Project Proposal
Project / Implementing a Stroke Early Supported Discharge Service
Date / 31 March 2014
Start & End Date / To start ASAP, and to run for 1 year, when effectiveness of the service will be reviewed
Author / Julie Caunt, Commissioning Manager
Project Aim and Objectives
The aims and objectives of a Stroke ESD team are:
  • To provide patients with a specialised and coordinated rehabilitation service either at home/care home following discharge from hospital.
  • Patients with stroke achieve safe living in their home environment/care home earlier than they would do under normal service provision.
  • To set achievable goals for each patient referred to the service.
  • To improve patients’ independence/functional ability and their quality of life following stroke.
  • To reduce length of stay in hospital in both acute and rehabilitation setting for appropriate patients following stroke
  • To ensure that timely information is provided to patients and their families at a time it is most required.

Project Benefits
The benefits of implementation of a Stroke ESD team are:
  • To provide eligible patients with accelerated and seamless transfer of care from hospital to home.
  • To allow some stroke patients to be discharged home/to a care home earlier but with a comparable level of support to that received in the acute setting. The Cochrane trial showed significant reductions in length of stay for patients referred to an Early Supported Discharge Team, of approximately 8 days. Other local Trusts did recognise a reduction in length of stay following implementation of an Early Supported Discharge Team, but the reduction varied and was not as much as 8 days. Patients who received ESD services returned home earlier and more likely to remain at home in the long term and to regain independence in daily activities.
  • To provide continuity of health and social care from the hospital into the community, supporting both the patient and the family during the transitional period.
  • To provide home visits where appropriate to identify potential risks, provide follow-up for new equipment, and address any concerns from carers.
  • To improve recovery from stroke. The Cochrane trial showed that patients were more likely to be independent and living at home 6 months after their stroke, and to express satisfaction with the services they received.
  • To reduce morbidity and mortality associated with stroke events
  • To further prevent future strokes
  • To improve patient satisfaction and quality of life for stroke patients

Finance and Resources
Based on the Cochrane trial that found 41% of stroke patients met the criteria for referral to the ESD team, and Accelerated Stroke Improvement Programme target of 40% of stroke patients being referred to the Stroke Early Supported Discharge team (which other local Trusts continue to achieve, the following table shows that 194 patients are expected to be referred to the service in a year.

Based on the recommendations per 100 patients per year caseload, the following table shows the additional funding required for the ESD team, taking into account cover for annual leave.

Agreement has been sought to fund the ESD service non-recurrently from MRET funds in 2014/15 initially. The outcomes of the service will need to be reviewed before any further funding for the service may be agreed.
Risks & Issues
The risks and issues associated with this proposal are:
  • There may be a need to recruit to the ESD team, which could delay the start date for go live.
  • Due to national shortages of some disciplines, it may prove difficult to recruit to some roles. There may be a possibility that existing CRH staff could be utilised.

Drivers
The drivers for implementation of a Stroke Early Supported Discharge Team are:
  • NHS Midlands and East Stroke Review - NHS Midlands and East has reviewed stroke care over the past few years as it was recognised that there was significant differences in clinical outcomes relating to stroke care across parts of the country. The aim of the review was to improve the quality of stroke care for people across the Midlands and East by improving the quality of life following stroke and the experience of patients. The review covered the entire pathway of stroke care from pre hospital care through to rehabilitation/social care and end of life.
There has been much work undertaken relating to hyper-acute and acute care, but there are gaps in stroke care still remain following discharge from hospital. One of the key performance indicators from the accelerated stroke improvement programme that continues to be monitored following this review is ‘40% of all stroke patients should be supported by a stroke skilled Early Supported Discharge team’.
  • NHS England Strategic Clinical Networks and Senate Yorkshire and the Humberundertook the annual peer review of Chesterfield Royal Hospital’s stroke service at the end of January 2014, and the panel felt strongly that an ESD pathway that is compliant with the National Strategy for Stroke should be developed jointly between the Trust and the CCG’s.
  • National Stroke Strategy – QM7 – Patients are offered a minimum of 45 minutes of active therapy that is required, for a minimum of 5 days a week, at a level that enables the patient to meet their rehabilitation goals for as long as they are continuing to benefit from the therapy and are able to tolerate it. This standard applies to therapy delivered in both hospital and community settings.
  • National Stroke Strategy – QM10 – People who have had stroke access high quality rehabilitation and, with their carer, receive support from stroke skilled services as soon as possible after they have had a stroke, available in hospital, immediately after transfer from hospital and for as long as they need… High quality specialist rehabilitation states Early Supported Discharge to a comprehensive stroke specialist and multi-disciplinary team, which includes social care, in the community, but with a similar high level of intensity to stroke unit care.
  • Royal College of Physicians: UK National Clinical Guidelines for Stroke Key Recommendation 2.1.1A – Commissioning organisations should ensure that their commissioning portfolio encompasses the whole stroke pathway from prevention through acute care, early rehabilitation and initiation of secondary prevention on to palliation, later rehabilitation in the community and long-term support.
  • Royal College of Physicians: UK National Clinical Guidelines for Stroke Key Recommendation 2.4.1A – Commissioning organisations should commission:
  • An inpatient stroke unit capable of delivering stroke rehabilitation as recommended in this guideline for all people with stroke admitted to hospital
  • Early Supported Discharge to delivery specialist rehabilitation at home or in a care home
  • Rehabilitation services capable of meeting the specific health, social and vocational needs of people of all ages
  • Services capable of delivering specialist rehabilitation in outpatient and community settings in liaison with inpatient services, as recommended in this guideline.
  • Royal College of Physicians: UK National Clinical Guidelines for Stroke Key Recommendation 3.8.1E – Provide early supported discharge to patients who are able to transfer independently or with the assistance of one person. Early supported discharge should be considered a specialist stroke service and consist of the same intensity and skill mix as available in hospital, without delay in delivery.

Problem/Opportunity
Stroke is the third largest cause of death in the UK and a third of people who survive a stroke are left with long-term disability, the effects of which can include aphasia, physical disability, loss of cognitive skills and depression.
Despite improvements in stroke care, over 30% of stroke survivors will have a persisting disability and need effective rehabilitation services.
Between 5% and 15% of patients are discharged into care homes and, conversely, about 25% of care home residents have had a stroke. At present these patients rarely receive any treatment from stroke rehabilitation services.
Currently the stroke service in North Derbyshire does not comply with the National Stroke Strategy Quality Markers, and outcomes for stroke patients are being compromised, with them suffering more disability, longer stays in hospital, increased burden for carers and additional long term health and social costs.
Current Stroke Service within North Derbyshire
Currently all patients suspected/diagnosed of having a stroke follow a stroke care pathway, where they present to the A&E Department at Chesterfield Royal Hospital (CRH), will either have a CT Scan within 1hour (if applicable) or within a maximum of 24 hours, and eligibility considered for thrombolysis (which is a clot thinning drug) and be administered this within 1 hour, if appropriate. They are then admitted direct to Eastwood Stroke Unit at CRH (as all stroke patients should be admitted direct to a stroke unit and should spend 90% of their stay on the unit), where they will receive the appropriate care and receive care from a number of disciplines by stroke specialist staff for the whole of their stay throughout the hyper-acute, acute and rehabilitation stages of their stroke care. The quicker a patient receives treatment, the better their chance of survival and recovery.
The Eastwood Stroke Unit at CRH has 36 beds, made up of the following:
  • 3 hyper-acute beds (monitored beds)
  • 13 acute beds
  • 20 rehabilitation beds
Implementation of a Stroke Early Supported Discharge (ESD) team would reduce the need for stroke patients needing to be outlied on other wards as many stroke patients would be able to go home earlier with ongoing support and assistance from the ESD team, freeing up beds on the stroke unit for other patients. Stroke clinical staff will screen patients for appropriate referral to the Stroke ESD team.
Following discharge from hospital, there are no stroke specific services. The only service patients can be referred to is the Community Rehabilitation Team run by Derbyshire Community Health Services (DCHS), which is not a stroke specific service. Therefore it is not possible to provide the intensity of rehabilitation required to achieve the best possible outcomes. This lack of stroke specific community rehabilitation means that some patients will remain in an acute bed for prolonged periods, as this is the only way to provide them with the necessary therapy.
Patients do however have access to a Stroke Coordinator, who establishes contact with the patient following discharge from hospital to determine their needs and they signpost to the appropriate services, which are also not stroke specific.
The current stroke service is therefore failing to meet the National Stroke Strategy recommendations (QM7 and QM10):
  • By not providing a service to continue patients’ therapy at a level that enables patients to meet their rehabilitation goals for as long as they are continuing to benefit from the therapy and are able to tolerate it, or;
  • By not having a stroke specialist service to continue to support patients for as long as patients require it at a similar high level of intensity to stroke unit care.
The National Clinical Guidelines for Stroke (RCP) recommend that stroke survivors discharged home directly after stroke treatment, but with residual problems, should be followed up by specialist stroke rehabilitation services. Additionally it is recommended that early hospital discharge should occur only where there is a specialist stroke rehabilitation team in the community and that early discharge to general non-specialist community services should not occur.
Implications
Workforce: CRH would need to recruit to provide the service.
Procurement:No implications identified.
Contracts: No implications identified.
IM&T:No implications identified.
Scope
The ESD service will accommodate all patients registered with North Derbyshire and Hardwick Clinical Commissioning Group GP practices.
Governance and Project Team
The Team would be run in accordance with the CRH Governance structure.
The CCG Project Delivery Team consists of Dr Ruth Cooper and Julie Caunt.
Key Stakeholders
The key stakeholders are:
  • Chesterfield Royal Hospital Stroke Team and appropriate Management Structure
  • CCG project members
  • NDCCG and HCCG Practices
  • Locality patients

Outcome Measures
The following table shows the indicators and targets following implementation of the ESD service. Baseline levels will need to be established with Chesterfield Royal Hospital.
Indicator / Target / Monitoring
Accelerated Stroke Improvement Indicator: 40% of all stroke patients should be supported by a stroke skilled Early Supported Discharge team / 35% - within 6 months following recruitment and full implementation (to be monitored on a monthly basis) / Monthly monitoring to be provided to NDCCG. Stroke deaths to be excluded from the total number of strokes each month. Provider to refresh previous month’s performance data to capture any patients discharged from the acute stroke service into a stroke rehabilitation bed that may be referred to ESD the following month
Reducing length of stay following implementation of the ESD service / Baseline to be set using pre and post ESD implementation length of stay data / Monthly monitoring to be provided to NDCCG
Proportion of stroke patients meeting their rehabilitation goals / Baseline to be set within 6 months of implementation / Monthly monitoring to be provided to NDCCG
To increase the number of patients spending 90% of their stay on the stroke unit. / Baseline to be set using pre and post ESD implementation length of stay data / Monthly monitoring to be provided to NDCCG
Number of patients assessed, and % on time within 24 hours of hospital discharge / 100% (and exception reporting for patients overdue) / Monthly monitoring to be provided to NDCCG
Average waiting time for initial appointment/assessment and number of patients on a waiting list / Provider to keep a record of referral date and date of initial appointment / Monthly monitoring to be provided to NDCCG
Number of patients eligible for ESD and number of patients received ESD / Provider to keep a record of the number of patients eligible for ESD, and the number of patients that received ESD / Monthly monitoring to be provided to NDCCG
Patient Satisfaction surveys to be undertaken / Number of patients to be surveyed per quarter to be determined with the Provider / To be undertaken quarterly and results reported to NDCCG
Bed days and occupancy rates split by acute stroke and stroke rehabilitation / To be monitored using pre and post ESD implementation baselines / Monthly monitoring to be provided to NDCCG
Referral from ESD to other services / Provider to keep a record of referral date to other services, and to report to NDCCG regarding any issues that arise regarding ongoing referral, ie delays patients experience / Monthly monitoring and reporting to be provided to NDCCG
Key Stages and Timeline
March 2014–Approval obtained to be funded through MRET funding (non-recurrently) but will be reviewed 1 year following implementation.
April 2014–Meet with CRH to discuss recruitment for the ESD team and expected timescales for recruitment, potential start date
To be completed following Finance & Resource Committee Review
Approved / Yes / No / Offered to other localities to pilot? / Yes / No
Any conditions specified?
All approved or only parts of full proposal approved?
Approved until date / Frequency of updates to Finance & Resource Committee

Project Proposal - Document Information

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Appendix 1

Referral Criteria and Eligibility for referral to the Stroke Early Supported Discharge Service:

  • Direct pathway of referral from the Stroke Unit at Chesterfield Royal Hospital as outlined in the National Stroke Strategy.
  • Transfer dependency will be that patients can transfer safely from bed to chair, ie can transfer with one, and able carer, or independently if living alone.
  • Within 24 hours of identification eligible patients will be referred to the ESD service.
  • Rehabilitation goals must be identifiable.
  • Patients will have a Barthel score of >9.
  • Referral is from an acute healthcare professional following comprehensive assessment.
  • The patient must be medically stable with appropriate medical investigations completed.

Caveats:

  • The patient cannot be discharged until necessary care, equipment and transportation are in place. Responsibility for this must be clearly defined locally.
  • Unsuitable home environment based on relevant clinical and/or social care assessment.

Referral Inclusion:

  • The patient/carers must give consent to ESD referral.
  • For patients discharged alone to a private address they must be able to maintain their own safety independently.
  • The ESD will inform the acute service and the patient/carer, of the rehabilitation and package of care they will be receiving when entering the service.

Discharge Procedure/Care Transfer

  • The ESD team will send a discharge summary to the GP and the stroke physician for information.
  • At the point of discharge from ESD, the patients’ medical care will be transferred to the GP.
  • Responsibility for 6 month review needs to be in line with current provision and national guidance.
  • Where further health care is required the relevant service should be identified.
  • Where further social care needs have been identified, the patient is transferred into Social Care services, which will assess and identify a person centred care plan.

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