Cheshire and Merseyside Cardiac and Stroke Networks Stroke Work Programme April 2011 March 2012

Transcription

1 Cheshire and Merseyside Cardiac and Stroke Networks Stroke Work Programme April 2011 March 2012 Working to improve the delivery of services for cardiac and stroke patients and their families.

2 Work Programme Context The Cheshire and Merseyside Stroke Network was formed in 2008 and works with all organisations in primary, secondary and tertiary care to encourage cooperation between those providing care for stroke patients and to ensure equitable access to services. It is now part of a larger Clinical Networks Team that covers Cancer, Stroke, Cardiac, Kidney, Neo-natal, Neurosciences, Critical Care and End of Life in Cheshire and Merseyside. The Network includes and works closely with patients, carers, health professionals, health managers, social care professionals and voluntary organisations to help achieve the targets set out in the National Stroke Strategy and the National Stroke Improvement Programme, along with regional and local quality indicators for stroke care. In doing so, the Stroke Network strives to reduce the incidence of stroke within Cheshire and Merseyside and to improve quality of care and outcomes for those who suffer a stroke, their carers and families. The Network covers a population of 2.3 million people and encompasses 8 Primary Care Trusts organised into 2 Clusters, 1 Strategic Health Authority, 9 Hospital Trusts, 2 Tertiary Centres, 15 Commissioning Consortia and a number of voluntary organisations. This work programme reflects national, regional and local priorities for the year 2011/2012 and received final approval from the Stroke Network Board in September There are 12 workstreams covering the whole spectrum of the stroke care pathway. The Stroke Network Support Team are responsible for ensuring that each workstream achieves its outcomes and progress against the Stroke Work Programme will be regularly by the Stroke Network Board. The Work Programme is consistent with the Quality, Innovation, Productivity and Prevention (QIPP) and the World Class Commissioning agendas, the NHS Operating Framework ( ) and the aims outlined in the NHS : from good to great command paper. Contact: Alastair Houghton, Stroke Programme Lead Merseyside and Cheshire Clinical Networks: a) Victoria House, 490 Knutsford Road, Warrington WA4 1DX Cheshire (Until October 2011) b) Suite 4 Woodcourt Riverside Park Southwood Road Bromborough Wirral CH62 3QX (From November 2011) alastair.houghton@cmcn.nhs.uk website: 2

3 Contents Workstream: Data... 4 Workstream: Preventing Stroke... 7 Workstream: TIA Workstream: Hyper-Acute Workstream: Direct Admission to an Acute Stroke Unit Workstream: Brain Imaging Workstream: Acute Stroke Workstream: Early Supported Discharge Workstream: Improving Access to Psychological Support after Stroke Workstream: Social Care Workstream: Assessment and Review Workstream: Communication Access Champion Training

4 Workstream: Data Owner: Jeanette Davies Date: 01/07/2011 Goal To provide consistent, timely and relevant data to support the strategic and operational activities of the stakeholders within the Network, North West Region and Nationally Drivers ASI Measures National Stroke Strategy NICE Clinical Guidelines for Stroke and associated long term conditions NICE Stroke Quality Standard DoH Stroke Vital Signs RCP SINAP RCP Regional AQ/CQINS Objectives To develop a comprehensive Stroke Network Data Management System (Reflecting the stroke pathway from consortium to community) To develop a consistent approach to the collection of data To meet the varied data needs of our national regional and local stakeholders through improved capability of reporting in a timely manner To ensure that Data is fit for purpose To support the development of a centralised data management team covering all networks to create more global working practices and outcomes Gather and present stroke data in the form of regular formal reports for the various network forums Activities Benchmark and review existing data streams in all health communities Identify barriers to data collection and accessibility Work with local economies to develop action plans to improve data collection and usage 4

5 Create a Data Strategic Development paper for implementation across all local economies Identify data streams and develop systems to collect data that has been traditionally inaccessible Regular reporting against national/regional data requirements Deliverables May September Benchmark and review of data June March Development of local economy action plans Developing system for reporting data in conjunction with our stakeholders May March Developing system for reporting data in areas which have been traditionally inaccessible Developing timely and accurate for our stakeholders at National, regional and local Review and refine systems Measures Meeting the requirements of national reporting Meeting mandated national performance measures Progress towards a comprehensive data management structure Progress to a consistent approach to data collection Regular reporting structure to pathway stakeholders A process for review of data and systems going forward 5

6 Financial Outcomes Improved reporting system that highlights areas of need or improvement Allows for a cost benefit analysis of the Stroke Pathway Enables all Stroke pathway stakeholder to make informed decisions Enables Commissioners to make more informed decisions Provides information to those who may wish to provide services to the Stroke Pathway Measure and demonstrate outcomes Identify patterns and good practice of collaborative care across the whole stroke pathway 6

7 Workstream: Preventing Stroke Owner: Anna Monaghan Date: 01/ Goal To identify and improve care of people with Atrial Fibrillation in Primary Care and Secondary Drivers National Stroke Strategy (2007) Accelerating Stroke Improvement Programme Quality Outcomes Framework Objectives To educate colleagues within Primary Care about Atrial Fibrillation, its detection, diagnosis, associated risks including Stroke and optimal treatment Activities Contact local PCT s to ascertain level of interest in AF training Building on the success of last year s pilot event, continue to engage with key partners regarding sponsorship and event coordination. Coordinate and deliver AF in Stroke Prevention Educational events in selected PCTs. Support where appropriate implementation and running of GRASP-AF Obtain data from AF registers pre and post education event Evaluate feedback from training sessions Evaluation of Public Health data relating to incidence of Stroke Deliverables May - June Contact local PCT s to ascertain level of interest in AF training May to March - Liaise with key partners re: sponsorship and event coordination 7

8 May to March - Coordinate and deliver AF in Stroke Prevention Educational events within selected PCTs. May to March - Support where appropriate implementation and running of GRASP-AF May to March - Obtain data from AF registers pre and post education event As appropriate throughout year Evaluate feedback from training sessions Prior to events and March 2012 Evaluation of Public Health data relating to incidence of Stroke Measures Feedback questionnaires following training sessions Quantitative data relating to number of people trained, their profession and health economy Public Health data: Relating to detection of AF within primary care and its appropriate treatment. Interrogation of GP AF registers: using GRASP- AF or other to determine whether there has been an increase in the number of high risk patients on anticoagulation. The National Stroke Strategy Quality Markers: QM2: Managing Risk - Those at risk of stroke and those who have had a stroke are assessed for and given information about risk factors and lifestyle management issues and are advised and supported in possible strategies to modify their lifestyle and risk factors. Risk factors are managed according to clinical guidelines, and appropriate action is taken to reduce overall vascular risk. QM18: Leadership and skills - All people with stroke, and at risk of stroke, receive care from staff with the skills, competence and experience appropriate to meet their needs. 8

9 QM19: Workforce Review and Development - Commissioners and employers undertake a review of the current workforce and develop a plan supporting development and training to create a stroke-skilled workforce. Accelerating Stroke Improvement Metric 1: Preventable Strokes - 60% of patients presenting with stroke with new or previously diagnosed atrial fibrillation will be on anticoagulation or have a plan for anticoagulation in the medical notes or discharge letter. Denominator- The number of patients discharged from hospital after an admission with a confirmed new stroke and with atrial fibrillation. Include patients admitted with diagnosis of stroke and new or previously diagnosed atrial fibrillation Include patients who have a new stroke whilst in hospital, who may have been admitted with a different primary diagnosis Include patients with intra-cerebral haemorrhage Exclude patients with TIA Exclude deceased patients Exclude patients who are admitted with a different diagnosis, with pre-existing stroke Numerator- The number of patients in the denominator, who were also discharged on anticoagulation, or who had a plan to commence anti-coagulation clearly stated in the discharge letter or medical notes. Quality & Outcomes Framework - Atrial fibrillation Management AF 1, 3 and 4: The practice can produce a register of patients with atrial fibrillation. The percentage of patients with atrial fibrillation diagnosed after 1 April 2008 with electrocardiogram (ECG) or specialist confirmed diagnosis. The percentage of patients with atrial fibrillation who are currently treated with anticoagulation drug therapy or antiplatelet therapy. 9

10 Financial Outcomes The annual cost to the NHS and PSS of strokes attributable to AF is estimated to be 148 million. The cost per stroke is estimated at 11,900 in the first year after stroke occurrence. It is estimated that 5,000 to 8,000 strokes a year could be averted by conforming to NICE guidelines on the prescribing of anticoagulants for AF. The cost of each stroke averted is estimated at 10,000 to 14,000 per annum. 10

11 Workstream: TIA Owner: Alastair Houghton Date: 01/07/2011 Goal To ensure that all patients suspected of having a TIA receive timely and appropriate treatment Drivers National Stroke Strategy, 2007 o QM2: Managing risk o QM5: Assessment referral to a specialist o QM6: Treatment Implementing the National Stroke Strategy: An Imaging Guide, 2008 RCP National Clinical Guidelines for Stroke, 2008 NICE Clinical Guideline 68, 2008: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) National Accelerated Stroke Indicators, ASI 5; Management of high risk TIA NICE Quality Standard: QS1 TIA Vital Sign - Line 2007: Number of people who have a Transient Ischaemic Attack (TIA) who are at higher risk of stroke Objectives Ensure that Health Care Professionals/GP s are able to recognise the symptoms of TIA Ensure that all patients suspected of having a TIA receive timely treatment and referral in line with national standards and guidelines Increase in the proportions of patients appropriately referred and treated within the target timescales for high risk and low risk TIA s Support all local economies to ensure that the TIA Vital Sign requirement for all high risk patients is achieved Ensure that TIA referral and treatment data is collected in a consistent manner across the Network 11

12 Activities Benchmarking against national standards and guidance in both primary and secondary care Providing Information and Education (Tailored approach for each health sector) Ensure that TIA is an agenda item at all appropriate meetings Develop processes to accurately measure referrals within primary and secondary care Develop a feedback mechanism to review and feedback progress to key stakeholders in this area Deliverables April - October Map & Benchmark local economies against national standards and guidance Develop processes for ongoing measurement and review October - November Develop Work-Stream Project Plan and Strategic Discussion Paper September December Meetings with key stakeholders and attending appropriate Network meetings December March Implementation of TIA workstream Feedback Information to stakeholders Measures Proportion of high risk TIA patients investigated and treated within 24 hours of first contact with a health professional 60% by April DH Vital Sign Proportion of all TIA patients investigated and treated within 7 days of first contact with a health professional 100%: National Stroke Strategy: QM5 12

13 Financial Outcomes Reduced incidence of stroke secondary to TIA Reduced costs associated with treatment of stroke in secondary and primary care Reduced socio-economic impact of stroke Cost benefit of return to work for patient and/or carer 13

14 Workstream: Hyper-Acute Owner: Jan Vaughan Date: 01/07/2011 Goal To ensure that all patients receive access to high quality 24/7 Hyper-Acute Services Drivers National Stroke Strategy Accelerated Stroke Indicators The National Institute for Clinical Excellence (NICE) Clinical Guideline CG 68 - Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack (2008). Objectives Improve patient outcomes maximized access to acute stroke services within 4.5 hours of symptom onset; maximised linkage to ongoing care services; both impacting on death, disability and dependency resulting from acute stroke; Meet clinical standards NICE guidance, RCP Guidelines, National Stroke Strategy Quality Markers of Service 7, 8, 9 and 18 Improve economic outcomes - reduce hospital bed days; reduce specialist rehabilitation costs; reduce longer term informal care costs down stream (e.g. the costs of nursing and mental health service costs borne by patients and families) and income lost to productivity and disability. Activities 24/7 Services already running in 4 trusts and in hours service in all but one trust. Engage with Warrington Hospital and Whiston Hospital to ensure that service is established in given time frame Liaise with NWAS to ensure the service can be rolled out Work with Macclesfield District General Hospital and Leighton Hospital to develop a telemedicine solution 14

15 Deliverables May June Follow up on all 4 hospital trusts who have not implemented a 24/7 service June July Whiston Hospital to go live. Contact Trusts for updates and any assistance required. May June Contact Leighton Hospital and Macclesfield District General Hospital to arrange visit to Countess of Chester Hospital May - March Bi monthly meetings with both trusts to ensure progress Measures Quality Markers QM7 Urgent Response: People with suspected acute stroke should be immediately transferred by ambulance to a hospital with a hyper-acute stroke service; delivering stroke triage, expert assessment, timely imaging and intravenous thrombolysis throughout the 24-hour period. QM8 Assessment: People with suspected stroke should have a structured clinical assessment by people with the right knowledge and skills. Patients requiring urgent imaging should be scanned in the next slot (in hours 9am to 5pm weekdays) and within 60 minutes out of hours. Skilled radiological and clinical interpretation should be available throughout the 24-hour period. Those with stroke should have early MDT assessment, including swallow screening within 24 hours. QM9 Treatment: People with stroke should have prompt access to an acute stroke unit; rapid access to brain imaging and expert interpretation and opinion of a consultant stroke specialist; 24 hour access to thrombolysis; intensive monitoring by nurses with the right knowledge and skills; and be managed by clinicians able to address respiratory, swallowing, dietary and communication issues. QM18 Workforce and leadership skills : All patients who have had a stroke should receive care from staff with skills, competencies and experience appropriate to their needs. 15

16 Local Network Measure: Proportion of patients treated (Thrombolysed) within 4.5 hours of arrival at hospital. *The actual Door-to-Needle time should be recorded in minutes. Financial Outcomes Improve economic outcomes through less disability leading to improved independence Reduced bed days Reduced specialist rehabilitation costs Reduction in longer-term informal care costs e.g. mental health and nursing costs borne by patients and families. Cost benefit of return to work for patient and carer Cost benefit of reduced package of care 16

17 Workstream: Direct Admission to an Acute Stroke Unit Owner: Alastair Houghton Date: 01/07/2011 Goal To ensure that all patients presenting with acute stroke within Cheshire and Merseyside are admitted to an acute stroke unit within 4 hours of arrival Drivers National Stroke Strategy, 2007 o QM8: Assessment o QM9: Treatment RCP National Clinical Guidelines for Stroke, 2008 NICE Clinical Guideline 68, 2008: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) NICE Quality Standard Quality Statement 3 National Accelerated Stroke Indicators, ASI 2; Direct admission to a stroke unit Objectives Ensure that all that all Acute Trusts have a system in place to identify and admit patients with acute stroke to an Acute Stroke Unit (ASU) Ensure consistency of approach across the Network in measuring Direct Admission to an ASU Activities Benchmarking processes Review data collection methods Identify barriers to meeting the 4 hour indicator Work with stroke teams to develop an action plan to deliver the required outcome Deliverables April October Benchmark current performance and data processes for all Acute Trusts October March Create a work plan for each local economy to deliver the required outcomes 17

18 Measures Proportion of patients admitted directly to an acute stroke unit within four hours of hospital arrival 90% of patients with confirmed stroke will be admitted to a stroke unit within four hours of arrival at hospital Financial Outcomes Reduced mortality and morbidity Reduced healthcare costs due to early intervention and optimised treatment Reduced hospital length of stay Reduced readmission to hospital following discharge Reduced dependency on health and social care services Reduced admission to institutional care Cost benefit of return to work for patient and/or carer 18

19 Workstream: Brain Imaging Owner: Alastair Houghton Date: 01/07/2011 Goal To ensure that all eligible patients within Cheshire and Merseyside have access to timely and appropriate brain imaging Drivers National Stroke Strategy, 2007 o QM5: Assessment referral to specialist o QM7: Urgent Response o QM8: Assessment o QM9: Treatment Implementing the National Stroke Strategy: An Imaging Guide, 2008 RCP National Clinical Guidelines for Stroke, 2008 NICE Clinical Guideline 68, 2008: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) NICE Quality Standard for Stroke Quality Statements 2 & 3. National Accelerated Stroke Indicators, ASI 4a & 4b; Access to brain imaging Objectives Ensure that all patients with suspected stroke have access to timely and appropriate brain imaging Ensure that all patients who undergo brain imaging have access to timely and appropriate diagnostic expertise Ensure that there is consistency in data collection and reporting for Brain Imaging across all Acute Trusts in the Network Activities Benchmark existing services against national standards and indicators Review data collection methods Identify barriers to meeting the 50% of patient scanned within 1 hour and 100% of patients scanned within 24 hours indicators respectively Work with selected stroke teams to develop an action plan to deliver the required outcomes 19

20 Deliverables April October Benchmark current performance and data processes for all Acute Trusts October March Create a work plan for selected local economies to deliver the required outcomes Measures ASI 4a; proportion of stroke patients scanned within one hour of hospital arrival o 50% of all patients with confirmed stroke will have a scan within an hour after arrival hospital ASI 4b; proportion of stroke patients scanned within 24 hours of hospital arrival o 100% of patients with a confirmed stroke will be scanned within 24 hours of arrival at hospital Financial Outcomes Reduced mortality and morbidity Reduced healthcare costs due to early intervention and optimised treatment Reduced hospital length of stay Reduced readmission to hospital following discharge Reduced dependency on health and social care services Reduced admission to institutional care Cost benefit of return to work for patient and/or carer 20

21 Workstream: Acute Stroke Owner: Alastair Houghton Date: 01/07/2011 Goal To ensure that all patients presenting with acute stroke within Cheshire and Merseyside spend 90% of their time on an Acute Stroke Unit Drivers National Stroke Strategy, 2007 o QM9: Treatment RCP National Clinical Guidelines for Stroke, 2008 NICE Clinical Guideline 68, 2008: Diagnosis and initial management of acute stroke and transient ischaemic attack (TIA) NICE Quality Standard Quality Statements 5 & 6 National Accelerated Stroke Indicators, ASI 2; Direct admission to a stroke unit and ASI 3; Acute Stroke Care Stroke Vital Sign Line 2004: Patients who spend at least 90% of their time on a stroke unit Objectives Ensure that all that all Acute Trusts provide appropriate care in the appropriate environment for patients admitted with acute stroke Ensure consistency of approach across the Network in measuring the proportion of time that patients spend on an Acute Stroke Unit Support all trusts in achieving and sustaining stroke services Activities Benchmark processes Review data collection methods Identify barriers to meeting the 90% stay on an ASU indicator Work with stroke teams to develop an action plan to deliver the required outcome 21

22 Deliverables April October Benchmark current performance and data processes for all Acute Trusts October March Create a work plan for each local economy to deliver the required outcomes Measures Proportion of patients spending 90% of their time on an acute stroke unit 80% by April DH Vital Sign Financial Outcomes Reduced mortality and morbidity Reduced healthcare costs due to early intervention and optimised treatment Reduced hospital length of stay Reduced readmission to hospital following discharge Reduced dependency on health and social care services Reduced admission to institutional care Cost benefit of return to work for patient and/or carer 22

23 Workstream: Early Supported Discharge Owner: Stephen Tilley/Louise Vernon Date: 01/07/2011 Goal To ensure that 40% of all eligible patients with confirmed stroke within Cheshire and Merseyside are supported to leave hospital by the availability of an Early Supported Discharge service Drivers National Stroke Strategy 2007 o QM10: High-quality specialist rehabilitation o QM12: Seamless transfer of care National Clinical Guideline for Stroke, Royal College of Physicians, 2008 National Accelerating Stroke Improvement Indicators ASI 9; Access to and availability of ESD services Objectives To ensure that there is an ESD service in every local economy or where this is not viable, an appropriate intermediate care service is in place To work towards an equitable system of delivery for ESD for all patients in the Stroke Network in line with national standards Activities Early Supported Discharge services are already established in 4 local economies with firm plans to establish ESD services in place in another 2. One local economy is considering its position as local demographics do not support establishing an ESD service and a further 2 business cases are currently being considered. Benchmarking existing services against national standards and indicators Working with local economies to justify and implement local ESD programmes Helping review and develop existing ESD programmes Sharing best practice of local and national ESD programmes within the Network Ensuring that ESD referral and treatment data is collected in a consistent manner across the Network 23

24 Deliverables April - July Support and reviewing the 4 services already established Share existing models and good practice with potential ESD service commissioners/developers July October Instigate 2 nd phase of ESD service development; i.e., those services currently in plan Agree time scales for establishing remaining ESD services (3 rd phase) November March Implement 3 rd phase of ESD service development Determine model of alternate provision in local economies not intending to establish ESD services Measures a) Presence/absence of a stroke skilled Early Supported Discharge Team (Yes/No) b) If yes, proportion of patients supported by a stroke skilled Early Supported Discharge Team: a. ASI target: 40% of patients with confirmed stroke will be supported to leave hospital by an early supported discharge team Financial Outcomes Reduced hospital length of stay Reduced readmission to hospital following discharge Reduced long-term dependency on health and social care services Reduced admission to institutional care Cost benefit of return to work for patient and/or carer 24

25 Workstream: Improving Access to Psychological Support after Stroke Owner: Jack Smith Date: 01/07/2011 Goal To meet the unmet need for the provision of timely and competent psychological support to people post-stroke Drivers National Stroke Strategy QM10 and 13 National Audit Office Report 2010 Care Quality Commission Review of Stroke Services 2011 Accelerated Stroke Improvement Metric 6: NICE Quality Standards for Stroke RCP National Clinical Guidelines 2008 NICE Clinical Guideline 91 British Psychological Society briefing paper Psychological Services for stroke survivors and their families. Other Improving access to psychological therapies (IAPT) Briefing Paper The Operating Framework (2011/12) Objectives Set the agenda and involve the relevant stakeholders as it evolves. Define the strategy to inform future budget holders and service providers of a Stepped Care model of care integrating Secondary and Primary care, and potentially the Third sector. Facilitate and support local economies to re-design, upskill existing workforce or develop new services that are evidence based, safe and value for money. Increase the proportion of people receiving NICE approved psychological assessment and interventions post-stroke in secondary care, primary care and community settings. Facilitate and Support accurate and timely reporting of clinical, patient and financial outcome data. 25

26 Activities Research best practice Map and benchmark psychological support in local economies Develop a work-stream project plan Facilitate and support the development of a Clinical Consensus group Facilitate and support the development of a standardised data recording and outcome management system Support the development of a Workforce Competency Framework Facilitate and Support the development of a formal Impact Assessment (Cost Benefits analysis) Facilitate and Support local Stroke Strategy Groups to develop business cases for improved service provision: Facilitate and support the phased implementation of the above Deliverables March - June Map & Benchmark local economies against standards and guidance. Set the agenda collaboratively. Develop Work-Stream Project Plan and Strategic Discussion Paper. May Present Psychology Work-Stream Project Plan and Strategic Discussion Paper to the Board for comment June Establish Clinical Consensus Group for Psychological Support Post-Stroke Assessment Tools and Intervention, Outcomes Framework and Minimum Data Set Workforce competences Impact Assessment 26

27 June & July Circulate and Present endorsed Work-Stream Project Plan and Strategic Discussion Paper to local Stroke Strategy Groups (and use Network Website for added transparency Collate local stroke strategy group feedback). August Finalise: Outcomes Framework and Minimum Data Set Workforce competency framework Impact Assessment Overall Strategic Outline Case Present Strategic Outline Case to the Stroke Network Board for approval. Publicise approved Strategic Outline Case. Implementation and evaluation across all local economies Measures Denominator Number of patients with confirmed diagnosis of stroke. Numerator Number of patients who have been screened/assessed using a validated tool to recognise anxiety, depression and cognitive problems by a service capable of appropriately managing mood, behaviour or cognitive disturbance. Proportion of Patients screened for mood, behaviour or cognitive disturbance within 6 weeks of diagnosis. Proportion of Patients seen by a psychology service within 6 months of their stroke. Proportion of patients with improved clinical outcomes/patient experience / financial costing Financial Outcomes Reduced Emergency Re-admissions within 30 days Reduced LOS in hospital or rehab bed Cost benefit of return to work and carer maintaining work Cost benefit of reduced time off work Cost benefit of reduced or no package of care Locally enhanced services (secondary and primary care, third sector staff with increased competences). 27

28 Workstream: Social Care Owner: Stephen Tilley Date: 01/07/2011 Goal Drivers To maintain and improve the provision of Social Care in the stroke pathway with the ultimate goal being the development of a joint stroke care plan for all stroke patients Community Care Act 1990 Health and Social Care Act 2008 A Vision for Adult Social Care Putting People First Think Local Act Personal Law Commission on Social Care (Summer 2011) Commission on the Funding of Care and Support (Summer / Autumn 2011) Care and Support White Paper (Late 2011) Social Care Reform Bill (Spring / Summer 2012) National Stroke Strategy (2007) Accelerating Stroke Improvement Programme ASI7 Objectives To educate and map the existing Social Care pathways within the local economies To understand and assess the impact of proposed changes in Social Care legislation to existing and new pathways To encourage an equitable approach to Social Care provision across the local economies Identify data streams that can effectively measure the impact of these changes Engage with other providers Activities Map existing and planned future pathways for Social Care provision (initially in a selected number of pilot areas) To map the financial Cost of delivering social care and the implications on costs in other parts of the pathway Ensure that strategic decision makers are fully up to date with the proposed changes and implications of those changes in Social Care 28

29 Engage with key stakeholders in shaping and delivering any new Social Care strategy Ensure that Social Care is a standard item on all strategic and operational forums Ensure that Social Care professional are represented fully in strategic and operational forums To identify and share good practice internally from within CMSN region and from other regions outside of CMSN Deliverables May - July Phase 1 of a set of joint care pathways being defined with a selection of pilot economies Ensure that a representative from the Social Care Sector is a permanent member of the Stroke Board Social Care representation introduced on key stakeholder groups August - December Production of Social Care Pathway for Stroke Strategy Project Plan for CMSN to take forward for Board approval Agree Social Care involvement in all appropriate appropriate network meetings (agenda item and representation) Agree measurement parameters for ASI 7 target Phase 2 of a set of joint care pathways being defined with a selection of pilot economies January March Develop a standard Joint Care Plan for discharged patients for use across all local economies Quarterly report to key strategic decision makers which detail Social Care provision, performance and future issues 29

30 Measures Move towards providing a joint care plan for 85% of patients who are discharged from hospital The level of engagement at key stakeholders meetings, for Social Care professionals Social Care pathways defined in all economies Financial Outcomes Reduced hospital length of stay Reduced readmission to hospital following discharge Reduced bed days Reduced long-term dependency on health and social care services Reduced admission to institutional care Cost benefit of return to work for patient and/or carer Better utilisation of Stroke Consultant time Cost benefit of return to work and carer maintaining work. Cost benefit of reduced time off work 30

31 Workstream: Assessment and Review Owner: Anna Monaghan Date: 01/07/2011 Goal Drivers Objectives To ensure that stroke patients are reviewed six months after leaving hospital. Accelerating Stroke Improvement Programme National Stroke Strategy (2007) Royal College of Physicians (RCP) National Clinical Guideline for Stroke (2008) National Service Framework for Older People (2001) 95% of patients with confirmed stroke will be reviewed at six months after discharge from hospital. Activities Benchmarking - Number of people discharged from hospital with a confirmed stroke that are reviewed between five and seven months post discharge. Determine who is to conduct the reviews Agree a standardised form to ensure that every review in each area covers the same information Assess how each local economy can link the information from six week, six month and annual reviews Deliverables May - September Benchmarking October - December Ascertain who is to conduct reviews January - March Agree use of GM-SAT and create links with 6 weeks review March Implementation, Assessment and Review Measures Accelerating Stroke Improvement Programme - ASI 8: Assessment and review - 95% of patients with confirmed stroke will be reviewed at six months after discharge from hospital 31

32 Denominator Number of people discharged from hospital with a confirmed stroke, who are alive six months following discharge from hospital. Exclude patients who have died Exclude patients who decline the review or who do not attend an appointment offered Exclude patients who live out of the area Include all patients, regardless of place of residence (i.e. home, care home intermediate care) Numerator Number of patients in the denominator who were reviewed at six months post hospital discharge. National Stroke Strategy (2007) - Quality Marker 14: Assessment and Review - People who have had strokes and their carers, either living at home or in care homes, are offered a review from primary care services of their health and social care status and secondary prevention needs, typically within six weeks of discharge home or to care home and again before six months after leaving hospital. Further Support to Measures Royal College of Physicians (RCP) National Clinical Guideline for Stroke (2008) any patient with residual impairment after the end of initial rehabilitation should be offered a formal review at least every six months National Service Framework for Older People (2001) - Following a stroke, any patient reporting a significant disability at six months should be reassessed and offered further targeted rehabilitation if this can help them to recover further function. Financial Outcomes Reduced emergency readmissions Improving secondary prevention Cost benefit of return to work for patient and carer 32

33 Workstream: Communication Access Champion Training Owner: Anna Monaghan Date: 21 st June 2011 Goal To provide training and support to change communication, culture and involvement to make interactions and services more accessible to people living with stroke and communication disability Drivers National Stroke Strategy (2007) Objectives To support and equip staff to cascade communication access training to embed communication access in services to bring about improved access, involvement, service and culture change Activities Recruit delegates to participate within project Organise and coordinate 2 day training event in conjunction with Connect Arrange Follow up meeting with delegates Monitor cascade of training Provide support and encouragement to delegates participating in project Evaluation of project success Deliverables May Recruit delegates to participate within project Organise and coordinate 2 day training event in conjunction with Connect June Arrange Follow up meeting with delegates June - March Monitor cascade of training June - March Provide support and encouragement to delegates participating in project March Evaluation of project success 33

34 Measures National Stroke Strategy (2007) - Quality Markers: QM 3: Information, advice and support: QM 4: Involving individuals in developing services QM 13: Long term care and support QM 14: Assessment and review QM 15: Participating in community life QM 18: Leadership and skills QM 19: Workforce review and development Financial Benefits Reduced hospital length of stay Reduced readmission to hospital following discharge Reduced dependency on health and social care services Reduced healthcare costs due to early intervention and optimised treatment Improved economic outcomes through less disability leading to improved independence Cost benefit of return to work for patient and/or carer 34