Over 100,000 people have a stroke in the UK every year. Whilst a third will be left with some form of long-term disability, affecting mobility, cognition, vision, psychological wellbeing or communication, many of those who survive, with appropriate and timely rehabilitation and support, can make a full and complete recovery.1
The majority of successful post-stroke care is delivered through consistent, patient-centred rehabilitation – a cyclical process involving assessment, goal-setting, intervention and reassessment provided by a team of multi-professionals specialising in stroke care – all working together to meet each individual patient’s needs.
“Getting stroke rehabilitation right throughout a patient’s recovery can have a significant impact, reducing mortality and dependency, whilst ensuring the patient and their loved ones’ experience as good a quality of life as possible,” explains Julie Trimble, Therapy Services Stroke Pathway Lead for the Newcastle Hospitals.
“Post stroke rehabilitation in hospital or at home is excellent in Newcastle but it has not always been possible to provide this to the same extent to patients in care homes.
“Around 5-15% of stroke patients are discharged from hospital to care homes and a quarter of nursing home residents will have had a stroke. Once discharged to care homes these patients’ recoveries are seen to plateau with functional gains declining, impacting on long-term disability and well-being,” continues Julie.
“Such inequitable access to strong rehabilitation puts these patients at risk of long-term disability, poorer health and well-being outcomes, which in turn increases the demand on health and social care systems and widens health inequality.”
Addressing the rehabilitation gap
Promoting equality and addressing health inequalities are at the heart of NHS England’s values.
The National Service Model for an Integrated Community Stroke Service (ICSS) (2022) recommended that ‘stroke rehabilitation services should assess and treat people with stroke living in a care home in exactly the same way they do patients living in their own home’ and that ‘commissioners and providers should collaborate to ensure that no imposed geographical boundary, referral process or criteria prelude patients from accessing ICSS services’.
To address the rehabilitation gap, Newcastle Community Stroke Service were awarded funding from NHS England (Stroke Quality Improvement in Rehabilitation (SQuIRE) catalyst funding) to develop, deliver and evaluate the impact of a stroke-specialist multidisciplinary service to stroke patients discharged to care homes in Newcastle.
Four eligible patients were recruited over a 6 month period in 2023/4 and received up to 8 weeks targeted patient-led, goal-centred rehabilitation from speech and language therapy, physiotherapy, occupational therapy and dietetics. Additionally, the team benefited from inclusion of social services.
A comprehensive online stroke specific training package was developed for care home staff to enhance knowledge and reduce the risk of functional deterioration in stroke patients in their care, coupled with face-to-face patient-specific education and information provided to relatives and carers.
Benefits for patients
The results were impressive. “Significant improvements were recorded in response times from referral to initial assessment and amount and intensity of therapy received,” says Julie.
“Patients benefited from receiving joined-up holistic stroke-specialist care from a team with well-established links with inpatient stroke services and significant experience of discharge planning and providing stroke specialist care in the community.”
The findings demonstrated that timely access and regular stroke-specialist intervention to stroke patients in care home settings has the potential to reduce costs to health and social care providers and patients and their family members.
For the patients included in this project, risk of harm was reduced avoiding readmissions within 8 weeks of discharge from inpatient stroke unit. In addition, function was optimised and improved outcomes were achieved with a corresponding reduction in, or maintenance of, level of impairment in the following areas:
- communication
- social participation
- transfers
- balance
- mobility
- self-care
- optimisation of swallow and nutrition
- monitoring and regulation of blood pressure.
Improvements were also observed in patient and carer quality of life and patient and carer experience measures.
Benefits for staff
Staff recruited valued the opportunities for skills development and building valuable inter-team and network-wide relationships. Benefits to staff included development of and improvement in the following areas:
- project and resource management
- leadership skills
- knowledge of improvement methodology
- knowledge and use of outcome and experience measures
- strategic knowledge of service provision, stroke guidelines and other national directives
- joint working, collaboration and understanding of MDT roles
- networking with other community stroke services regionally and nationally, specifically sharing best practice
- self-awareness e.g. building resilience, tenacity and negotiation.
Praise for the care homes team from family members included:
‘(the team) made a positive and significant difference to my mum’s mental and physical wellbeing and ability after her stroke… the input made her significantly more motivated to improve… without this… my mum would have not made have made any or as much progress as she has since her stroke’.
‘Being part of this project has given our dad a better quality of life. The staff have given him advice about how he can meet his needs with his personal care. He has been given coping strategies to help him cope with his decline in his mobility.
‘The team have helped him to take a slower approach about things when trying to do things for himself, when mobilising with support, when accessing his surroundings to be more aware in relation to his own safety and when meeting his care needs.
‘The team have provided him with adapted ways to help him to stand up safely…. (we and our dad) feel that without the level of support, advice and help provided by this project, he would not be able to even consider extra care and would be in a care home for the rest of his life’.
Equitable care
This project has enabled the team to develop the rehab service to people in care homes and demonstrate how outcomes can be improved with targeted skills and interventions. They have learned a huge amount about the stroke rehab needs of people in care home settings and hope to positively influence the development of equitable services and improve outcomes to all patients after stroke.
This gap in service has been acknowledged with commissioners locally and has been added to a list of priorities for future funding. Findings will be shared with delegates at this year’s UK Stroke Forum. We hope that this valuable piece of work will move us one step closer to creating an equitable pathway for stroke patients discharged to care homes in the Newcastle area.
The team have approached this project with huge enthusiasm and demonstrated how timely stroke rehab can improve outcomes for people who live in care home settings.
Ewan Dick, Associate Director of Allied Health Professionals and Therapy Services for the Newcastle Hospitals
“The passion and expertise to address some of the inequality in outcomes has produced some powerful messages and I know the team across the stroke pathway will continue to work with the Trust and health commissioners to advocate for patients and find ways of sustainably delivering rehab across settings.”
1. National service model for an integrated community stroke service – February 2022
