For many years in our Community Stroke Service within Worcestershire we have seen increasing numbers of stroke survivors. This includes the most severe stroke survivors who are often limited in their rehabilitation potential by numerous other co-morbidities, frailty and the extent of their stroke. They invariably require care within a nursing home setting or home with a package of care. Our commissioned service has only ever stipulated a 'one-off specialist visit' and then sign-posting to other services or education to carers/family. During covid, this part of our service was actually dropped in order to concentrate on discharging patients out of hospital to home much earlier. We were left with a huge backlog of stroke survivors with the most need, many of which had secondary complications.
We are passionate about this cohort of our patients and know from experience that without specialist support, they can develop a myriad of secondary problems such as contractures, complex pain conditions, pneumonias, depression & anxiety etc - all preventable conditions.
We applied for some West Midlands SQuIRe funding (Quality Improvement for Stroke) and were delighted to have our submission approved. This has allowed us to recruit some new members to the team to enable us to have the resources to give these patients a specialist bespoke assessment, as per the national Integrated Community Stroke Service Model and then planning appropriate goals/education with the patient and carers. The resource is small - 0.5WTE SLT Band 6, 0.6WTE Band 3 Rehab Assistant, 1.0 WTE Band 6 Physio or OT, 1.0 WTE Band 7 Physio or OT, a non-clinical project manager 1.0WTE Band 7 and monies to purchase x2 specialist supportive chairs to loan to nursing homes.
We organised several team away days for the whole countywide team to get buy-in for the project and collate ideas of how to run it. We soon formulated new referral forms, assessments for complex stroke survivors and worked out how logistically we would be responsive to these referrals (within 72hrs). Staff were really enthusiastic to support these patients. The project was launched live on 7th August.
We anticipate that the benefits will not only be a much improved quality of life for these patients, but also a reduced incidence of readmission and secondary complications as mentioned above. We also hope that we can alleviate anxiety of loved ones and educate carers in working alongside us to learn about appropriate positioning, seating, communication skills, low-level exercises and supporting around cognitive and mood difficulties. We also hope to see a reduced length of stay in our inpatient rehab unit as staff will be more confident to discharge these patients earlier, knowing that we can assess in a needs based way and plan rehab/care/education quickly.
We have recruited a project manager who will be our 'data-cruncher'. We will be using a variety of outcome measurements to evaluate the effectiveness of this project including functional outcome measurement such as Barthel and TOMs (Therapy Outcome Measurement), a quality of life outcome measurement (EQ-5D-5L) and patient and carer feedback questionnaires. We are also designing staff satisfaction questionnaires.
As we are only at the beginning of our year's project, we don't have data yet to support what we anticipate, but are confident that we can make a difference to people's lives with a team that has stroke specific skills and knowledge and who are all highly experienced.
We also perceive this funding/project to be a catalyst for us rolling out the national Integrated Community Stroke Model, as our project relates to Pathway 3 of the model. We will offer support based on needs and goals for up to 6 months and offer a review at 6 months using the Greater Manchester Stroke Assessment Tool. We would then refer on to our Integrated Neurology Service for further support after 6 months.
