Psychological care after stroke: A national update

1. Psychological care after stroke: A national update Dr Ian Kneebone Associate, NHS Improvement – Stroke http://www.improvement.nhs.uk/stroke/Psychologicalcareafterstroke/tabid/177/Default.aspx

2. ASI 6: Timely access to psychological support Proportion of patients who have received psychological support for mood, behaviour or cognitive disturbance by six months after stroke. Target: 40 % by April 2011

3. ASI 6 Psychological care within 6 months of stroke

4. National Update Multiple examples of good practice on the SI website: Evidence paper: Kneebone & Lincoln (2010) Stroke Improvement programme. Psychological support: State of knowledge.

5. National Update Specific guidance: Screening for emotional disorder Screening for cognitive deficits

6. Does the patient have a communication difficulty? Yes No Flow chart for people under 65 years Administer the DISCs Administer the HADS Scored 2 or more? Staff concerns? Score 9 or more on D scale? Yes invalid No Yes Yes No Administer SADQ H10 Administer suicide question from BASDEC 6 or more? No Yes Respond with true? Report to nurse in charge. Non-depressed range No Yes Suicide question from BASDEC Respond with true? Depressed range Report to nurse in charge No Yes Non-depressed range

7. Weeks 1-3 (or before discharge if <3weeks) OT to administer MOCA or ACE-R + Star Cancellation Informs team of results – rehab planning Week 4 Does patient have communication problems? Yes No OT to administer RCPM OT to administer RBANS Scores less than 19? What cognitive domains are affected? Informs team of results No Yes Assess cognitive problems further using functional assessment. Interfering with rehab? Week 6 onwards. Review. If impaired, discuss treatment options with psychologist Interfering with rehab? No No Yes Yes Review further assessment /treatment options with psychologist Review further assessment /treatment options with SALT and psychologist. 6 month review. Any cognitive problems reported? Yes No Is patient going back to work or do they have cognitively demanding lifestyle or responsibilities (e.g. childcare) Monitored by GP, refer for Stroke Association support etc Comprehensive neuropsychological assessment by clinical neuropsychologist No Yes

8. National Update Screening for emotional disorder 2006 55% (RCP 2007): 2012 88% (RCP 2013) Screening for cognitive deficits 2006 71% (RCP 2007) for whom it was applicable? 2012 81% (RCP 2013)

10. ASI 6 Psychological care within 6 months of stroke

11. From around the nation • Progress is better than that measured. • Many teams not yet submitting data, have undergone major service reorganisation to improve psychological care • Midlands and East stroke review • Clinical psychology posts being built into specs for ESD and community rehab teams • Widespread use of economic case to support bids for clinical psychology

12. From around the nation • Progress is better than that measured. Dorset: -Trained IAPT in communication skills after stroke (SALT led) -IAPT trained stroke practitioners in recognising mental health problems -Established a clear referral pathway (IAPT level 3)

13. Befriending: Connect • Reassure – You are not alone – ‘normalising’ • Listening ear • Give Time • Empathise – Shared experience • Encourage and Support • Tips and Ideas – Signposting (McVicker & Eustice, underway)

14. Befriending: Connect • Information – Link to ongoing support • A chance to discuss opportunities • ‘A role model’ • ‘A inspiration for a positive future and what ‘me with aphasia’ could look like’ (McVicker & Eustice, underway)

15. Motivational Interviewing • “to support and build a patient’s motivation to adjust and adapt” • “working with patient’s dilemmas and ambivalence…supporting and reinforcing optimism and self-efficacy”

16. Motivational Interviewing • Elicit person’s own solutions • Elicit person’s usual coping style that was successfully used in the past • Explore application in the present & the future

17. Motivational Interviewing • An RCT, has shown Motivational Interviewing can improve mood after stroke (Watkins et al., 2007) • Administered by nurses with specific training and supervision

18. SSNAP Organisational audit 2012

19. Sentinel Stroke National Audit Programme (SSNAP) Six month (post admission) follow up 8.2.1 Was the patient screened for mood, behaviour or cognition since their stroke using a validated tool? Yes No No but 8.2.2 If yes, was the patient identified as needing support? Yes No 8.2.3 If yes, has this patient received support for mood, behaviour or cognition since their stroke Yes No No but

20. RCP National Clinical guidelines for stroke 2012 • Stroke services should adopt a ‘stepped care’ approach to delivering psychological care. • All patients after stroke should be screened within 6 weeks of diagnosis, using a validated tool, to identify mood disturbance and cognitive impairment (NICE guidance) • Recommendations for management of depression, anxiety, fatigue, cognition, emotionalism

21. CCG Outcomes Indicator Set • People who have had a stroke who: • • are admitted to an acute stroke unit within four hours of arrival to hospital • • receive thrombolysis following an acute stroke • • are discharged from hospital with a joint health and social care plan • • receive a follow-up assessment between 4-8 months after initial admission • Mortality within 30 days of hospital admission for stroke

22. CCG Outcomes Indicator Set • Ensuring people feel supported to manage their condition • • People feel supported to manage their condition • Enhancing quality of life for people with mental illness • • Access to community mental health services by people from BME groups • • Access to psychological therapy services by people from BME groups • • Recovery following talking therapies (all ages and older than 65)

23. The economic case for a clinical psychology led service

24. NHS savings from provision of psychological care over two years

25. Savings around £98,000 year 1 Savings around £59,000 year 1

26. Potentially a renewed interest in compassionate care for patients and development of culture where this is possible • Legal responsibility for staff to be open about incidences of harm (including neglect) • Services which expose patients to risk prevented from continuing