Dorset Improving Psychological Support after Stroke Project

Sara Leonard Lead Manager

Dorset Cardiac and Stroke Network

Dorset Improving Psychological Support after Stroke in the Community Project

The scale of the problem

Summary of original pilot project

Issues and sustainability

Progress since pilot

Ongoing challenges and next steps

Today I will cover…….

A significant proportion of stroke patients with depression

remain undiagnosed or inadequately treated (Hackett et al 2005).

0

10

20

30

40

50

60

70

80

90100

Cognition Anxiety Depression

Up to 75% experience cognitive impairment

(RCP 2009)

Prevalence of post stroke depression

independent of disability is approx

33% (Hackett et al, 2005)

Anxiety rates of 30- 49% up to 12 years post stroke

(South London Stroke Register)

The scale of the problem

National Stroke Strategy (2007) Central importance of a psychological pathway of rehabilitation

RCP National Clinical Guidelines for Stroke (2009) Patients with stroke should be routinely screened for depression anxiety and cognition

NICE Quality Standard for Stroke (2010) Screen within 6 weeks of diagnosis … to identify mood disturbance and cognitive impairment

NICE Quality Standard for Depression in Adults (2011)People with depression should receive appropriate psychosocial interventions or collaborative care according to the degree of depression, associated chronic health problems and its impact on function

National Guidance

Collaborative Care

Close collaboration between primary and secondary physical health services and specialist mental health services

Case management supported from senior mental health professionals

A range of interventions including patient education, psychological and pharmacological interventions

Long term coordination of care and follow up.

Collaborative Care

Mental Health Strategy 2011

The National ambition for psychological care after stroke

Little had been done. STRONG support from

local people. Pilot Site – North and

South West Dorset. Collaborative working New Pathway Training – developed

and provided Monitored Accreditation & Oscar

Summary of original pilot project

Step 1

Under Step 1 DIPSS trained staff are able to:

Ask initial screening questions

Employ nationally validated screening assessment tools as appropriate

(e.g. PHQ9, GAD-7, SADQ-10)

Risk Assess.

Provide initial support and information.

(Including for sub-threshold scores).

Progress to Step 2 (persistent sub-threshold, mild to moderate)

Refer on as appropriate.

Step 2 Initial Management

Under Step 2 DIPSS trained staff are able to:

Offer Sleep Hygiene Advice

Undertake Active Monitoring

(discussing problems, providing information on depression and arranging a further assessment)

Provide information on self-referral/refer to local IAPT services for Step 2 low intensity psychosocial interventions and/or drug treatment.

PPI Involvement

• Patient & carer representatives on steering group

• Patient & Carer easy-read feedback forms

• Dorset Stroke Network PPI Forums – ongoing and specific

• Stroke Network PPI Members with aphasia

PPI Involvement

Band Costs per hour with on costs (mid

point)

Hours Total cost

Clinical Neuropsychologist

8D £46.94 15.0 £704.10

Service Improvement Manager

7 £22.02 15.0 £330.30

UK Forum for Stroke Training accreditation £300.00

DEVELOPMENT & ACCREDITATION OF TRAINING £1,334.40*

*One off cost – funded by Network

Cost of Psychology Training - DEVELOPMENT

Band Cost per

hour

Hours Cost per course*

Number of

courses

Total cost

Clinical Neuropsychologist

8D £46.94

7.5 £352.05 3 £1,056.15

Assistant 7 £22.02

7.5 £165.15 3 £495.45

COST TO DELIVER TRAINING (3 x courses @ £517.20 each) £1,551.60*

*plus: – administrative support for booking venue/confirming places– catering costs

• Funded by Network

Cost of Psychology Training - DELIVERY

Band Cost per

hour

Hours Cost per course

Places Total cost

Community Rehab Team Leader

7 £22.02 7.5 £165.15

Community Senior Physio/OT/SALT

6 £18.38 7.5 £137.85 20 £2757.00

Physiotherapist 5 £15.26 7.5 £114.45

COST TO ATTEND TRAINING £2757.00*

*Cost to provider

• Does not include travel expenses

Cost of Psychology Training - ATTENDANCE

• Not including accreditation process:

• Delivery: £517.20 per course

• Attendance: £2,757.00 per course

= £3,274.20 per course

(20 delegates)

Total cost of psychology training

*One off cost

Both costs funded by Network

Cost of Communication Training –

DEVELOPMENT & DELIVERY

UK Forum for Stroke Training accreditation

(existing training package)

£300.00*

Delivery of 3 day course by Speech & Language Therapist £750.00

Band equivalent

Cost per

hour

Hours Cost per

person

Places Total cost

Psychological wellbeing

practitioners

6 £18.38 22.5 £413.55 12 £4,962.60

COST TO ATTEND TRAINING £4,962.60*

*Cost to provider

• Does not include travel expenses

Cost of Communication Training – ATTENDANCE

• Not including accreditation process:

• Delivery: £750.00 per course

• Attendance: £4,962.60 per course

= £5,712.60 per 3 day course

(12 delegates)

Total cost of Communication Training

Training delivered

end of January

Proportion of clients formally screened

3

7

27

3532

45

72

Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11

%

Training

Proportion of stroke patients receiving formal screening for

psychological issues after stroke during contact with community teams

Training delivered

end of January

Proporportion of clients receiving psychological support

4846

68

76

93 93

89

Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11

%

Training

Proportion of stroke patients receiving support for psychological issues

after stroke during contact with community teams

Number of stroke survivors and carers each month supported by PCMH

1

2 2

5

2 2

0

1

2

3

4

5

6

Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11month

Community rehabilitation/stroke staff are well placed to screen for psychological issues after stroke in the

community.

With support and training they are able to provide low level support for psychological issues as an integrated part of

holistic care, referring those with persistent or more significant levels of distress to specialist primary mental

health and clinical neuropsychology services.

It was decided to roll the project out across Dorset!

Following evaluation it was concluded…

Issues and sustainability

Issue Action

Data Collection • Forms redesigned• Seeking national advice – ongoing!

Need for refresher training • Now being provided!

People not seen by Communication Trained staff

• New pathway - to ensure happens.

Physical barriers to access • Looking into – home visits?

Including Carers? • Included in Pilot• Re ongoing practice – responsibility lies with social care. Carers assessments.• Possible to review in future?

Huge demands on community rehab teams

• Building relations / open communication• Make process as easy as possible.• Ongoing issue!

Progress since pilot. We will now look at….

• Communication Training

• Psychology Training

• Ongoing challenges & next steps

• 2 additional 3 day training courses

• 18 additional CMHT/IAPT staff

• Total now trained = 26

• Process to ensure stroke patients are seen by communication trained staff

• Reflective practice/refresher training – to be provided

Communication Training

Better Communication Training

Better Communication TrainingPre and Post Training Knowledge Scores

02468

1012141618

1 2 3 4 5 6 7 8 9 10 11 12 13

Individual trainees

Kn

ow

led

ge

sc

ore

s (

Ma

x

po

ss

ible

sc

ore

= 1

6)

Pre-Score Post-Score

Better Communication Training

Did the Communication Training meet your needs?Yes, completely 17 (94.5%)

Yes, partly 1 (5.5%)

No, not at all 0 (0.0%)

””Very good balance between “Theory based” and practical knowledge. I think the course enabled me to enhance my ability to communicate better with, and understand the difficulties faced by, people who have had a stroke.”

Better Communication Training

What was the most useful aspect of the training?72% specified meeting and talking to people with aphasia

“All of it! Understanding how a stroke affects a person mentally as well as physically. Meeting and talking to stroke patients”

“The conversations with the aphasic people. This exercise was very important – to experience these conversations and for my own confidence.”

• 3 training sessions in rollout area Jan-Mar 2012• 46 new rehabilitation/stroke staff trained. Including new

areas/stages of pathway• Total trained to date = 92• 1 more training session – April 2012. 13 staff signed up.• Total trainees by end April 2012 = 105• Refresher training April (for pilot) & Aug/Oct 2012 (for

recent training)

Psychology Training

0

1

2

3

4

5

6

7

8

9

Kn

ow

led

ge

sco

re (

Max

10)

1 2 3 4 5 6 7 8 9

9 different knowledge areas

Knowledge gained in 9 DIPSS Training Areas

Knowledge before training Knowledge gained

Knowledge Gained – top 5 areas

DIPSS Knowledge Area Knowledge Gained

What can be done to improve coping and well being after stroke

22%

Normal adjustment process after stroke 19%

Signs of anxiety and depression and how to screen using formal screening tools

17%

Simple strategies which can support services users who are distressed

17%

Situations when referral on for more formal or intensive input might be needed

16%

65%

16%

72%

13%

81%

9%

81%

9%

56%

19%

71%

13%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Ph

ysio

OT

SA

LT

Str

oke

Co

ord

ina

tor

Oth

er

Ove

rall

Self evaluated learning achieved by profession

Previous Knowledge Knowledge Gained

60%

20%

72%

14%

75%

12%

72%

9%

60%

21%

66%

16%

0%10%

20%30%40%

50%60%70%

80%90%

Phy

sio

OT

SA

LT

Str

oke

Coo

rdin

ator

Oth

er

Ove

rall

Self evaluated learning achieved by profession 2011 & 2012

Previous Knowledge Knowledge Gained

Distribution of DIPSS psychology trained staff

20112012

• Feedback from 18 people so far in rollout period

• 88% said a member of the stroke team had discussed how they were coping emotionally since they came home.

• Of these people:– 100% ‘Helpful’ or ‘Very Helpful”– 100% member of staff understood their concerns “A

great deal” or “quite a lot”

• 2 people didn’t discuss how they were coping emotionally - 1 would have liked to.

Qualitative Feedback

• I enjoyed our chat and I felt quite reassured to be told I appeared to be coping well with my disability.

• Comforted• Relieved to have someone to discuss my

problems with• Very pleased for their advice• I found it very reassuring to discuss my

problems• It was important to be asked about ones

emotions it helps towards coping• Relieved to have some support - someone who

understands what is happening

How people felt ….

Ongoing challenges & next stepsIssue Action

•Data Collection

•Physical barriers to accessing IAPT

•Capacity of rehab/stroke teams

• Ongoing issues!

• New screening tools • DISCS (Aphasia) & BASDEC (older people)

• Sustainability – training & funding • To be discussed

• IAPT/Talking Therapies going out to “Any Qualified Provider”

• Ensure AQP sign up to pathway

• Communicate referral changes to all staff

• Provision of Step 2 psychosocial interventions

• Explore possibilities for clinical supervision to enable additional Step 2 support

•Review new innovative ways of providing support e.g. i-pod apps, tele-support etc.

• Patient and Carer Feedback • Further work planned

• Roll out to all Long Term Conditions • Work has started

Frances AvissPatient and Public Involvement Lead

& Service Improvement ManagerDorset Cardiac and Stroke Network

Tel: 07736 245 266

e-mail: frances.aviss@bp-pct.nhs.uk

For further information…..