Psychological Care in North Staffordshire A Pathway in Development - - PowerPoint PPT Presentation

Psychological Care in North Staffordshire

A Pathway in Development

Emma Hall Stroke Co-ordinator

Psychological Care in North Staffordshire

• Presentation Contents
• North Staffordshire Stroke Service
• Assessment of Mood
• Assessment of Cognition
• Providing Psychological Care
• Challenges

Psychological Care in North Staffordshire

• North Staffordshire Stroke Service

 32 Acute Beds / Trolleys  20 Stroke Rehabilitation Beds  Stroke Early Supported Discharge Team  In excess of 1000 admissions per year (approximately

850 North Staffs residents)

 Length of Stay on the Acute Stroke Unit – 6 days  Length of Stay on the Rehabilitation Ward – 40 days  Average time with Early Supported Discharge team 4

to 6 weeks

Psychological Care in North Staffordshire

• Acute Stroke Unit
• Short Length of Stay
• 60 – 70% of patients are discharged directly to

their place of residence

• Less then 20% of patients are transferred to
• ngoing bed based rehabilitation
• Majority of referrals to Early Supported

Discharge come from the Acute Stroke Unit

• Seven day working on the Acute Stroke Unit

Psychological Care in North Staffordshire

• Stroke Rehabilitation Unit
• Most complex and challenging patients
• 60 – 70% of patients are discharged to

their place of residence

• Significant reduction in length of stay with

targets to decrease this further

• Therapy staff are not yet working over 7

days

Psychological Care in North Staffordshire

• Early Supported Discharge
• Well established team
• Small clinical team
• Currently a 5 day service
• Achieving the Accelerating Stroke

Improvement Programme target of supporting 40% of all discharges

Psychological Care in North Staffordshire

• Common Themes Across the Service
• A desire to ensure that the patients admitted to
• ur service have the appropriate psychological

care

• Access to relevant training programmes
• Improved team working
• Robust Multidisciplinary Meetings / Case

Conferences with opportunity to discuss all patients with multi-professional representation

• Access to Clinical Psychologist dedicated to

Stroke

Psychological Care in North Staffordshire

• Psychological Care
• “All patients after stroke are screened within six

weeks of diagnosis, using a validated tool to identify mood disturbance and cognitive impairment”

• NICE Quality Standard (2011)
• Accelerating Stroke Improvement Programme

has a target to achieve for 40% of patients to receive psychological support within six months

• f their stroke

Psychological Care in North Staffordshire

• Psychological Care
• Has been recognised as essential as

physical rehabilitation

• There should be a clear policy and

pathway for the recognition and assessment of cognitive and emotional needs which includes choice and timing of measure, recording and communicating results

Psychological Care in North Staffordshire

• Stepped Approach to Assessment of

Mood

• All patients should be assessed with a

simple brief standardised assessment which should be followed up by interview

• In cases where moderate to severe

symptoms are evident referrals should be made for specialist support (Clinical Psychology and / or psychiatry)

Level Support Level 1

Level common to many strokes. General difficulties coping Mild and transitory symptoms of mood / cognitive disorders Little impact on rehabilitation Routine assessment by member of the multidisciplinary team and discussion at team meeting Support can be provided by multidisciplinary team members

Level 2

Mild to moderate symptoms of impaired mood and / or cognition Interfering with rehabilitation Routine assessment by member of the multidisciplinary team May require additional (to routine) assessment Discussion at team meeting including with Clinical Psychologist Team approach to treatment strategy

Level 3

Severe and persistent disorders of mood and or cognition Require specialist intervention and pharmacological treatment and suicide risk assessment May have proved resistant to treatment at levels 1 and 2 Requires intervention by Stroke Clinical Psychologist Routine and additional assessment from the multidisciplinary team Prompt referral to Clinical Psychology Agreed treatment approach between Clinical Psychologist and the multidisciplinary team Regular discussion within team meetings regarding progress May require referral to psychiatry or

• ther mental health services

Psychological Care in North Staffordshire

• Assessment of Mood
• One month after stroke or just before

discharge or at the six week follow up

• Three months after stroke
• Six months after stroke
• Annual Review

Psychological Care in North Staffordshire

• Assessment of Mood
• Initial Interview, Physical and Functional Assessment -

Yale Question asked

• Mood then forms part of the discussions at each of the

Multidisciplinary Case Conference

• Process for further assessment of mood is the

determined by:

 Cognitive Status  Language problems  Age of the patient  MDT discussion  Clinical Psychologist

Psychological Care in North Staffordshire

• Mood Assessments Used
• Yale Question
• Under 65 without language problems – Hospital

Anxiety and Depression Scale (HADS)

• Over 65 without language Problems – Brief

Assessment Schedule Depression Cards (BASDEC)

• Communication or cognitive deficit evident –

Visual Analogue Mood Scale (VAMS); Stroke Aphasic Questionnaire – Hospital 10 (SADQ- H10); Depression Intensity with Circles

Psychological Care in North Staffordshire

• And then what…….
• Discussion with the multidisciplinary team as to the

results of scores – this can include discussion with Clinical Psychologist for support with any strategies for the best / appropriate management plan

• Decision as to the best way to proceed and determine

management plan accordingly

• Continue to monitor and report / record any changes
• Discussion with the patient and / or carers and families –

may also need additional support or education (family meetings)

Psychological Care in North Staffordshire

• Assessment of Cognition
• Cognitive assessment should be

conducted as part of a comprehensive clinical assessment

• Cognitive assessments should take place

in conjunction with functional assessment by Occupational Therapists

Psychological Care in North Staffordshire

• Assessment of Cognition
• Should take place at weeks 1 to 3 or

before discharge if earlier than 3 weeks

• After these initial weeks it may be

appropriate to carry out a more detailed cognitive assessment (if required)

• Patients should be reviewed at six months
• Clear pathways should exist for referral to

Clinical Psychology / Neuropsychology

Psychological Care in North Staffordshire

• Assessment of Cognition
• Initial Interview, Physical and Functional

Assessment to ascertain if any obvious cognitive problems are evident

• Montreal Cognitive Assessment (MoCA) is used

across the Stroke Service

• To commence using the Repeatable Battery for

the Assessment of Neuropsychological Status (RBANS)

• Access to other assessments if required

Psychological Care in North Staffordshire

• And then what……
• Discussion with the multidisciplinary team as to the

results of scores – this includes discussion with Clinical Psychologist for support with any strategies to best support patients if this is required

• Decision as to the best way to proceed and determine

management plan accordingly

• Continue to monitor and report / record any changes
• Discussion with the patient and / or carers and families –

may also need additional support or education (family meetings)

Psychological Care in North Staffordshire

• Providing Psychological Care
• Access to Clinical Psychology – not all patients

require referral but the opportunity to discuss and acknowledge that the strategies that are put in place are appropriate is reassuring. By not referring everybody we ensure that there is time for those patients that do require immediate / urgent intervention

• Clear referral process to Clinical Psychology

Psychological Care in North Staffordshire

• Providing Psychological Care
• Training – this is required for all staff and locally

we provide this specifically at:

 Stroke School  Stroke Rehabilitation Course  Psychological Care Training (levels 1 and 2)

• Acknowledgement that all staff can / do provide

a degree of psychological care to our patients but have an awareness of when they require additional support

Psychological Care in North Staffordshire

• Providing Psychological Care
• Utilise existing services such as:

 Healthy Minds  Improving Access to Psychological Therapies (IAPT)

• Work in collaboration with the Stroke Association

/ Social Care services etc. and ensure that their staff are involved in training programmes

 Life after Stroke model commissioned  Partnership working with Social Care  Links with other services

Psychological Care in North Staffordshire

• Providing Psychological Care
• Dedicated support – from the Heart and

Stroke Network; from local commissioners and across the North Staffordshire Stroke Service

Psychological Care in North Staffordshire

• Providing Psychological Care
• Developed stroke service which includes

Acute, Rehabilitation, Early Supported Discharge, established six weeks reviews

• About to commence six month reviews

which will be further opportunity to monitor / review patients at that point

• Involved in research to establish twelve

month reviews

Psychological Care in North Staffordshire

• Providing Psychological Care
• Information – ensuring that patients and

their families and carers have access to relevant information, advice and support

Psychological Care in North Staffordshire

• Challenges
• Large Stroke Service – provision of assessment across

all facets of this service

• Which assessments to use
• When to do the assessments
• Who should be completing the assessments
• Loss of individualised care
• How to ensure that any assessments that are completed

form part of the rehabilitation and management plan

• Appropriate referral to Clinical Psychology
• Ongoing development of the pathway

Psychological Care in North Staffordshire

• Acknowledgments
• Shropshire and Staffordshire Heart and Stroke

Network

• Dr Lorna Roberts (Clinical Psychologist for

Stroke)

• Margurite O’Mara, Advanced Occupational

Therapist (Early Supported Discharge)

• Laura Sillito, Advanced Occupational Therapist

(Stroke Rehabilitation)

• Alice Wheat / Jo Morris, Advanced Occupational

Therapists (Acute Stroke)