Early Supported Discharge (in the context of Stroke Rehabilitation
in the Community)
Gold Standard Framework
This document was produced with reference to national standards for best practice (e.g. NICE
guidelines), a consensus document on stroke (Fisher et. al, 2011) and local expert
opinion/benchmarking of ESD teams within Cheshire and Merseyside
Early supported discharge (ESD) teams should be commissioned as part of a whole pathway
commissioning approach (National Stroke Strategy, 2007)
Stroke
Rehabilitation
“People who have had strokes access high-quality rehabilitation and, with their
carer, receive support from stroke-skilled services as soon as possible after
they have a stroke, available in hospital, immediately after transfer from
hospital and for as long as they need it” Quality Marker 10, Stroke Strategy
PART 1 – Models of Service Delivery
Aim of Early
Supported
Discharge (ESD)
Team
An ESD team should, according to needs and preferences of individual
patients:
• Facilitate earliest possible safe discharge from hospital, (wherever
possible to the usual place of residence).
• Provide high quality, stroke specialist multi-disciplinary rehabilitation;
the initial frequency and intensity of therapy intervention must be at
least equivalent to what would be provided on a stroke unit and be
reduced gradually based on need. It should not result in a delay in
care.
• ESD is just one part of the patient pathway for a proportion (typically
about 40%) of stroke patients. Locally, consideration should be given
to how ESD fits within the entire pathway to ensure there is not a two
tier system at the expense of non-ESD patients and to ensure smooth
transition into longer term rehabilitation and support services.
• An integrated approach with Social Care is essential and a joined up
approach to commissioning may be needed to facilitate this.
Different models
of ESD
The models may vary depending on what is provided across the whole
pathway within a locality but all should provide the same level of quality.
In reach vs Outreach
Consideration of the local context and a whole pathway approach is key to
ensuring the highest quality of rehabilitation for all patients. Outreach teams
will need to work closely with community rehabilitation teams to ensure there
are no excessive gaps when referring on. In contrast, in reach/community
based teams should have a presence on the ward and be a key part of the
discharge planning in order to facilitate the meeting of quality standards e.g.
first contact within 24 hours of discharge, joint MDT care plan negotiated with
patient/carers within 72 hours of referral to ESD team etc
Referral Criteria
5 or 7 day service
All ESD teams should offer at least a limited service at weekends to enable safe
and timely discharge and respond to urgent needs. Therapy intervention at
weekends should be available based on patient choice and if it is clinically
appropriate. Analysis of capacity and demand should inform planning service
delivery over 7 days that meets the required quality standards.
ESD
• 18 years +
• Registered with a GP or residents (by postcode) within a defined area
• Clinical diagnosis of stroke (or subarachnoid haemorrhage if other suitable
services are not available)
• Under the care of a Stroke Consultant
• Medically stable
• Continence and nutrition plans in place and needs can be met
• Risk assessment indicates patient is safe to be at home (taking into
account home circumstances)
• The discharge destination is a suitable environment in which to carry out
rehabilitation
• The patient is able to engage in rehabilitation and progress towards goals
• Can transfer independently or with one person/have a barthel score
greater than 9 – for pure ESD provision. There is increasing evidence
within established ESD teams that more complex patients can also benefit
from ESD, e.g. those that transfer with two.
Where an ESD pathway is part of a broader community rehabilitation team or
accepts more complex patients as part of a whole pathway approach (different
referral criteria) this will have implications for team composition and skill mix.
Length of time can
access ESD
pathway
Non – ESD Pathway for patients outside of ESD criteria
There should be clear local guidance for pathways for non-ESD patients.
Recommended range= between 6 and 16 weeks depending on the longer term
rehabilitation and support services available.
The ESD pathway should be a core component of a stroke rehabilitation and
support pathway with access to stroke skilled staff for up to six months post
stroke depending on need.
Patients eligible for an ESD pathway will typically require the high intensity of
input for up to 6 weeks. For patients that require further stroke specialist
rehabilitation at a reduced intensity (including non-ESD patients) there should
be appropriate pathways in place.
e.g. ESD and non-ESD pathways provided by the same team (often community
based)
Managed transition from an ESD team (often outreach) to a community
stroke or neuro team
To ensure flow through these pathways it is important to for stroke
rehabilitation teams to have clarity on other support services post the stroke
specialist rehabilitation period (e.g. emotional support, life after stroke
programmes, cardiac rehab etc.) including those provided by CCG funded
voluntary sector providers. Opportunities to work in collaboration with these
services and the voluntary workforce (e.g. carers, expert patients, volunteers)
should be explored locally to ensure an integrated whole pathway approach
A gold standard ESD team will work closely with acute staff and community
teams and support services to ensure flow of patients along the entire
pathway. Commissioners may need to consider how to address any blocks in
the pathway or consider options for continued rehabilitation post ESD when
required, potentially through a whole pathway approach.
Part 2 – Workforce and Skill Mix
Early supported discharge teams should:
• Be multi-disciplinary
• As a minimum should include dedicated physiotherapy, occupational
therapy, speech and language therapy and access to psychological
support in line with the sentinel stroke national audit
programme/NICE guidelines
• Have specialist knowledge in stroke care and rehabilitation
• Be organised by a team coordinator – a Band 7 AHP with at least 5
years experience in neuro/stroke. Additional sessions should be
allocated for this to ensure there is no negative impact on face to face
time within one therapy discipline.
For a 100 patient per year caseload (note – these figures were based on
providing a 5 day service and would need adjusting to provide a 7 day service):
• 1.0 Physiotherapist (dedicated)
• 1.0 Occupational Therapist (dedicated)
• 0.5 Speech and Language Therapist (dedicated)
• 0-0.5 Social Worker (consideration will need to be given to how to
achieve an integrated model if there is not dedicated social worker
time into the team)
• 0-1.2 Nurse (more nursing input will be required for teams where
increasingly complex patients are discharged earlier and supported by
the team)
• 0.1 Physician (teams that have this typically use the time to contribute
to an MDT meeting)
• 0.25 assistant (though many teams make greater use of assistant roles)
• Access to Psychological support
• Access to dietetics
Based on a consensus (Fisher et. al., 2011)
Improvements in access to psychological support by ESD patients need to be
demonstrated over time in line with the national drive to improve access to
psychological support.
Skill Mix:
•
•
•
Services can be flexible and use judgement in the use of skill mix to
ensure a high level of specialist knowledge and skills and adequate
support for the range of grades within the team, e .g. assistant
practitioners taking on extended roles where there is support available
from qualified staff with specialist skills and experience, band 5 staff
working jointly with a senior clinician until a level of competency is
attained.
There are opportunities with the possibility of collaboration between
stroke services and whole pathway, outcome based commissioning to
think innovatively about these workforce issues, e.g. having an
expert/consultant therapist across a larger geographical patch to focus
on quality and improvement, ensuring a range of posts at different
bands across the team, flexing staff across integrated pathways,
coordinated approaches to recruiting and developing new graduates,
e.g. rotational posts, maximising the skills of assistant practitioners.
Managers and commissioners should consider local geography and
travelling distances and costs when agreeing staffing levels.
Part 3 – Measuring quality, performance and outcomes
A gold standard ESD team should:
• Have agreed local processes for collection of performance data
Measurement
• Will be registered with the Sentinel Stroke National Audit Programme
and
(SSNAP) and input all required fields to SSNAP on a regular basis
Improvement
• Will own their own performance data and will work with senior
managers and commissioners locally to drive improvements
• Have a service improvement plan in place which addresses workforce,
recruitment and retention issues; staff training and development;
improvements in data collection and reporting, and quality of clinical
care against NICE guidelines.
• Audits itself against the NICE stroke rehabilitation guidelines and
incorporates into service improvement plan to be shared with
commissioners as required
• Evidence that the service has contributed to work with all stakeholders
to look at financial sustainability of all services across the whole stroke
pathway, including consideration of unbundling of the stroke tariff
Quality of care
and patient
experience
Quality Indicator
Measure
Measures collected through SSNAP
can be looked at by Trust and CCG
Submit data on all relevant measures
and receive quarterly reports
Local arrangements should be in place
to ensure seamless transfer of care,
e.g. joint discharge visits, joint
discharge planning meetings
Agreed process developed jointly
(ESD team(s) and acute team), 100%
of transfers of care in line with local
process
Joint health and social care plan
100% of patients with a personal copy
developed jointly with families that
supports seamless transfer from
hospital (need a clear and regionally
agreed and understood definition of
this to ensure relevance to patients
with different needs)
of a joint health and social care plan
developed in collaboration with
patients, carers and families
Ensure patients are safe for discharge,
e.g. equipment in place, training of
carers completed, appropriate
nutrition/continence plans in place
Exception reporting of readmissions
or incidents relating to unsafe
discharge
Local arrangements in place to ensure
integration with social care for those
that need it
Potential measures: reduction in total
number of visits from ESD and social
care due to shared planning,
exception reporting of delayed
discharge due to delays in social care
packages
All patients eligible for ESD are able
to access it (typically around 40%
depending on case mix)
Report % and exception reporting of
where patients are unable to access
ESD
Visit at home within 24 hours of
discharge by a relevant member of
the specialist stroke rehabilitation
team for assessment of patientidentified needs and the development
of shared management plans
Shared responsibility with the acute
service to reduce or (for established
ESD teams) maintain a low level of
length of stay
100% patients have rehabilitation
goals jointly agreed with patient/carer
within 72hours of discharge - the
patient and their family/carers should
receive a copy of the goals which is
appropriately formatted for their
individual needs.
Provide 45 minutes of therapy from
each relevant stroke rehabilitation
therapy (physiotherapy, occupational
therapy and speech and language
therapy) for a minimum of 5 days per
Report on % achieved
Exception reporting of delayed
discharge due to capacity of ESD team
Report on % achieved
Measured by % of patients receiving
45 mins of each therapy, 5 days a
week for first 2 weeks post discharge
week to people who have the ability
to participate, and where functional
goals can be achieved. Intensity to be
reduced gradually with a planned
transition to longer term
rehabilitation and support services.
Outcomes
Mood screen completed within 6
weeks if not completed as an
inpatient
Report on % achieved
Increasing levels of access to
psychological support when needed
Referral rates and/or waiting times
Patient experience measures agreed
with local commissioners via a survey
of all patients
100% patients receive a survey.
To include questions about:
• level of satisfaction with their
involvement in the
development of the joint
health and social care plan
• % of patients that report
receiving a copy of this plan
• Carer satisfaction with
support and training prior to
and during discharge
•
•
•
Key markers of
quality longer term
rehabilitation (ESD
or broader
community
stroke/community
neuro rehab
teams) - %
increases from
baseline targets to
be defined
•
•
•
•
Collect the nationally agreed outcome measures and submit these via
the SSNAP audit (where possible this should the primary method for
measuring outcomes used by commissioners)
100% of patients should have a record of outcome measures within
one week of arrival to the team that can be reviewed within an agreed
timeframe. Changes over time to be reported.
Will have own local processes for measuring and reporting on
outcomes agreed with commissioners as appropriate that include
- Patient centred scale
- Functional outcome measure
- Patient satisfaction
- Mood screen
Reduce dependency and enable patients to self-manage, e.g. by
working in collaboration with third sector organisations
Increasing number of patients able to access psychological support
Increasing number of patients able to access return to work support if
appropriate
A joined up whole pathway approach to reviews at 6weeks, 6 months
and 12 months post stroke
There should be the flexibility for re-referral into stroke specialist
rehabilitation services where it is clinically appropriate e.g. botox
therapy for spasticity – re-referral rates to be reported to
commissioners to identify gaps
Contributors
A task and finish group produced the document at an initial meeting which was reviewed at a
follow up meeting. The document was shared for wider consultation via a stroke therapist
network meeting along with a group of patients/carers, a representative from the Stroke
Association and a commissioner.
Name
Jenny Ryan
Ruth Witham
Jane Hogan
Denise Coughlin
Tony Probbing
Michelle Keay
Jennifer Currie
Stella Dynes
Marie Florian
Claire Hammill
Role
Stroke Specialist Occupational Therapist,
ESD, Wirral University Teaching Hospital
NHS Trust
Chair, C&M Stroke Therapist group
Clinical specialist physiotherapist in
Stroke, ESD, Warrington & Halton
Hospitals NHS Trust
Stroke Specialist Occupational Therapist,
ESD, Aintree University Hospitals Trust
Stroke Specialist Occupational Therapist,
ESD, St Helens and Knowsley NHS
Teaching Hospital NHS Trust
Therapy Manager, Wirral University
Teaching Hospital NHS Trust
Senior Dietitian, Gerontology and Stroke,
Royal Liverpool and Broadgreen
University Teaching Hospital NHS Trust
Physiotherapy Team Lead (ESD), Royal
Liverpool and Broadgreen University
Teaching Hospital NHS Trust
Stroke Specialist Occupational Therapist,
Liverpool Heart and Chest Hospital
Quality Improvement Lead, CMSCN
Involvement
2 meetings and
comments
2 meetings and
comments
2 meetings
2 meetings
1 meeting
1 meeting
1 meeting
1 meeting
1 meeting
2 meetings
References
Department of Health (2007) National Stroke Strategy. CQC.
Fisher, J. et. al. (2011) A Consensus on Stroke: Early Supported Discharge. Stroke
(p1392-1397)
National Institute for Health and Care Excellence (2013) Stroke Rehabilitation: Long term
Rehabilitation after Stroke. NICE.