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Stroke Early Supported Discharge (ESD) Teams/ Post-acute Rehabilitation Services Benchmarking Report November 2014

Stroke Early Supported Discharge (ESD) Teams / Post –acute Rehabilitation Services Benchmarking Report Authors: Claire Hammill, Quality Improvement Lead (CMSCN) & Ruth Grainger, Data Analyst, (CSU). Contributions from all stroke specific ESD teams across Cheshire & Merseyside Date: November 2014 Version: 1.1

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Contents 1

Executive Summary and Recommendations

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1.1 Background Information on ESD Services 1.2 The Role of Strategic Clinical Networks 1.3 Aim of Benchmarking Process and Report 1.4 Benchmarking Process 1.5 Current Network Position 1.6 Recommendations

3 3 4 4 4 5

Benchmarking Information

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2.1 Overview of Current ESD Teams 2.2 Populations served 2.3 Outreach/In reach 2.4 Eligibility for ESD 2.5 Seven day services 2.6 Maximum period for accessing the service/Intensity of Input 2.7 Post ESD rehabilitation 2.8 Compliance with National Standards for ESD 2.9 Summary

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Workforce and Skill Mix

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4

Other key themes

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4.1 Quality of Care and Outcomes 4.2 Integration with Social Care 4.3 Psychological Support 4.4 Unbundling the tariff

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Summary

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2

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Tables: 1 Overview of Current ESD Teams Models of Service Delivery 2 Overview of Current Situation in Areas without ESD provision 3 Progress of Teams towards National Standards 4 Overview of staffing for ESD Teams 5 Staffing Levels Compared to Recommended Levels

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Appendix 1 - Sentinel Stroke National Audit Programme (SSNAP) data Appendix 2 - Criteria for Accessing ESD Services

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References

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1 Executive Summary and Recommendations 1.1 Background Information on ESD Services (National Guidance) “People who have had strokes access high-quality rehabilitation and, with their carer, receive support from stroke-skilled services as soon as possible after they have a stroke, available in hospital, immediately after transfer from hospital and for as long as they need it” (Quality Marker 10, Stroke Strategy, 2007) An ESD team should, according to needs and preferences of individual patients: •

Facilitate earliest possible safe discharge from hospital, (wherever possible to the usual place of residence).

•

Provide high quality, stroke specialist multi-disciplinary rehabilitation; the initial frequency and intensity of therapy intervention must be at least equivalent to what would be provided on a stroke unit and be reduced gradually based on need. It should not result in a delay in care.

ESD is just one part of the patient pathway for a proportion (about 40% are considered eligible) of stroke patients. Some ESD teams are taking increasing numbers of complex patients. 1.2 The Role of Strategic Clinical Networks “The purpose of the Strategic Clinical Networks (SCN) is to provide a model through which professionals, organisations and service users collaborate across organisational boundaries to deliver programmes which result in improved health and wellbeing outcomes and improved quality of patient care” (Cheshire and Merseyside SCN Business Plan, 2014) Stroke services are currently within the remit of the SCNs and the aims and objectives in relation to stroke services are outlined in the Cheshire and Merseyside work plan. It includes: -

Equitable access to high quality rehabilitation support

-

Supporting commissioners to reduce variation informed by comparative data

To inform the work to achieve these aims, the network support team was tasked with benchmarking stroke ESD provision by the CVD community.


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1.3 Aim of Benchmarking Process and Report Across England there continues to be great variation in rehabilitation and community services (CQC, 2011). The aim of this benchmarking exercise is to: 1. Outline the current service provision across Cheshire and Merseyside 2. With reference to national standards, identify gaps and variation 3. Inform the development of network agreed best practice frameworks 1.4 Benchmarking Process A benchmarking template was developed with reference to national guidance including National Stroke Strategy (DOH, 2007), Stroke Rehabilitation in the Community: Commissioning for Improvement (Broomhead et. al., 2012), Cardiovascular Disease Outcomes Strategy (DOH, 2013), Stroke Rehabilitation guidelines (NICE, 2013) and the NHS Outcomes Framework (DOH, 2012) and CCG Outcomes Indicator Set 2014/2015. A member of the SCN support team met with ESD leads and jointly completed the template. Data has also been included from the Sentinel Stroke National Audit Programme (SSNAP) in appendix 1. 1.5 Current Network Position The 12 Clinical Commissioning Groups (CCGs) across Cheshire and Merseyside are responsible for ensuring their residents can access high quality stroke rehabilitation services. Local geography and location of hospital trusts/patient flows, along with historical models of service delivery, has led to the development of different models of community rehabilitation across the patch: -

There are currently 7 ESD services/pathways that provide ESD for residents of 8 CCGs, some of which have evolved into a community stroke team that incorporates an ESD pathway.

-

1 CCG has a comprehensive community neuro rehabilitation service but is not currently commissioned to provide the intensity in the first few weeks of early supported discharge.

-

2 CCGs have recently jointly commissioned a whole pathway approach to community rehabilitation including ESD; this is due to be operational in December 2014.


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-

1 CCG has a generic rehabilitation team with some staff having neurological specific skills and experience.

•

The length of time over which patients can access ESD varies from 3-6 weeks through to indefinite, based on need for an ESD pathway that flows straight into a stroke community rehabilitation pathway.

•

There is considerable variation in provision for non-ESD patients and post-ESD support (whether that be stroke specialist rehabilitation for up to 12 months if needed, referral onto a community neuro rehabilitation team for which there can be a wait or, in one case, no access to Occupational Therapy).

•

In order to provide stroke specialist rehabilitation at the same intensity as would be provided in hospital for patients eligible for early discharge (including weekend cover); there are considerable workforce constraints to be considered.

•

There is significant variation in longer term emotional and psychological support and in the integration between health and social care.

1.6 Recommendations •

Consideration should be given to commissioning ESD as part of a whole pathway approach in line with the national clinical guideline for stroke, (Royal College of Physicians [RCP]) guidelines 2012). This would include patients accessing seamlessly specialist neurological rehabilitation teams post-ESD.

•

We are recommending that commissioners use the Cheshire and Merseyside SCN gold standard framework for stroke ESD services to inform commissioning decisions.

•

In areas without an ESD team, consideration should be given to how, going forward they can ensure the same standards of care immediately post discharge, particularly around intensity of input.

•

Neighbouring ESD providers should ensure that patients are able to access the most appropriate ESD service to ensure a seamless pathway (regardless of GP or postcode).

•

In line with the 7 day services agenda, discussion between providers and commissioners about how to deliver this in practice would be helpful. The regional clinical consensus is that as a minimum, there should be weekend cover to ensure timely discharge and respond to urgent queries without compromising care Monday to Friday.

•

There is a need to explore workforce models to ensure recruitment and retention of staff with appropriate skills and experience; seven day working is an additional challenge to


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This. Further work is required to understand capacity and demand to inform staffing levels going forward. Where teams pilot innovative approaches to workforce, these should be evaluated with good practice shared across the region. •

Provision of psychological and emotional support in post-stroke patients should be available to all patients where needed. Further work is needed to reduce variation.

•

Social care and access to social workers is essential for an effective ESD service.

•

All ESD and community rehabilitation teams should be registered with and submitting data to SSNAP. The teams therefore need to develop robust systems for doing this. This will enable them all to have a much better understanding of their performance and inform improvements.

•

Patient/carer involvement is fundamental to any work going forward to enable services/commissioners to truly understand what is required from stroke rehabilitation in the community.

•

Commissioners to be offered the opportunity if helpful, to discuss this report on a 1:1 basis with Cheshire and Merseyside Strategic Clinical Networks (CMSCN) to enable them to make best use of the information in relation to their own services.


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2 Benchmarking Information 2.1 Overview of Current ESD Teams Tables 1 and 2 outline the current models of community stroke rehabilitation across Cheshire and Merseyside. Table 1 includes ESD specific teams or pathways. Table 2 outlines the situation in areas where there is not an ESD specific team or pathway. 2.2 Populations Served There is variation across the network regarding the populations that can access an ESD pathway (criteria for each team is outlined in appendix 2). Natural flows within Cheshire and Merseyside will also have an impact on the patient journey. For example, the Aintree team (based at Aintree Hospitals NHS Trust) provide ESD for all South Sefton residents and any patients discharged from Aintree Hospital who live within Liverpool CCG boundaries. This service will differ from that received by Liverpool residents who were inpatients at the Royal Liverpool and Broadgreen University Hospital Trust (RLBUHT). This leads to variation in service provision for residents within the same CCG. Where an ESD team sits within a community Trust, it is more likely to align directly with CCG boundaries, e.g. Knowsley. Where a patient lives within a CCG boundary but has an out of area GP there is a risk of services not being made available. For example, if a stroke patient lives within the Western Cheshire CCG boundary but has a Wirral GP, there is a risk of the patient falling through the gaps in service provision. Halton residents in particular are at risk of inequitable provision; there are informal arrangements for Halton residents to access ESD depending on where they received their acute care. This is currently being reviewed by commissioners. 2.3 Outreach/In Reach Teams are typically referred to as in reach (based in the community) or outreach (based in the hospital). In Cheshire and Merseyside there are currently four outreach teams and two in reach teams. Outreach teams tend to have closer working relationships with acute teams which should facilitate smoother and timelier early discharge. This may be more challenging for community based teams, particularly where they in reach into more than one hospital. However, community based teams that provide ESD as one pathway within a broader stroke community rehabilitation team can ensure smoother continuity of care for beyond the ESD Stroke Early Supported Discharge (ESD) Teams / Post –acute Rehabilitation Services Benchmarking Report Authors: Claire Hammill, Quality Improvement Lead (CMSCN) & Ruth Grainger, Data Analyst, (CSU). Contributions from all stroke specific ESD teams across Cheshire & Merseyside Date: November 2014 Version: 1.1

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period and availability of stroke specialist rehabilitation for those patients not eligible for ESD. It may not be helpful to specify one model that should be commissioned as there are advantages and disadvantages to each. It is more important to understand the local context and to focus on a whole pathway approach which takes into account patient flows. 2.4 Eligibility for ESD The RCP (2012) state that “early supported discharge [should be provided] to patients who are able to transfer independently or with assistance of one person.” A consensus on stroke document (Fisher et. al., 2001) reiterates that the greatest benefits of ESD are for those with a mild to moderate disability. Anecdotally, some teams are reporting they are receiving patients with more complex needs. There is the risk that ESD teams are commissioned to provide early supported discharge for eligible patients (around 40%) for a relatively short period of time, but are trying to provide a service to a greater number of more complex patients. This will impact on capacity and may be detrimental to meeting quality standards. Teams are reporting this is happening because of gaps in the broader pathway, or in some cases to take patients out of hospital to free up beds and reduce length of stay. This reiterates the need to commission early supported discharge pathways as part of a whole pathway approach. 2.5 Seven Day Services Five out of seven ESD teams currently provide a 5 day service but there are discussions to extend to 7 days. The other two provide some level of 7 day cover. Therapists agreed that the priority is to ensure discharge is not delayed and to respond to urgent queries to reduce readmissions. Understanding demand for the service across a 7 day period would help to plan capacity to meet the demand. 2.6 Maximum Period for Accessing the Service and Intensity of Input There is clearly significant variation in the length of time patients can access rehabilitation from ESD teams ranging from 3-6 weeks for a team that works closely with their community neurological rehabilitation team to manage the transfer of care, to those with an integrated team that have no limited timeframe. Overall, teams report challenges in being able to provide the initial 45 minutes of each relevant therapy for a minimum of 5 days per week (NICE guidelines, 2013). Some are able Stroke Early Supported Discharge (ESD) Teams / Post –acute Rehabilitation Services Benchmarking Report Authors: Claire Hammill, Quality Improvement Lead (CMSCN) & Ruth Grainger, Data Analyst, (CSU). Contributions from all stroke specific ESD teams across Cheshire & Merseyside Date: November 2014 Version: 1.1

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to provide it where clinically relevant; this is less likely for Speech and Language Therapy. Others use skill mix to provide one session that works on rehabilitation goals from more than one discipline, e.g. using assistant practitioners. There is agreement that there is a lack of clarity on what this standard means in practice. Where teams report on this target on the national stroke audit (SSNAP) it is very difficult to interpret due to the variation on which patients are considered eligible. 2.7 Post-ESD Rehabilitation Some ESD teams have concerns that patients receive high intensity input that stops suddenly with a gap until patients can receive therapy from broader community neurological or more generic rehabilitation teams. One team has no occupational therapy service to refer onto after ESD input has finished. It is anticipated that there will continue to be local variation in the length of time patients can access ESD teams depending on local circumstances. This is acceptable where a whole pathway approach is taken to ensure patients can access appropriate support and rehabilitation for up to 12 months post stroke and that the appropriate components of that support are provided effectively. 2.8 Compliance with National Standards for ESD Table 3 summarises reported compliance with national quality standards. In addition, some teams have robust evidence to support compliance. To ensure equity across the network, there needs to be agreement on the quality standards being used to benchmark against. Some teams need to develop more robust processes locally for collection of data and the Sentinel Stoke National Audit Programme (SSNAP) now provides the mechanism for postacute teams to do this. 2.9 Summary Stroke specialist ESD services are an important and integral part of the stroke pathway and should provide consistent quality of timely, safe and well supported discharge home. This report highlights gaps and variation across the network. There are advantages and disadvantages to outreach versus in reach models. Decisions as to which model is used should be based on local circumstances. ESD services should not be commissioned in isolation, but as part of a whole stroke pathway approach. The length of time patients can access an ESD team may therefore differ, depending on the availability of Stroke Early Supported Discharge (ESD) Teams / Post –acute Rehabilitation Services Benchmarking Report Authors: Claire Hammill, Quality Improvement Lead (CMSCN) & Ruth Grainger, Data Analyst, (CSU). Contributions from all stroke specific ESD teams across Cheshire & Merseyside Date: November 2014 Version: 1.1

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services post-ESD. The focus should be on ensuring transitions between teams enable patients to receive rehabilitation in line with national best practice. Providing smooth discharge and the high intensity and frequency of rehabilitation that is recommended is a challenge, particularly when commissioners are looking to commission 7 day services. There are significant challenges in terms of implementation that need to be considered, e.g. understanding capacity and demand across a 7 day period to ensure appropriate staffing.

3 Workforce and Skill Mix Having an appropriately skilled and competent workforce is essential for ensuring a high quality of care to achieve the best possible patient outcomes. It is difficult to make comparisons between ESD teams for a variety of reasons; one of these is the variation in staffing levels and skill mix within the teams. Fisher et. al. (2011) proposed staffing levels for ESD teams based on a 100 patient per year caseload providing a 5 day service: • • • • • • • • •

1.0 Physiotherapist 1.0 Occupational Therapist 0.5 Speech and Language Therapist 0-0.5 Social Worker (consideration will need to be given to how to achieve an integrated model if there is not dedicated social worker time into the team) 0-1.2 Nurse (more nursing input will be required for teams where increasingly complex patients are discharged earlier and supported by the team) 0.1 Physician (teams that have this typically use the time to contribute to an MDT meeting) 0.25 assistant (though many teams make greater use of assistant roles) Access to Psychological support Access to dietetics

Fisher’s document does not give guidance on levels of experience or grade of staff, other than they should have specialist knowledge and skills in stroke care. Consideration also needs to be given to variation in pathway length and travelling times when deciding on staffing levels. The current staffing levels for all teams are outlined in table 4. Table 5 shows an analysis of staffing compared to the recommended levels.


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Whilst acknowledging the difficulties in making comparisons between teams based on this information due to variation in models of service delivery and number of referrals, there are some key themes that can be identified: •

The analysis indicates there is a deficit in staffing levels within Cheshire and Merseyside which may warrant further local discussions.

•

Physiotherapy & Occupational Therapy - All teams that provide ESD have dedicated physiotherapy and occupational therapy staff.

•

Speech and Language Therapy - 5 out of 7 teams that provide ESD have dedicated speech and language therapy staff. It is worth noting that national stroke audit data (SSNAP) indicates that there are gaps in provision of speech and language therapy within the acute phase and there may be benefit of reviewing this service on a pathway basis.

•

Nursing - Cheshire and Wirral Partnership Trust and the team based at RLBUHT have dedicated nurse input.

•

Stroke Physicians - RLBUHT ESD also have a small amount of input from a stroke physician, as does Wirral ESD team.

•

Assistant Practitioners - All teams have assistant practitioners as part of or inputting into the team. There is variation in how these roles are used.

•

Social Care - One team has a dedicated social worker. Other teams report there are challenges in providing an integrated model with social care.

•

Most teams do not have dedicated time for a coordinator role to manage the team on a daily basis although this is recommended in Fisher’s document (2011).

•

There is variation in the banding of different roles. Some teams report difficulties in recruiting to certain posts.

Chart 1 (below) shows occupational therapy and physiotherapy staffing levels adjusted based on referrals. It does not take into account the length of the pathway (shown on the chart).

Chart 2 (below) shows the numbers of therapy assistants for each team adjusted based on numbers of referrals.


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Chart 1 – Staffing Levels as a Proportion of Referrals

6 wks

6-8 wks

Reduce intensity by need – no limit

6 months

12 wks

3-6 wks

12 wks

Chart 2 – Assistant Staffing Levels as a Proportion of Referrals


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4 Other Key Themes 4.1 Quality of care and Outcomes There is great variation in the range of outcome measures used. Variation in populations and severity of stroke make it very difficult to compare outcomes across different areas. Some teams use the Warrington classification system to stratify stroke patients by severity giving a more robust approach to comparing outcomes. A consistent approach to measuring outcomes across the network is required; this may build on the requirements already in SSNAP. Most teams use some method of gaining the views and feedback of patients and use this information to inform improvements. 4.2 Integration with social care The core purpose of ESD teams is to provide earlier supported discharge home. This requires an integrated approach with social care (National Stroke Strategy, 2007) particularly as many ESD teams are taking increasingly complex patients. In Cheshire and Merseyside, one ESD team has a dedicated social worker. Another team reports very good joint working (being co-located). There is a clear national agenda to address the boundaries between health and social care; consequently there are real opportunities for commissioners to explore different models as part of a whole pathway approach to commissioning. A joint health and social care plan on discharge from hospital is one national marker of a quality service (included on the SSNAP audit and on the CCG outcome indicator set). There is variation in the interpretation of this quality marker and a need for clarity and a shared understanding across Cheshire and Merseyside. 4.3 Psychological Support The National Stroke Strategy (2007) outlined the need for a “greater proportion of individuals/carers who are screened to identify need for psychological support and whose identified needs are met”. This was further supported by the psychological care after stroke document (Gillham, S. et. al., 2011) which outlines a ‘stepped care’ model, and the national parity of esteem agenda. The national stroke audit (SSNAP) includes ‘mood and cognition screen within 6 weeks of stroke’. Many patients are discharged from hospital before six weeks and in some acute trusts they are aiming to complete a screen prior to discharge, often by an occupational therapist. Stroke Early Supported Discharge (ESD) Teams / Post –acute Rehabilitation Services Benchmarking Report Authors: Claire Hammill, Quality Improvement Lead (CMSCN) & Ruth Grainger, Data Analyst, (CSU). Contributions from all stroke specific ESD teams across Cheshire & Merseyside Date: November 2014 Version: 1.1

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Once screened, most teams are able to make referrals into a generic psychology service, often for high need patients only. In some areas, OT’s have been upskilled to provide support in line with the stepped care model. The newly commissioned service for South Cheshire and Vale Royal stroke ESD and community rehabilitation team includes a small amount of clinical psychology time in the service specification. There is also the important contribution of third sector organisations in providing support for stroke survivors and their families, particularly the Stroke Association. There is a need to explore further the needs of stroke survivors and their families in terms of ongoing emotional and psychological support; any work across the region to develop clarity on what good should look like should have considerable engagement of stroke survivors/carers from the outset. As commissioners take forward work on stroke pathways, it is essential to consider how to improve psychological support in line with the stepped care model, e.g. stroke specialist staff being skilled up to level 2 as part of a whole pathway approach. 4.4 Unbundling the Tariff One aim of ESD teams is to provide the same quality and intensity of rehabilitation at home, thereby reducing length of stay for patients. In doing this, resources could be shifted in order to fund ESD services and make efficiency savings at the same time. It was not an aim of this piece of work to identify funding flows for ESD teams however, unbundling the tariff has not happened anywhere in Cheshire and Merseyside. There is national guidance in development to support this. In addition there is work underway in other networks (e.g. Manchester) that could be accessed to inform commissioning locally.


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5 Summary “Rehabilitation after stroke works. Specialist co-ordinated rehabilitation, started early after stroke and provided with sufficient intensity, reduces mortality and long-term disability. Early rehabilitation is effective when provided in specialist stroke units or as part of properly organised early supported discharge and longer-term support in the community, according to need” (National Stroke Strategy, 2007, p36)

Over several years, there have been improvements across Cheshire and Merseyside in the provision of stroke specialist rehabilitation in the community; in particular with the number of areas that have, or will have in the very near future, a stroke early supported discharge team with recurrent funding. The seven established teams all have above the national average number of stroke patients accessing ESD support. Currently, the focus nationally is to work towards high quality stroke services from onset of stroke right through to longer term Support, ESD being key to the smooth transition from acute care to rehabilitation and support in the community. This benchmarking report aimed to: 1. Outline the current service provision across Cheshire and Merseyside 2. With reference to national standards, identify gaps and variation 3. Inform the development of network agreed best practice frameworks

This report and the recommendations (see executive summary, section 1) can be used to inform commissioning of stroke specialist rehabilitation going forward. All ESD and community rehabilitation teams should input data to the national stroke audit (SSNAP). There is a need to develop a shared understanding of what is required across the whole patient journey from stroke onset through to life after stroke support. Stroke specialist ESD can be the key to achieving reduced length of stay and supporting a smooth transition home. However, post ESD provision should not be forgotten emphasizing the need for a whole pathway approach to commissioning.


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Table 1 - Overview of Current ESD Teams Models of Service Delivery ESD Team

Population Served

Stroke Funding specific

Liverpool & South Sefton ESD Team @ Aintree University Hospital/South Sefton and Liverpool CCGs

South Sefton or yes Liverpool GP/Postcode/ Stroke patients discharged from Aintree Hospital

Recurrent

Cheshire Wirral Partnership NHS Foundation Trust/Western Cheshire CCG

Chester and Cheshire yes West GP (incl Neston & Ellesmere Port) Population: 242, 764

5 day Was short ESD only term – In reach to Countess of recently Chester made recurrent

5 Boroughs Partnership/St Helens CCG and Halton CCG

yes St Helens Local Authority Boundary or St Helens GP (and Halton*) St Helens population: 186, 743

Recurrent ESD only 6-8 weeks 5 day – contract Outreach from Whiston (being under Hospital reviewed) review

yes Liverpool Heart and Knowsley GP or Chest Hospital/ postcode. Population: Knowsley CCG 149 108

Method

ESD only Outreach

Recurrent Combined ESD and community rehab In reach to Whiston, Aintree and RLBUHT

5 day/ 7 day service? 5 day

Max period for Post ESD provision accessing service 12 weeks Liverpool residents: neuro rehab team, South Sefton residents: generic rehab team. Can be a wait post-discharge from ESD for community services – this varies (often around 6-8 weeks) 6 weeks

Seamless transfer of care to PT/OT neuro services. 3 month wait for neuro SLT services

St Helens patients referred to Allen Day Unit or St Helens reablement/community team, Halton residents referred to Halton Community Neuro Team

7 day (full None – needs Provides pathway for all patients 5 day with led, gradually so no handovers to other stroke on call for reduce input or community neuro rehab teams weekends)


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Table 1 cont. - Overview of Current ESD Teams Models of Service Delivery The Royal Liverpool Liverpool, Population: yes 195,355 and Broadgreen University Hospitals NHS Trust/ Liverpool CCG

Recurrent Established ESD strand 5 day block within comprehensive contract stroke outreach service in most appropriate safe discharge destination

6 months

Warrington and Halton Hospitals NHS Foundation Trust/Warrington CCG and Halton CCG

Warrington, Halton** yes and Newton le Willows

6 weeks- 3 Following the 6 week period of weeks by acute ESD if patients still require hospital team ongoing therapy they can with seamless continue with the community transition for stroke team on a less intensive final 3 weeks of rehabilitation programme ESD by community stroke team

Wirral University Teaching Hospital NHS Foundation Trust/ Wirral CCG

Wirral

Recurrent ESD only 5 day Outreach - Warrington and Halton patients who flow through Warrington Hospital. There is a referral system for patients from Warrington admitted to Whiston who don’t get repatriated to Warrington hospital Recurrent ESD only (piloted taking 7 day

yes

some more complex patients) Outreach

12 weeks

Work collaboratively with Carers Trust team to facilitate selfmanagement. Referred on to community neuro rehab team if any ongoing rehab needs

Can access Physio outpatients, but no OT outpatient service. SLT input can continue where needed as this team is not ESD specific

Population figures provided by teams *St Helens service picks up mainly Widnes residents from Halton in a reciprocal agreement where the Warrington service picks up Newton le Willows residents and where this makes sense according to patient flow into hospital - this is currently being reviewed by commissioners. ** Currently taking only Halton residents that flow through Warrington Hospital. As above, this is currently being reviewed by commissioners. Stroke Early Supported Discharge (ESD) Teams / Post –acute Rehabilitation Services Benchmarking Report Authors: Claire Hammill, Quality Improvement Lead (CMSCN) & Ruth Grainger, Data Analyst, (CSU). Contributions from all stroke specific ESD teams across Cheshire & Merseyside Date: November 2014 Version: 1.1

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Table 2 - Overview of Current Situation in Areas without ESD provision Team

Population Served

Stroke specific

Provide a well-established yes and comprehensive community neuro rehab service to North Sefton (and West Lancashire – separate team not included in this report) NHS South Cheshire Newly commissioned (due to yes CCG and NHS Vale be operational Dec 14)for Vale Royal and South Royal CCG Cheshire CCG residents commissioned from East Cheshire NHS Trust Southport and Ormskirk Hospital NHS Trust/ Southport and Formby CCG

East Cheshire NHS Trust

On discharge from hospital patients are referred to a generic rehabilitation team (some staff having neurological specific skills and experience)

Funding Recurrent

Recurrent

Method

5 day/ 7 day service? Jointly managed 5 day team across acute and community but different bases

Maximum period for accessing service None – based on need

Whole pathway 7 day ESD and community rehab with clinical and psychological reviews In reach to Leighton Hospital

6 weeks ESD and 16 weeks community rehab

no


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Table 3 – Progress of Teams towards National Standards ESD Team

% with first contact within 24 hours of discharge

Liverpool and South Sefton Early Supported Discharge Team @ Aintree University Hospital/South Sefton and Liverpool CCGs

95% of first contact within 24hrs. 5% not seen within 24hrs because of late referral post discharge

45 mins of therapy daily Joint MDT care plan negotiated with patient/carers within 72 hours of referral to ESD team Joint MDT care plan negotiated If required with patient and carers within 72 hours of referral to ESD – care plan usually in place within 24hours, have an MDT version on discharge from ward

Meet on wards before discharge and give Seen within 72 hours, initial Cheshire Wirral care plan in place within 72 Partnership NHS first appointment hours Foundation Trust/Western Cheshire CCG Most are assessed by ESD team on the 5 Boroughs ward prior to discharge. Occasionally this Partnership/St Helens CCG and isn’t met if ESD team are particularly busy/delayed referral from ward/staff Halton CCG absence or if discharged at the weekend especially around bank holidays. Taken home by ward staff and ESD team – this has streamlined the pathway and reduced duplication, feedback has been positive

Patient led – Support workers can provide daily OT/Physio input if needed. SLT max – twice a week from SLT, topped up to 4 times a week if needed by therapy assistant. Yes for 5/7 days, use skill mix of staff rather than having every profession visiting daily. (not 45mins from each therapy service). Couldn’t provide this on current funding; may not be appropriate. Patients have fed back that they wouldn’t want therapy at weekends. Review of contract will consider reduced weekend cover to meet needs of patients newly discharged from hospital.


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Table 3 cont. – Progress of Teams towards National Standards KPI is currently 48hours

The Royal Liverpool and Broadgreen University Hospitals NHS Trust/ Liverpool CCG

No – it’s a 5 day service and due to capacity Have fortnightly MDT meetings Therapists able to manage diary for individuals there is not the opportunity to meet patients OT/PT/dietetics to support based on need (up to 5 days per week occasionally if needed) and carers on the ward prior to discharge. discharge planning Dietetics can see within 24 hours where required.

100% have a first visit from one or both Warrington and Halton Hospitals (physio and OT) NHS Foundation Trust/Warrington CCG and Halton CCG Wirral University Aim is 100% - do link sessions before they Teaching Hospital go home and give an appt. Will ring if can’t NHS Foundation get out to home.

Usually see all ESD patients within 72 hours and agree goals verbally at this visit.

Daily therapy 4- 5 times a week. Will use skill mix as needed.

Liverpool Heart and Chest Hospital/ Knowsley CCG

92.5% discharged with joint Daily if appropriate – patient led. care plan – others would be those not known to team at all Could in theory get 45mins of each therapy. Though not SLT

99% (from SSNAP) on discharge from hospital

Trust/ Wirral CCG

Most don’t want 7 day service – usually new referrals & to avoid readmissions. Flexibility between acute and ESD to flex to demand. Do offer daily therapy; often use therapy assistants on a shared care plan. Tailored to patient need. Most get about 5 a week based on need.


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Table 4 – Overview of staffing for ESD Teams Aintree Population served Number of referrals per year Band 5 Physio Band 6 Physio Band 7 Physio Band 5 OT Band 6 OT Band 7 OT Band 5 SALT Band 6 SALT Band 7 SALT Band 6 Dietitian Band 7 Dietitian Social Worker Band 5 Nurse Band 6 Nurse Band 7 Nurse Band 3 Assistant Band 4 Assistant Band 4 SALT Assistant

250366

CWP 242764

264

184

1.5

1.5

0.89 1

Halton & St Helens Knowsley Southport & Ormskirk RLBUHT Warrington & Halton Wirral 186743

149108

154 1 1

250

195355

125700

320295

360

180

324

1 1

1 1

1.5 1

1.5

1 1

0.6

1 1

0.64 1.19

0.5 1

0.5

0.5

* *

1.5 1 0.3 0.7 0.2 0.4 1

1.6 1 ^ ^ ^

1 1

0.6

119080

0.5 0.5 1 0.2 0.5

0.5 0.8

3

2 1

1

Support from consultant at MDT meetings

3

*

4 0.6 Y

1.8 1 Y

* denotes patients can access support from these disciplines; however there is not a dedicated post within the ESD team. May involve separate referral. ^SALT is dedicated part of ESD team but also continues to offer support beyond the ESD pathway 0.5Warrington residents only, Halton residents can access stroke community nursing ** Knowsley’s team provide an ESD pathway and a longer term community rehabilitation pathway. The staffing levels shown are to provide both these pathways. Southport and Ormskirk provide a community neurological rehabilitation pathway but are not commissioned to provide a stroke specific ESD pathway. The SLT input into this team is from staff with neuro specific skills that are a part of a more generic team.


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Table 5 – Staffing Levels Compared to Recommended Levels

Aintree/South Sefton

CWP

Role

Referrals per year

Recommended Actual staffing staffing levels (wte) levels based on consensus document (2010) for a five day service

Time over which patients can access the service

Physio

264

2.64

1.5

12 weeks

OT

2.64

1.89

SLT

1.32

0.6

1.84

1.5

OT

1.84

2

SLT

0.92

0.5

1.54

2

OT

1.54

0.6

SLT

0.77

0.5

Physio

5BP/St Helens and Physio Halton

Knowsley

184

154

Physio

250

2.5

2

OT

(72 ESD)

2.5

2

1.25

0.5

SLT Southport and Ormskirk

Physio

2

OT

1.83

6 weeks

6-8 weeks

No defined limit

SLT RLBUHT

Warrington and Halton

Wirral

Physio

3.6

2.5

OT

3.6

2.5

SLT

1.8

1.2

1.8

1.5

OT

1.8

1.5

SLT

0.9

0

3.24

2

OT

3.24

2.6

SLT

1.62

SLT input not allocated in wte

Physio

Physio

360

180

324

6 months

3-6 weeks

12 weeks

*Knowsley provide ESD and longer term community rehabilitation and reduce level of intensity gradually based on need

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Appendix 1 - SSNAP Audit Data The Sentinel Stroke National Audit Programme (SSNAP) is a detailed national data set that has focused on hyper-acute and acute services with growing national emphasis on postacute teams. There is also data available from secondary uses service. Currently, only Wirral ESD and Warrington ESD teams submit data to SSNAP and there is work ongoing across the region to support more post-acute teams to submit data. However, there is some data provided by acute teams (on a hospital or CCG basis) that can offer some insights into ESD teams:

Chart 3a

Figure provided by ESD teams

56% 62%

48.6%

61.2%% 34.78% Not known

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Chart 3b

Charts 3a and 3b show the acute teams that are discharging to an ESD team/pathway. There is ongoing debate about the definition of an ESD team/pathway including the criteria for eligibility and the intensity of support offered. This makes it very difficult to make comparisons of the data between trusts. However, where an area has an ESD team/pathway, the number of patients accessing ESD support is high compared to the national average. There is a newly commissioned pathway for Vale Royal and South Cheshire residents (due to be operational December 2014); this should be reflected in the data for Leighton hospital next year. Discrepancies between the SSNAP data and locally reported figures may be due to data quality, out of area patients (particularly for Countess of Chester Hospital due to the flow of Welsh patients that do not access local ESD teams), and the interpretation of or accurate reporting on the question around discharge destination on SSNAP.

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Chart 4 - Proportion of Patients Treated by a Stroke Skilled ESD Team January – March 2014

When looked at by CCG (chart 4), approximately 30% to 60% of patients are receiving ESD which is above the national average and generally in line with the national figures that suggest around 40% of patients are eligible for ESD. Vale Royal and South Cheshire CCGs will have an operational ESD team from December 2014. Where teams do not have an ESD specific team or pathway, there is a need to ensure they are meeting the same quality and standards of care (e.g. intensity of input immediately post discharge from staff with stroke specialist skills). There is also variation in equity of access to and quality of rehabilitation beyond the initial ESD period. For example, Southport and Ormskirk may not provide the intensity of ESD within the first few weeks, however they do provide a stroke specialist service offered that is not time limited but based on need. A whole pathway approach to commissioning could help to ensure equity and quality across the whole patient journey.

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Chart 5 - Length of hospital stay for each CCG (SUS data)

Access to ESD teams will be just one of a number of factors that contribute to the overall length of stay following a stroke. This is borne out by the fact that the CCGs that currently do not have an operational stroke ESD team (Southport and Formby, Vale Royal, South Cheshire and Eastern Cheshire) all have a length of stay on or below the national average.

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Appendix 2 Criteria for Accessing ESD Services Arrowe Park Hospital/Wirral

Patients who are over 18, and residents or registered patients of a GP within NHS Wirral and meet the following; Under the care of a stroke consultant. Diagnosis of a new stroke following a clinical decision made by a consultant or stroke specialist. Medically stable for discharge home or place of care. Consents to early supported discharge with agreement from carers. Compliant with rehabilitation programme and goals identified prior to discharge. Able to transfer independently or with support from a trained carer. Home environment/place of care suitable as assessed by MDT

Cheshire Wirral Partnership

Under the care of a stroke consultant who have clinically diagnosed a new stroke event. Medically optimised/stable for discharge home or place of care. Able to consent to ESD with agreement from their carers. Able to maintain their safety with a supported care package or assistance from family/friends. Able to transfer with the assistance of one trained carer with appropriate recommendations made for equipment required if necessary. Home environment/place of care assessed as ‘safe and suitable’ by the Therapy MDT prior to discharge as well as potential risks to lone workers identified. Clinical diagnosis in all therapy domains required to be in the mild to moderate range of impairment. Stable on oral feeding of modified diet/fluids and established PEG feed where necessary, with VFSS assessment ideally for those whose aspiration is silent. Continence to be manageable for a carer at home. Level of cognitive/perceptual ability to be managed at home with a carer/family support

Knowsley

100% of patients who are admitted to a hospital with a confirmed diagnosis of stroke will be known to the Community CVD service and recorded on a stroke register, contact will be made with all patients for health and social care reviews. Patients must be a Knowsley resident and/or be registered with a Knowsley GP and meet the following criteria; Criteria for ESD service: Medically stable. Have the capacity to understand and benefit from the service. Have a safe and appropriate home to return to. Able to transfer with assistance of one. Needs no more than one therapist per session. The above criteria is for ESD, however the team see all stroke patients

South Cheshire and Vale Royal

The stroke ESD service will accept referrals for patients who meet all of the following criteria: • Over 18 years old • Registered with a GP in South Cheshire and Vale Royal • Diagnosis of a stroke following a clinical

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decision made by a stroke consultant and/or CT scan result • Medically stable for discharge home • Under the care of a stroke consultant • Requirements for on-going multi-disciplinary specialist assessment and intensive neurological intervention • Appropriate discharge environment identified and assessed by MDT, including residential and care homes • Able to transfer independently or with support from family member or carer who has received training • Consents to early supported discharge with agreement from their carer/s • When the mental capacity of the patient to make a decision re ESD is in question the decision for discharge should be made in the best interests of the patient by the MDT following appropriate assessment Taken from the service spec that has recently gone out to tender Royal Liverpool University Hospital/Liverpool

• Registered with a Liverpool GP • New diagnosis of stroke/within 6 months of stroke • Under the care of a stroke consultant • Appropriate discharge environment identified in the Liverpool area • No other criteria – all patients are eligible – criteria is not as tight as other ESD teams, take all patients

Southport & Formby District General Hospital (no

Any adult (18+) with an acquired neurological deficit – all stroke patients accepted if they have ongoing therapy needs. Can be due to a new onset or exacerbation of an existing condition

University Hospital Aintree/South Sefton

Over 18 years of age who are registered with a South Sefton/Liverpool GP/postcode, who have been admitted to hospital following an acute stroke and as follows; Patient will be under the care of the stroke consultant. Patients assessed as benefitting from the ESDT service following pre-discharge/MDT planning meeting. Appropriate discharge environment identified. Medically stable. Transfers assessed as safe. Must consent to referral (if particular been discharged early). Patient must be able to maintain their safety, with a supported care package or assistance from family/friends. Patient must have been assessed by therapists whilst an in-patient within the hospital. Rehabilitation goals agreed with MDT. Will accept nursing home and rest home patients. Will accept patients referred form stroke review clinic if a newly diagnosed stroke and preventing admission.

Warrington Hospital/Warrington & Halton

Where the patient has expressed a wish to go home and is to be supported by family and/or carers to be able to achieve this and does not meet the criteria below

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individual assessments will be made. Patients who can transfer with two. Patients who have the ability to climb stairs or who can accommodate downstairs living. Capacity to understand the process and any risks as a result of ESD. Registered with a Warrington GP/Halton GP/NLW GP. Medically stable, able to be managed in a Primary Care setting. Feeding nutrition needs managed. Manageable continence. Have added milder frail and elderly to reduce readmissions and complex resettlement of complex patients which has increased numbers accessing ESD. Still find it difficult to achieve 40% (? SLT support may be contributing as not able to accept patients that have dysphagia needs) St Helens & Halton

Aged 18 or over. Under the care of a stroke consultant. Conformed diagnosis of stroke. Medically stable for discharge home or place of care. Consents to ESD with agreement from carers. Compliant with rehabilitation programme and goals prior to discharge. Able to transfer safely independently or with one able carer. Most eligible patients will have a Barthel of greater than 9. The patient is safe to be left at some times over a 24 hour period with support e.g. telecare. Home environment /place of care assessed as suitable based on relevant clinical /and or social care assessment

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References

Broomhead, D. et. al. (2012) Stroke Rehabilitation in the Community: Commissioning for Improvement. NHS Improvement. Care Quality Commission (2011) Supporting life after stroke. Review of services for people who have had a stroke and their carers. CQC. Cheshire and Merseyside Strategic Clinical Networks Business Plan (2014) CMSCN Department of Health (2013) Cardiovascular Disease Outcomes Strategy. DOH. Department of Health (2012) NHS Outcomes Framework 2013-2014. DOH. Department of Health (2007) National Stroke Strategy. CQC. Fisher, J. et. al. (2011) A Consensus on Stroke: Early Supported Discharge. Stroke (p1392-1397) Intercollegiate Stroke Working Party (2012) National clinical guideline for stroke, 4th edition. London: Royal College of Physicians. National Institute for Health and Care Excellence (2013) Stroke Rehabilitation: Long term Rehabilitation after Stroke. NICE. Gillham, S., et. al. (2011) Psychological Care after Stroke: improving stroke services for people with cognitive and mood disorders. NHS Improvement Sentinel Stroke National Audit Programme, Royal College of Physicians https://www.rcplondon.ac.uk/projects/sentinel-stroke-national-audit-programme

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