained staff
2011
2012
Qualitative Feedback
• 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.
How people felt ….
• 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
Ongoing challenges & next steps
Issue
Action
•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
For further information…..
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.uk