Bath and North East Somerset Community Health and Care Services

Bath and North East Somerset Community Health and Care Services:

Specialist Neurology and Stroke Services (Adults)

SD48

1. Introduction

Specialist Community Neurology and Stroke Services provide specialist intensive rehabilitation and management for people in the community following a new stroke, brain injury, spinal cord injury or an acute exacerbation of their neurological condition. These services can provide rapid intervention to prevent hospital admission and also facilitates Early Supported Discharge from hospital.

The specialist neurology and stroke services currently available in Bath and North East Somerset (B&NES) can broadly be categorised as Early Supported Discharge / Urgent Care and Planned Rehabilitation.

1.  Early Supported Discharge / Urgent Care

This is for patients who require rapid and/or intensive intervention either prevent hospital admission or to expedite discharge from hospital. The service is available 7 days per week and through comprehensive specialist assessment, treatment and management, the service aims to help people to continue their recovery or management, become more independent and to adapt to life at home, at work and within their local community.

2.  Planned Rehabilitation

This is for patient’s requiring non-urgent assessment and interventions to help with the aim of maximising the patient’s understanding of their condition and how to manage it so that they can maximise their independence. In addition to the general planned rehabilitation service, there are several specialist elements which are:

Specialist Neurology Nursing

Patients with long term neurological conditions such as Multiple Sclerosis (MS), Motor Neurone Disease (MND), Parkinson’s Disease (PD) and other movement disorders may receive support through from diagnosis to end of life care from Specialist Neurology Nurses.

Outpatient Neuro-Rehabilitation

A specialist neuro-rehabilitation outpatient service is available for patients with neuro-rehabilitation needs who require consultant led follow up and spasticity management clinics, specialist physiotherapy, orthotics and psychology input in the community.

Community Stroke Support

Finally, a Communication Support Service is provided for patients who have aphasia as a result of their stroke. A Community Co-ordinator is also available to assist people who have a stroke and their carers to access a variety of services.

2. Purpose

2.1 Aims and Objectives

The overarching aim of specialist neurology and stroke services is to support patients who have either a neurological condition or a stroke to manage their condition and maximise their independence. Where possible the services aim to do this by promoting self-care through advice, information, education and health promotion.

The objectives of the services are to:

·  Provide high quality therapy and nursing care to people in their own homes.

·  Plan and deliver personalised care, promoting health and wellbeing and self-care by advising, educating and supporting people and their families.

·  Undertake comprehensive assessments and provide treatment and management to help patient’s effectively manage their condition, continue their recovery (where appropriate) and maximise their independence.

·  Develop goal orientated rehabilitation programmes set jointly with the service user and their carer.

·  Support, advise, inform and educate carers in their role, enabling them to access appropriate support networks.

·  Work closely with the care agencies in order to ensure good continuity of rehabilitation between therapy visits.

·  Review people following a stroke at 6 weeks and 6 months post discharge in line with national guidance.

·  Provide advice on drug and symptom management to service, carers, GPs and other health and social care professionals.

·  Support service users in how to administer injections for disease modifying therapies.

·  Work closely in partnership with GPs, social care, voluntary sector and other health care providers to promote the best outcomes for the patient and family.

·  Prevent hospital admissions as well as screen and track service users in hospital so that there is no unnecessary delay in facilitating their return home.

·  Minimise premature dependence on long term residential care.

·  Support patients with long term conditions to self-care and feel self-empowered in the management of their condition.

·  Develop and empower the workforce to ensure they are equipped to deliver a high quality service.

3. National/local context and Evidence base

National Context

Neurological conditions result from damage to the brain, spinal column or nerves, caused by illness or injury. Many of the precise causes of neurological conditions are not yet known and anyone can suffer from, or be at risk of developing a neurological condition, although for some progressive neurological conditions, the incidence increases with age. Some neurological conditions are life threatening and most of them severely affect people’s quality of life and many cause life-long disability. Neurological conditions can be fitted broadly into four groups:

1.  Sudden-onset conditions

These account for 3-4% of people with neurological conditions. They include traumatic brain and spinal injury, stroke, encephalitis, meningitis, Guillain-Barre syndrome, trigeminal neuralgia and idiopathic intracranial hypertension. Many of these conditions are resource intensive at the outset, require access to emergency treatment and intensive rehabilitation and have lifelong and often unrecognised impacts on future functioning.

One of the most common sudden-onset conditions is stroke. Stroke is the third largest cause of death in England and between 20-30% of people who have a stroke die within a month. Every year approximately 110,000 people in England have a stroke and there are over 900,000 people living in England who have had a stroke. Stroke has a devastating and lasting impact on the lives of people and their families and a third of people who have a stroke are left with long term disability. This means that about 300,000 people in England have a moderate or severe disability as a result of a stroke.

2.  Intermittent and unpredictable conditions

These affect about 60% of all people with neurological conditions and conditions include epilepsy, migraine, cluster headache and cavernoma. The unpredictability of these conditions often have a significant impact upon an individual’s ability to function on a daily basis.

3.  Progressive conditions

About 20% of people with a neurological condition have one that is progressive. This group includes a large number of different diseases including motor neurone disease, Parkinson’s disease, later-stage multiple sclerosis, muscular dystrophy, progressive supranuclear palsy, ataxia, brain tumour, dementia, and Huntington’s disease. If not managed well, this group of people can be extremely resource-intensive and result in unscheduled hospital admissions.

4.  Stable with changing needs

Accounting for around 17% of all people with neurological conditions, this group include those diagnosed with cerebral palsy, fibromyalgia, myalgic encephalomyelitis, narcolepsy, spina bifida and hydrocephalus, Tourette syndrome and congenital hemiplegia.

It is estimated that there are now 12.5 million people in the UK with a neurological condition and the cost of managing these conditions has risen significantly over the last five years. However, evidence shows that continued co-ordinated multidisciplinary rehabilitation in the community setting improves long term outcomes for patients and can help to reduce hospital admissions (National Service Framework for Long Term Conditions, 2005).

Local Context

In 2014/15, there were 3,518 people on GP registers who were recorded as having a previous stroke or transient ischaemic attack. The emergency admission rates for strokes and mortality from stroke rate are not significantly different in B&NES to the England average. However, there is a lower proportion of stroke patients 75 years and over discharged back to their home or usual place of residence compared to the national picture.

With regard to other neurological conditions, there are no registers of the numbers of people affected. Prevalence estimates can be found in the Bath and North East Somerset Joint Strategic Needs Assessment - http://www.bathnes.gov.uk/services/your-council-and-democracy/local-research-and-statistics/wiki/neurological-conditions.

4. The policy context

The following guidance is pivotal to the delivery of specialist neurology and stroke services:

·  Professional Guidelines and Standards from professional bodies such as the Royal College of Nursing

·  Care Quality Commission (CQC) Regulations

·  Neurological Alliance (2014)Joint Strategic Needs Assessment for People Living with Neurological Conditions

·  Royal College of Physicians (2011) - Local adult neurology services for the next decade

·  National Stroke Strategy (2007)

·  Royal College of Physicians (2008) - Guidelines for Stroke

·  National Institute of Clinical Excellence (NICE) Quality Standard (2010) – Stroke in Adults

·  National Audit Office (2011) - Services for people with neurological conditions

·  Royal College of Physicians (2003) – Rehabilitation following Acquired Brain Injury National Clinical guidelines

·  NICE guidance (2014) – Multiple Sclerosis in Adults: Management

·  NICE Quality Standard (2016) - Multiple Sclerosis

·  NICE guidance (2006) – Parkinsons Disease: Diagnosis and Management

·  NICE guidance (2016) – Motor Neurone Disease: Assessment and Management

This is not an exhaustive list and the service should be provided in line with other relevant guidance.

Providers are expected to participate in relevant audits such as the Sentinel Stroke National Audit Programme (SSNAP).

5. Service Delivery

5.1 Service Model

Specialist neurology and stroke services should be accessible to all people with neurological conditions, including stroke. People should be able to access community rehabilitation via a single point of entry and at any point along the pathway (i.e. not just following an acute inpatient admission). Community rehabilitation is goal-orientated and provides assessment, intervention, rehabilitation and patient education to patients who have had a stroke. Goals will be incorporated into a personalised care plan that allows the patient to take ownership of their rehabilitation and reviewed regularly with the patient throughout the treatment period. Where goals have previously been set for patients these should be followed up. Patients should be allocated a named care co-ordinator whose role is to monitor the implementation and review of the care plan and progress of any onward referrals to other services. While initial assessment of the patient is carried out by a qualified professional, some of the care may be delivered by rehabilitation assistants under the supervision of a qualified therapist. Specialist rehabilitation and support will address the following issues either directly or by onward referral where required:

·  Mobility and movement

·  Communication

·  Everyday activities (e.g. dressing, washing, meal preparation)

·  Emotional and psychosocial issues (e.g. depression and adjustment difficulties)

·  Swallowing

·  Nutrition

·  Impaired cognition

·  Continence

·  Relationships and sex

·  Pain

·  Employment Issues

Early Supported Discharge / Urgent Care

The Early Supported Discharge service model is based on that recommended by the National Stroke Strategy (2007) and the Royal College of Physicians (RCP) Guidelines for Stroke (2008).

The service consists of a specialist community interdisciplinary team closely interfacing with secondary, tertiary and primary care. It is able to provide intensive specialist rehabilitation for adults who have had a stroke, brain injury, spinal cord injury or have an acute exacerbation of their neurological condition.

Specialist assessment is provided and an individualised treatment and management plan developed following agreement of goals with the service user and carer. Intensive intervention for people following acute stroke is delivered in line with RCP recommendations (i.e. 45 minutes per identified therapy per day).

Many of the service users supported by the service have significant and complex needs. The service provides case management support for those people accessing a range of services and co-ordinates their journey through these services as appropriate. Interventions are not time limited and the service will continue to provide rehabilitation as long as intensive support is required and relevant goals are identified.

The service is provided by Specialist Physiotherapists, Occupational Therapists, Speech & Language Therapists, Nurses, Clinical Psychologist and Clinical Assistants. The service in-reaches into local inpatient units and also facilitates discharges from stroke and neurology beds at the Royal United Hospital, St Martin’s Hospital, Paulton Hospital, Frenchay Brain Injury Rehabilitation Unit, Glenside Hospital, Salisbury NHS Foundation Trust, North Bristol NHS Trust and University Hospitals Bristol NHS Foundation Trust.

The service aims for patients who have had a stroke to be discharged home with intensive support from this team within 7 days of their hospital admission. The service also provides reviews of the health and social care needs of service users following an acute stroke at 6 weeks and 6 months as stipulated in the National Stroke Strategy and CQC Life after Stroke guidance.

Planned Rehabilitation

The Planned Rehabilitation service model provides specialist rehabilitation and management for adults who have a neurological condition or stroke, in the community using a person-centred, holistic approach.

Through comprehensive specialist assessment, treatment and management, the service aims to help people to continue their recovery or management, maximising their independence. However, as the service supports people through the changing course of their neurological condition, many people will have significant and complex needs. There will be a significant number of people accessing the service who are primarily following a path of reduction in independence so therefore interventions are not time limited to be able to meet these long term needs.

The service facilitates service users’ improved understanding of their condition and how to manage it, ensuring that opportunities for promoting well-being and self-management are maximised. The service also provides case management support for those people accessing a range of services and co-ordinates their journey through these services as appropriate.

The service consists of a specialist community multi-disciplinary team closely interfacing with secondary, tertiary and primary care. The service works in an interdisciplinary way in order to maximise outcomes for the service user and to achieve greater flexibility, making best use of resources. The service is provided by Specialist Physiotherapists, Occupational Therapists, Speech & Language Therapists, Nurses, Clinical Psychologist and Clinical Assistants and each patient will have a named care co-ordinator and personalised care plan.

Specialist Neurology Nursing

The Specialist Neurology Nursing Service provides specialist nursing support and management for adults who have MS, MND or a Movement Disorder from diagnosis through to end of life care. The service facilitates service users’ improved understanding of their condition and how to manage it, ensuring that opportunities for promoting well-being and self-management are maximised. This includes providing advice on medicines and symptom management and providing case management to support patients in accessing a range of services. The service supports people through the changing course of their neurological condition, the majority of whom are primarily following a path of reduction in independence so interventions are not time limited in order to meet these long term needs.