NHS Croydon
Claire Godfrey AD Adult
Strategic Commissioning
Community Stroke Team
Consultation with user forums on experience of
stroke service
Public health needs analysis
Mapping current services using LEAN
methodology and identifying gaps
Development of service specification for
community stroke service
Redesign of pathway and additional investment
to meet demand
Commissioning Reviews
Consultation with Older People’s Network and
Voluntary Sector Providers for Older People
Reported feeling “abandoned to cope alone after
acute stroke care ended”
Informed decision to commission care for all
stroke patients and include annual review as
part of community stroke specification
Pathways within Community Stroke
Community stroke service available to all stroke
patients with pathway based on need
Stroke Association
 Carer
and Family Support
 Stroke Groups
 Communication Support
Community Stroke Team intervention including nursing,
rehab and generic workers
Continuing Care
Stroke register with annual reviews all stroke patients
Commissioning Reviews
Part of stroke co-ordinators role - Responsibility to ensure annual
reviews completed
Aims to review
 Care and support delivered via appropriate pathway
 Appropriate ongoing care and support after rehab phase and types
of support received at 1 year
 Number of patients independent at 1 year
 Identification of new problems and concerns requiring possible
intervention including carer concerns
 User experience feedback
Results to support strategic development and commissioning via stroke
steering group
Stroke Reviews Pilot
Dr Emma Cotterill - Clinical Psychologist
Jane Dundas - Stroke Co-ordinator
Pilot - Stroke Reviews
Developed within Croydon Community Stroke
Rehabilitation Team (CNRT)
Pilot format – 2 parts to the review
Pilot Development team:
 Jane
Dundas, Stroke Co-ordinator
 Dr Emma Cotterill, Clinical Psychologist
 Jade Redfern, Assistant Psychologist
 Darren Beales, Physiotherapist
Stroke Reviews Pilot - structure
Part 1
Service User Self assessment questionnaire
Sent out 4 months post discharge from CNRT (10
months - 1 year post stroke)
Telephone follow up if questionnaire not returned, questionnaire completed on telephone
Questionnaires scored
Passed to stroke co-ordinator for follow up – if
opted for this contact
Stroke Reviews Pilot - structure
Part 2:
Stroke Co-ordinator provides telephone follow
up or home visit
Onward actions:
 Referrals made to other services/professionals
 Re-referral for further episode of rehabilitation
Review report to GP/Consultant + copy to
Issues Raised from Pilot– Part 1
Positive and non intrusive way to reach service users
Time saving way of encouraging service users to ‘opt in’ for further
People with communication difficulties or significant cognitive
impairment may not be able to complete self assessment
questionnaire or telephone questionnaire
Self Assessment questionnaire sent to service users – need version
for carers?
Requires an administration lead on the project e.g. to co-ordinate
Results of Pilot – Part 2
Patient Feedback
Quick, cost free
Convenient – no travel
Treated as an individual
Contact point
Telephone not for dysphasic patients but carers able to
Only 3/18 no further needs - satisfied with telephone
contact alone
9/18 satisfied with telephone contact but preferred face
to face
Remaining 6/18 didn’t mind
Stroke Co-ordinator perspective
14/18 face to face preferable
Unable to provide holistic assessment on
the telephone
Additional 9 who requested no contact
may benefit from assessment
Unable to assess carer needs
Stroke Co-ordinator perspective
Time pressures
 Stressful – repeated calls
 Need for admin support
 Great for patients who have minimal
needs, offers window for future contact
 Patient needs information about review
process at discharge
National Stroke Strategy
Projected Stroke prevalence
Responsibility for review?
Pilot completed in CNRT - consider pathwaywide review? Who is responsible?
Hospital Stroke Consultants
Stroke MDT
Essential - Access to patient information
Desirable – Previous knowledge of the patient
Questionnaire encourages self
 Screens patients who have needs and
those who don’t
 Patient choice
 Carers of patients with dysphasia able to
raise issues
Patients with impairments, particularly
communication/cognition require face to
face assessment preferably at home
 Home visits lasted in excess of one hour
 Travel time
 Onward referral process and report
writing time consuming
The future
Applicable to this client group (post rehab)
 Questionnaires valuable
 Weekly MDT follow-up clinic (20 patients/month)
 Led by Stroke (nurse) co-ordinator + access to
therapists & psychologist
 Social services link desirable
 Assessment proforma
 Home visit if appropriate
Cost implications
 Transport
to clinic
 Therapy time
 Admin support
Benefits and cost savings
Encourages self assessment
 Stroke prevention
 General health promotion
 Self referral pathway
 Access to information
 Access to support
 Positive patient experience
Review Pilot Results
Pilot -Stroke Reviews – Part 1
Can you tell us about any improvements in your mood & coping since discharge
Can you tell us about any problems in your mood and coping since discharge
Can you tell us about any improvements in your memory and thinking since discharge
Can you tell us about any problems in your memory and thinking since discharge
Can you tell us about any improvements in your physical abilities since discharge
Can you tell us about any problems with your physical abilities since discharge
Can you tell us about any improvements in your communication since discharge
Can you tell us about any problems in your communication since discharge
Can you tell us about any improvements in your social life and social/work activities since
Can you tell us about any problems in your social life and social/work activities
Results of Pilot – Part 1
Questionnaires Sent
Questionnaires completed
Questionnaires completed via post
Questionnaires completed via telephone
27 (62%)
Service users/carers who refused/opted out via phone or post
Questionnaires unable to complete over telephone due to
communication difficulties
Unable to make direct contact via phone/post
Not returned/other
Results of Pilot – Part 1
Questionnaire Data:
No significant concerns reported on questionnaire
16 out of 27 wanted to be contacted by stroke coordinator
2 people did not opt either way so were passed to
stroke co-ordinator
11 out of 27 highlighted only one area of difficulty
on questionnaire
3 people highlighted all 5 areas of difficulty
Results of Pilot – Part 1
13 people highlighted physical difficulties
9 people highlighted mood difficulties
8 people highlighted social difficulties
5 people highlighted memory difficulties
5 people highlighted communication
Results of Pilot – Part 2
18 followed up by stroke co-ordinator
10 telephone reviews
8 home visits
 1 referred to Falls service
 1 referred for further short rehab intervention
 All provided with relevant written information as
 All needed secondary prevention advice
Results of Pilot – Part 2
9 referred to Stroke Association – needs
for carer support, benefits advice
 All advised of support groups
 All advised of educational groups
 Some medical issues raised with GPs