The integrated pathway of care for people with stroke in

Torbay & Southern Devon

Rhoda Allison

March 2014

Stroke rehabilitation in Babylonia 1600 BC

(Reynolds & Kinnier Wilson, 2004)

Massage Hot poultices (flax seed, barley,

beer, tamarisk) Incantations Quite a lot of bandaging

‘If when he tries to bend or stretch out he howls with pain and saliva flows from his mouth an animal spirit has possessed him’

Stroke care in the 21st century

Acute care and thrombolysis Start rehabilitation early Emphasis on increasing the intensity of functional practice Early supported discharge schemes Recommendations about life after stroke Management of long term disability

Self management Health and social care checks Access to further rehabilitation if there are goals

Typical stroke pathway of care

Acute stroke

unitStroke rehab unit

Social Care

services

GP provides medical

care

Work and

leisure

Voluntary sector

Health and social care

reviews

ESD or community

team

What is integrated care?

Torbay & Southern Devon model of Mrs Smith (and her son Robert)

‘Seamless care’

No barriers between health and social care services

Joint health and social care teams aligned to GP practices- people only tell their story once, staff all in the same office using shared information

Pooled budgets

Close relationships with voluntary sector

No barriers between the acute hospital and community services

Tracy’s story

Tracy is a 44 year old woman She lived in a flat on her own, relatively close to her parents

and worked in Torquay as an administrator She sustained a severe left sided stroke in June 2011 This caused:

Complete paralysis of the right side of her body Communication disability- difficulty receiving information

and expressing herself Reduced swallowing This all had a huge emotional impact

Tracy’s pathway

Acute stroke

unit

Stroke rehab unit

Home to live with her parents

Stroke Association

Hub

Community team, social

care, GP

Peer Support

Swimming twice each

week

Enabler for social

inclusion

Respite services

Stroke rehab unit

Longer term plans

Community team, social

care, GP

Long term needs are incredibly complex

Stroke is the leading cause of disability in the western world

Not all young people are able to return to work

Carers provide so much support but also have their own needs

All agencies involved need to link together

How is technology helping?

Electronic discharge summaries Infoflex

Joint records (up to a point) PARIS, Windip

Entire community shares access to imaging, lab results and clinical guidelines; PACS, Cyberlab

Web based resources, education, TV Hiblio

Staff diaries managed on Outlook with smart phones- co-ordinated visits

What more could we do?

Support integration further Electronic notes!!!!

Use technology to enable staff to be more efficient: Collecting data Arranging appointments

Use technology to maximise rehabilitation opportunities- it’s all about practise:

‘I’m such a good lover because I practise such a lot on my own’

Woody Allen