Healthcare for London’s stroke
rehabilitation commissioning
guidance: an introduction
Dr Tony Rudd
London Stroke Clinical Director
Healthcare for London is part of Commissioning Support for London – an organisation providing clinical and business support to London’s NHS.
Lecture outline
• Background
• Brief review of evidence
• Key elements for a comprehensive stroke
service
National Stroke Strategy, DH, 2007
“For those who have had a stroke and
their relatives and carers, whether at home
or in care homes, to achieve a good
quality of life and maximise independence,
well-being and choices”.
Everyday in London…
Approximately 54 people will have a stroke.
6000 per year with lasting disability.
Stroke pathway
Stroke
Primary
Rapid
Thromb
Unit
Prevention detection -olysis
care
Tailored
Community
rehab
Self care/
Peer support
Sign posting
Access to leisure,
employment,
other
opportunities
Quality information for users and carers
Quality information for professionals
A workforce skilled in working with people with stroke
Preventing a further stroke or TIA
Living with a disability
Acute phase recovery
Learning to live with a
disability
Chapters in rehabilitation commissioning
guide
•
•
•
•
•
Inpatient rehabilitation
Community rehabilitation
Early supported discharge
Support structures
Regular review
Stroke Unit care
• Every PCT commissions inpatient
rehabilitation that is available for all stroke
patients. This should start as soon as
possible and continue for as long as
required. This service must meet all of the
performance standards.
100
80
60
Percent Survival
40
Stroke unit
20
SU-censored
Conv entional wards
0
CW -censored
0
1
2
3
4
Survival time (years)
5
6
7
8
9
10
time (min.)
160
140
Belgium
120
England
100
Switzerland
80
Germany
60
40
20
0
total therapy
physio-therapy
occupational therapy
speech therapy
other therapies
Effects of augmented exercise therapy time after
stroke
Kwakkel et al, 2004
• 20 trials, n=2686
• Significant effect on activities of daily living in
first 6 months after stroke
• No ceiling effect for therapeutic intensity
• 16 additional hours
Community rehabilitation
• Every PCT should commission a
community rehabilitation service for stroke
patients, delivered by staff with stroke
specialist skills. Service configuration
should be locally determined and the
service must meet all of the performance
standards.
Outpatient Service Trialists
Personal ADL
Outpatient Service Trialists
Extended ADL
Equipment and environmental
adaptations
– 47% of equipment never used
(Gitlin et al, 1996)
– Lack of information on
availability
(Mann et al, 1995)
– Stroke patients using more
equipment / environmental
adaptations and significantly
more independent at one year
after stroke
(Logan et al, 1995)
Simple, inexpensive AND effective
Community rehabilitation
• Key gap: A lack of timely access to a
community rehabilitation team can lead to
delays within rehabilitation causing a loss
of improvements gained during
rehabilitation.
• Priority for development: Every PCT
should ensure access to a responsive
stroke specialist community rehabilitation
service.
Early supported discharge (ESD)
• Every PCT should commission an early
supported discharge service for people
who would benefit. This service should
include staff with specialist stroke skills
and must meet all of the performance
standards.
Early supported discharge services
• Eight trials (data from seven) from UK,
Norway, Sweden, Australia, Canada, USA
• Heterogeneity of services
• Average reduction in hospital length of
stay by 9 days (95% CI 5-15; P<0.0001)
• Apparent reductions (P<0.01) in death/
institutional care and death/dependency
• Modest reduction in costs?
ESD trialists (2001)
Early supported discharge services
•
•
•
•
Not applicable to all stroke patients
Can accelerate discharge home
Appear to improve subsequent recovery
Best results with ESD services
coordinated and provided by a
multidisciplinary rehabilitation team
ESD trialists (2001)
Early supported discharge
• Key gap: Many London hospitals do not have access to
ESD; ESD services that do exist may operate in isolation
without a fully developed community stroke rehabilitation
service, resulting in poor exit strategies from the
rehabilitation pathway.
• Priority for development: An ESD service must be seen
as an addition to a community stroke rehabilitation
service. An ESD service should be appropriately
resourced to offer the same intensity of rehabilitation as
an inpatient stroke service.
Support services
•
1.
2.
Everyone who has had a stroke, and their carers,
should have:
A key support worker such as a family support
worker or community matron to provide:
navigation and advocacy; a link with the inpatient
and community rehabilitation teams and other care
providers.
A designated person from health or social care
who is the key contact for the patient and carer
whilst in each setting, such as a therapist, social
worker, or healthcare assistant.
Support services
• Key gap: There is a lack of collaboration
between health and social care provided
services leading to confusion for patients,
families, carers and staff regarding access to
services and support.
• Priority for development: Every PCT should work
collaboratively to develop support roles that
cover the whole stroke pathway in order for
patients, families, carers and staff to have
access to services and support.
Regular review
• For the first 12 months following stroke, all
people who have had a stroke and their
carers should have a regular review and
assessment of ongoing medical, social
and emotional needs as both an inpatient
and in the community.
Regular review
• Key gap: There is no specific follow up
programme in place for stroke patients.
• Priority for development: Every PCT
should ensure participation of all services
along the pathway, including GPs and
social care, with respect to ongoing
management.