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Post stroke care

Post stroke care


Treating stroke patients in the community reduces the length of stay in hospital, costs and results in better outcomes

NHS Gloucestershire Clinical Commissioning Group (CCG) and Gloucestershire Care Services NHS Trust are working together to place emphasis on the successful delivery of specialist community-based, fast stream rehabilitation and nursing care following a stroke.   
Motivated by the significant national evidence base, health and social care providers and commissioners in Gloucestershire have developed both an early supported discharge rehabilitation service and a specialist nurse assessment and follow-up service for individuals who have had a stroke and who could clinically benefit from fast stream intensive rehabilitation and specialist care. Both services are based in the community and delivered across Gloucestershire.
The early supported discharge service offers an early discharge from an acute hospital following a stroke with intensive rehabilitation delivered in an individual’s place of residence.
A proportion of, rather than all stroke patients, will derive clinical benefits and optimum recovery from this type of service depending on their individual conditions.  
The evidence concludes that an early discharge to a specialist team can reduce long-term mortality and institutionalisation rates for up to 50% of appropriate stroke patients and lower overall costs.1 To meet these improvements, the evidence also offers that rehabilitation should be provided by a comprehensive stroke specialist and multidisciplinary team in the community, but with a similar level of intensity to stroke unit care.2
Further findings from the Cochrane Review3 of seven completed trials indicate that early supported discharge services can reduce the length of hospital admission in selected stroke patients and provide an outcome at least as good as hospital care.
Assessment and follow-up by specialist nurses in Gloucestershire at home provides a wider specialist multidisciplinary team approach alongside the offer of an early supported discharge service.
The relevant national strategies also reinforce this approach to services. Both the National Service Framework for Long Term Conditions3 and the National Stroke Strategy4 echo the recommendations of the Cochrane Review, by suggesting that specialist community stroke services offer:  
A reduced length of stay in hospital when compared with conventional rehabilitation.
Decreased health and social care costs.
Better overall outcomes for individuals.
Increased independence when compared to conventional rehabilitation following a stroke.
Increased patient satisfaction.  

Specialist healthcare professionals
In Gloucestershire, a countywide approach was adopted, offering specialist nursing staff and therapists with qualifications and experience related to practicing stroke care. There are challenges to providing any community services across Gloucestershire because of the geography.
Gloucestershire is a largely rural county with a population of around 600,000. Around 50% of the population is based in the more urban areas of Cheltenham and Gloucester, with the remaining residents right across the county. This requires flexibility from our community teams who usually work out of a variety of locations.  
The early supported discharge team provides individuals with a seamless transfer of care from hospital to home with a discharge plan that has fully involved the individual and their family where appropriate. The service comprises practitioners skilled in stroke rehabilitation including physiotherapists, occupational therapists, nurses, rehabilitation support workers, speech and language therapists, and administrative support staff with links to psychology services, social workers and the local intermediate care and re-ablement services.
Early supported discharge provides intensive therapy following hospital discharge and works to promote independence; well-being and self-care and deliver outcome focused therapeutic care. A model of the service can be seen at Figure 1.

The specialist nurses first assess individuals and offer support to their carer and/or families within six weeks following a hospital discharge.
For early supported discharge patients, this is around the time that the intensive period of their clinical therapy will be coming to a close. A follow-up appointment with specialist nurses takes place at about six months post discharge to again review progress and future needs.
At the team’s discretion, the support offered can be over a longer period of time if required, and individuals are able to self-refer back into the service.
All support is carried out either over the telephone or via home visits, and the nurses are able to link patients to a variety of services, depending on their needs. The team also acts in an advisory capacity for other community services and training programmes across the county including the early supported discharge team of stroke therapists.  

The outcomes
A diagram of the early supported discharge pathway illustrated with 2013/14 data for Gloucestershire is provided at Figure 2.

The diagram at Figure 2 demonstrates that around 41% of stroke patients in Gloucestershire are being treated by the early supported discharge team, which is a considerable number of individuals who are now able to leave hospital earlier and receive specialist rehabilitation in their place of residence. This meets our original expectations for a fully established early supported discharge service where clinically appropriate patients are able to access the service through good links with secondary care.
Both services enter results into the national Sentinel Stroke National Audit Programme (SNNAP) audit for stroke care, which is managed by the Royal College of Physicians. Earlier this year, Gloucestershire Care Services as the provider of both services reviewed their last quarter results for 2014. For the specialist stroke nurses, the findings were as follows:
Two hundred and twenty nine six-month follow up appointments were completed, out of a possible 235 patients (97% as opposed to 19% nationally).
Assessments were completed slightly      
     sooner than elsewhere.
Face to face assessments were completed for 87% and telephone 13%.
Six patients had a further stroke in line with national figures.
For the early supported discharge team the results were that 46% of stroke patients were treated by the early supported discharge team as opposed to 27% as a national SNNAP average per area; and the majority of individuals had some improvement in their condition following treatment by the team. This is illustrated by the diagram in Figure 3.

Hannah Layton, clinical programme manager, transformation and service redesign directorate, NHS Gloucestershire CCG.

1 Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. 2012. 12;9:CD000443. doi: 10.1002/14651858.CD000443.pub3 (accessed 18 September 2015).
2 Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. 2012. 12;9:CD000443. doi: 10.1002/14651858.CD000443.pub3 (accessed 18 September 2015).
3 Department of Health. National Service Framework for Long Term Conditions, Department of Health. 2005. (accessed 18 September 2015).
4 Department of Health. National Stroke Strategy. 2007. (accessed 18 September 2015).
5 Fearon P, Langhorne P, Early Supported Discharge Trialists. Services for reducing duration of hospital care for acute stroke patients. 2012. 12;9:CD000443. doi: 10.1002/14651858.CD000443.pub3 (accessed 18 September 2015).


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