Stroke Research making a difference to practice Early

Stroke Research making a difference to practice Early Supported Discharge versus General Rehabilitation: A Debate Dr Rebecca Fisher University of Nottingham

A Debate – Oxford Style • “This house proposes the motion for the Implementation of evidence based Stroke Early Supported Discharge services”

Overview • Early Supported Discharge (ESD): an essential part of the stroke care pathway • Guidelines for the implementation of ESD services • Stroke Rehabilitation Implementation research

Overview • Early Supported Discharge • Community Stroke Service • Key differences • Making research accessible • Evidence based care • Recommendations

Stroke Specialist Care • • Evidence supports stroke specialist care Stroke Unit Trialist’s Collaboration, 2006 ESD: Langhorne 2005; Fisher et al 2011 Outpatient Service Trialists, 2003 • Stroke unit vs general medical ward • Stroke specialist ESD • Stroke specific intervention vs routine care

ESD – Key issues • • ESD Policy CLAHRC ESD research ESD Consensus – core components Mapping/Evaluation – emerging issues – – Eligibility Early intervention Existence of other community services Effectiveness

ESD Policy • National Stroke Strategy, RCP guidelines, Accelerated Stroke Improvement Programme • Proportion of patients supported by a stroke skilled Early Supported Discharge team (40% by April 2011) Hospital Acute Rehab Home Rehab ESD Rehab Support

CLAHRC ESD research • Provision of the best evidence based care to patients • Framework and tool-kit for Stroke Rehabilitation Implementation research • Are ESD services effective when implemented in practice?

ESD Consensus • • • Cochrane systematic review – Langhorne 2005 Does ESD work? – Yes How do you set up an ESD service in practice? What are the key messages from the literature? Accessible to commissioners Guidelines for service providers

ESD Consensus • Ten ESD trialists involved (P Langhorne, B Indredavik, C Wolfe, M Power, H Rodgers, L Holmqvist, E Bautz-Holter, N Mayo, C Anderson, O Morten Rønning) • Core elements of an ESD service: list of statements • Statements integrated into ESD service specification for the East Midlands • Fisher et al. 2011. A Consensus on Early Supported Discharge. Stroke, 42: 1392 -1397 • Uncertainty remains – emerging findings from qualitative research

Consensus statements: Team composition • • Team Composition Stroke specialist, multidisciplinary For 100 patients per year caseload: OT (1. 0), Physio (1. 0), SALT (0. 4) Physician (0. 1), nurse (0 -1. 2), social worker (0 -0. 5) Consensus not reached: Rehab assistant Interpretation: role of assistant depends on model of rest of team and overall remit of team

Consensus statements: Model of team • Model of team working • An early supported discharge team should plan and co-ordinate both discharge from hospital and provide rehabilitation and support in the community. • Key worker, co-ordinator • An early supported discharge team should be based in the hospital. • Interpretation: ESD as an extension of acute phase of stroke pathway

Consensus statements: Intervention • Specific eligibility criteria • Live safely at home, based on medical stability, practicality and disability (barthel score 10/20 to 17/20) • Transfer safely from bed to chair i. e. can transfer safely with one with an able carer, or independently if living alone. • Hospital staff and ESD team staff should identify patients for ESD

Eligibility • ESD effective for mild/moderate stroke patients • Most patients have a Barthel score 10 -17 • Target 40% • Decision made when? (post-stroke) • By whom? • Cross boundary working

Early & Intensive • Early Supported Discharge - What is early? • Early post stroke: referral within 7 -14 days • Earlier discharge: provision of rehab on hospital wards required to reach eligibility (~30+ days) • Reduction in length of stay (effectiveness) • Importance of Physician: patients are medically stable • High intensity of intervention (QM 10): 7 day working, daily visits, role of rehab assistants • Responsiveness and Intervention length (no waiting list)

Early & Intensive Total Stroke admissions – 769 ESD service seeing approximately 28% of stroke patients

Existence of other community services • Intervention: fixed term or as long as patients needs? • Existence of other community services • Local considerations for implementation • Commission ESD as part of stroke care pathway • ESD and Community Stroke team • Plan what happens after ESD • Consider link/impact on social care

Effectiveness • • • Is the ESD team functioning effectively? Functional benefits for patient: rehab at home Accelerating discharge: Measuring length of stay (cost) No increase in institutionalisation, readmission rates Who monitors readmission & institutionalisation rates? • Functionality: use of outcome measures • Increase in ADL • Robust methods

Success - Cost • The annual cost of the ESD team should be less or equal to the annual savings made by reduction in length of stay in hospital. • Are savings realised? Only by unbundling tariff • Commissioner/ provider & national/local • Early discharge (7 -14 days): unbundling options • Earlier discharge: following provision of rehab on hospital wards - How to unbundle? • Range and distribution of length of stay for ESD patients • What proportion of patients can, and are, discharged early (e. g. within 7 -14 days)? • What proportion of the total stroke population are ESD eligible? • Are we clear on how to monitor readmissions?

Recommendations • • Review service provision in hospital and community Commission ESD and community stroke teams Ensure pathway for more severe patients is planned Robust data collection: define and monitor length of stay and readmission rates Analyse retrospective data - two ESD streams and proportions of patients eligible for ESD Joint commissioning across organisations Joint data monitoring Involve social care (esp. community stroke teams)

Summary • ESD consensus provides core elements of ESD • Guidelines for the implementation of ESD services in practice – are benefits still evident? – – – – Multidisciplinary team composition: Role of Physician Model: Early, Responsive, Intensive intervention Eligibility: mild to moderate, medically stable Plan what happens after ESD Effectiveness: patient functionality Early & Earlier: tariff consequences Whole pathway commissioning based on robust data

ESD vs Community Stroke Teams Early Supported Discharge Team Community Stroke Service Team Composition ESD consensus specifies OT, Physio, SALT, Physician, nurse, social worker, rehab assistant(? ) To be defined. Likely to include OT, Physio, SALT, nurse, social worker Multidisciplinary Team Model Coordinated stroke specialist multidisciplinary team; plans discharge from hospital & provides rehabilitation and support at home. Key worker system. Joint decision making between hospital ward staff and ESD team. Coordinated multidisciplinary team; provides rehabilitation and support for stroke patients in the community. Therapists work as a team, however manage their own caseloads. Decisions made by hospital staff; accepted on basis of eligibility criteria. Eligibility Criteria Based in part on level of disability (e. g. barthel score of 10 -17), ability to transfer, medical stability and whether patient can patient live safely at home. Based on medical stability and whether patient can live safely at home. Patient needs to manage with maximum of one visit per week. Referral Considerations Patient would benefit from intensive rehabilitation facilitated by continued medical support at home. Patient would benefit from some rehabilitation at home i. e. has community focused goals Hospital Length of Stay Can be up to (and beyond) 30 days – however, aim is to reduce length of stay. Decision based on when best to transfer patient. Referral Decisions: By Whom

ESD vs Community Stroke Teams Early Supported Discharge Team Responsiveness Caseload Days per Week Intensity of Intervention Components of Intervention Length of Intervention Community Stroke Service ESD team is responsive and agile. Take referrals immediately; visit patient within 24 -48 hours of them arriving home. Usually around 16 patients at any one time. Operates a waiting list per clinician. 5 -7 days 5 days Daily visits to patient, sometimes twice per day. Short-term goals focusing on activities of daily living, speech and mobility. Social care issues are addressed. Once or twice weekly visits. Fixed time period, usually 6 weeks Patients are prioritized if necessary. Caseload number varies; caseload is managed by waiting lists. Activities of daily living and mobility; focus also on longer term goals including vocational issues, participation in social activities and re-integration. Social care issues are addressed. As long as patient needs or team operates a standard length of intervention.

The ESD Research Team • • • Marion Walker Rebecca Fisher Fiona Nouri Micky Kerr Kay Gaynor Hazel Sayers Amy Moody Iskra Stariradeva Christine Cobley Marie Ashmore