Dorset Improving Psychological Support after Stroke Project

1. Dorset Improving Psychological Support after Stroke in the Community Project Dorset Improving Psychological Support after Stroke Project Sara Leonard Lead Manager Dorset Cardiac and Stroke Network

2. 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…….

3. A significant proportion of stroke patients with depression remain undiagnosed or inadequately treated(Hackett et al 2005). The scale of the problem Up to 75% experience cognitive impairment (RCP 2009) Anxiety rates of 30- 49% up to 12 years post stroke (South London Stroke Register) Prevalence of post stroke depression independent of disability is approx 33% (Hackett et al, 2005)

4. National Guidance 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 careaccording to the degree of depression, associated chronic healthproblems and its impact on function

5. 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

6. Mental Health Strategy 2011

7. The National ambition for psychological care after stroke

8. 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

10. 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.

11. 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.

12. PPI Involvement 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

13. Cost of Psychology Training - DEVELOPMENT *One off cost – funded by Network

14. Cost of Psychology Training - DELIVERY *plus: • administrative support for booking venue/confirming places • catering costs • Funded by Network

15. Cost of Psychology Training - ATTENDANCE *Cost to provider • Does not include travel expenses

16. Total cost of psychology training • Not including accreditation process: • Delivery: £517.20 per course • Attendance: £2,757.00 per course = £3,274.20 per course (20 delegates)

17. Cost of Communication Training – DEVELOPMENT & DELIVERY *One off cost Both costs funded by Network

18. Cost of Communication Training – ATTENDANCE *Cost to provider • Does not include travel expenses

19. Total cost of Communication Training • Not including accreditation process: • Delivery: £750.00 per course • Attendance: £4,962.60 per course = £5,712.60 per 3 day course (12 delegates)

20. Proportion of stroke patients receiving formal screening for psychological issues after stroke during contact with community teams Training delivered end of January

21. Proportion of stroke patients receiving support for psychological issues after stroke during contact with community teams Training delivered end of January

22. Number of stroke survivors and carers each month supported by PCMH

23. Following evaluation it was concluded… 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!

24. Issues and sustainability

25. Progress since pilot. We will now look at…. • Communication Training • Psychology Training • Ongoing challenges & next steps

26. Communication Training • 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

27. Better Communication Training

28. 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.”

29. 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.”

30. Psychology Training • 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)

32. Knowledge Gained – top 5 areas

35. Distribution of DIPSS psychology trained staff 2011 2012

36. Qualitative Feedback • 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.

37. How people felt …. • 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

38. Ongoing challenges & next steps

39. Frances AvissPatient and Public Involvement Lead & Service Improvement ManagerDorset Cardiac and Stroke NetworkTel: 07736 245 266e-mail: frances.aviss@bp-pct.nhs.uk For further information…..