The feasibility and benefits of a remote stroke rehabilitation service
Emma Garratt
Clinical Lead Physiotherapist / Interim Ward Manager
Oxford Health NHS Foundation Trust
Summary:
The Oxfordshire Stroke Rehabilitation Unit (OSRU) is a 20-bed inpatient service, delivering intensive specialist rehabilitation for patients following acute stroke. Specialist ongoing rehabilitation post-discharge has been a historical challenge, as only generic community rehabilitation services are commissioned within the county. In March 2020, due to national COVID-19 directives and reallocation of staff to support the front line, capacity for follow up rehabilitation from generic community services was limited. A remote follow up service was set up, delivered by a full time Specialist Physiotherapist from the OSRU team who was shielding at home. The aim of the service is to provide a specialist stroke rehabilitation service remotely, support patient transition to the community and promote life after stroke.
Patients receive a telephone call within seven days post discharge to complete an initial assessment and discuss ongoing input. Sessions are delivered remotely via telephone (or preferably videocall) for those able to access this. Any patients who cannot access the remote service are referred for urgent face to face input. Support/advice from other members of the multi-disciplinary team is sought as required. Intervention mostly falls into one of three brackets; advice and support, exercise progression and video rehabilitation sessions. Patients can access the service for as long as they require, receiving up to three sessions per week depending on service capacity and individual need.
So far, the service has helped over 80 people discharged from OSRU. Positive patient feedback suggests remote follow up post discharge aids transition from hospital to home. Preliminary data suggests rehabilitation via video call is feasible for some, primarily those who have technology available and someone to support them with the process. Objective outcome measures demonstrate statistically significant gains in functional independence at point of discharge from the follow up service. Patients are supported until a point when they feel ready for discharge, and sessions are dictated by their individual needs. This model of follow up supports patient empowerment, and ownership of their rehabilitation journey.
In summary, our project outcomes demonstrate successful innovation during the pandemic to ensure post-discharge support for our patients. The existing gap for specialist community rehabilitation has also been partially filled by this service, although further work is needed to ensure those requiring specialist face to face input can access it. The service is continuing at present and models for longer term delivery are currently being explored.
Background:
The Oxfordshire Stroke Rehabilitation Unit (OSRU) is a 20-bed inpatient service which provides short term specialist rehabilitation for patients following acute stroke. The multidisciplinary team consists of nurses, doctors, physiotherapists, occupational therapists, speech and language therapists, dietitians and a visiting orthoptist. Patient length of stay is four weeks on average. Patients receive intensive rehabilitation input during admission from all relevant professions, with therapists aiming to provide a minimum of 45 minutes of therapy per day, five days per week. Approximately 60-70% of patients return home on discharge, with others receiving ongoing care in residential/nursing homes.
Providing ongoing specialist rehabilitation post-discharge from the service has been a long-term challenge. It has been well established in research that intensity of rehabilitation is important, especially in the first six months post-stroke, to maximise functional independence and return to previous life roles. Whilst this is provided by our inpatient service, intensity quickly reduces once patients are discharged to the community due to lack of specialist services. Oxfordshire’s generic community therapy service provides rehabilitation input but has limited capacity to meet longer term needs of patient’s post-stroke, and most clinicians lack training and experience in this specialist area of rehabilitation.
Insufficient community-based rehabilitation is a national problem, with extensive work by the Stroke Association showing patients often feel ‘abandoned’ when they leave hospital, and like they ‘drop off a cliff’. Stroke recovery was named as an area of focus in the NHS long-term plan. Preceding the Covid-19 crisis, national stroke strategies were focused on improving provision of community rehabilitation and improving life after stroke. Sadly Covid-19 put these developments on hold with many community services reconfigured to support the NHS frontline. A report from the Stroke Association in September 2020 (link below), which surveyed over 2000 stroke survivors, highlighted the national impact. Approximately 50% of patients reported cancelled appointments and 39% reported insufficient rehabilitation input. In Oxfordshire the generic community therapy service was restructured to meet the needs of the COVID-19 crisis, resulting in reduced rehabilitation capacity for patients discharged from OSRU.
A senior clinician in our inpatient rehabilitation team (Specialist Physiotherapist) was shielding during the pandemic, and therefore unable to work face to face. A new service was established to provide remote follow up for patients discharged from OSRU, aiming to fill the gap left by redeployment of community teams to the front line. This service also provided the additional benefit of stroke specialist follow up, which was not historically available.
The aims of the follow up service were to provide a specialist stroke rehabilitation service remotely, support patient transition into the community and promote life after stroke.
Description:
The service is run by one whole time equivalent Specialist Physiotherapist, with support from the Clinical Lead Physiotherapist for data collection and caseload management. Patients receive a telephone call within seven days post discharge to complete an initial assessment and discuss their ongoing rehabilitation needs. Sessions are delivered remotely via telephone (or preferably videocall) for those able to access this. Videocalls are conducted using Microsoft Teams software. Any patients who cannot access the remote service are referred for urgent face to face input from the community therapy service with specialist advice provided as required. Support or advice from other members of the inpatient multi-disciplinary team is sought as required.
Intervention generally falls into one of three brackets; advice and support, exercise progression and video rehabilitation sessions. Goals for the intervention are set at the beginning and reviewed each session. Patients can access the service for as long as they require, receiving up to three sessions per week depending on service capacity and individual need. Discharge is always a joint decision between the patient and the clinician, when a point is reached that input is no longer required, or if care is being handed over to a face to face team for further progression.
Data is collected for each patient, including number of contacts, length of contact, onward referrals and objective outcome measures. The Barthel Index (BI) and Therapy Outcome Measure (TOMS) are completed remotely for all patients, with additional measures as required depending on individual impairments. Data is collated in an excel spreadsheet and all clinician contacts are recorded in the trust electronic notes system.
At point of discharge all patients are posted a feedback questionnaire to return to the inpatient service (self-addressed envelope included). Questions include numerical rating from 1-5 of how helpful they found the service, how much they feel it has aided their rehabilitation and recovery, and whether they would choose this method of follow up again (yes/no). All patients are encouraged to contact the inpatient team post-discharge if they have any further queries.
Data evaluation of this project is in the early stages. All patients discharged from OSRU since March have been contacted, excluding those discharged to another hospital (n=79 on 13/09/20). Of these 79 patients there are currently 35 complete sets of data.
(3 patients had passed away and 1 had been readmitted. 14 patients are still receiving input. 26 patients were admitted during March/April when local outcome measure collection was suspended due to the Covid-19 crisis. These data sets have all been discounted for purpose of analysis.)
Outcome Measures
Two thirds of patients saw an improvement in outcome measures at point of discharge. Average improvement on the Barthel Index (BI) was 2.2 (/20), and average improvement on the Therapy Outcome Measure (TOMS) was also 2.2 (/20). The minimal clinically important difference (MCID) for the BI is 2 and the TOMS is 0.5. Average improvement of 2.2 on both measures suggests input results in a meaningful change to patient’s lives. Of patients who didn’t see improvement, all only received 1 session. It is likely these patients either had no need for ongoing input, or their needs could not be met by a remote service.
Onward Referral
16 patients were receiving ongoing input from the Community Therapy Service (CTS) at point of discharge or were referred for further intervention. 19 patients were not referred on, as no further input was needed. For some patients, the follow up service seems able to meet ongoing rehabilitation needs without face to face contact. There is potential this could be a more efficient model of delivery, due to savings in travelling time. Additionally, this model enables patients to be followed up by clinicians who specialise in stroke rehabilitation, which has been a challenge historically.
Patient feedback
23 complete feedback questionnaires have been received to date. Of these:
• All rated the service 4 or 5 (/5) when asked how helpful they found it• 21/23 rated the service 4 or 5 (/5) when asked how well the service helped them to progress their rehabilitation (2 rated it 3)• An additional question was recently added, asking patients if they would choose this method of follow up rehabilitation again. Only 10 questionnaires with this included have been received so far. 9/10 responded yes.
In summary, this service has effectively supported patients discharged from OSRU during the pandemic. It is also partially meeting a historical gap in provision of specialist stroke rehabilitation post-discharge. Preliminary data suggests outcomes are improved for 2/3 of patients and the service is an acceptable substitute for face to face contact for some patients. Continuity of care from inpatient service to community has been improved and feedback suggests patients feel well supported. It is hoped this service can continue as data suggests it can aid transition from hospital to home, improve outcomes, reduce burden on face to face community teams and provide a positive patient experience. Funding has been requested to run the service for a further 12 months to enable more detailed evaluation.
All patients discharged from OSRU are followed up by the remote service. Throughout the pandemic, patients discharged to nursing homes have been disadvantaged, receiving minimal rehabilitation/community follow up, despite often having the most complex needs. This primarily relates to restrictions on external staff accessing care homes due to infection control measures and reduced capacity within community rehabilitation teams. Our remote follow up service enables those in nursing homes to be offered the same input as those in their own home, with onward referral for face to face input made and justified to care home managers as required. It is hoped our service is ensuring patients discharged from OSRU to care homes are not being unfairly disadvantaged during the pandemic because of their discharge location
