Leading change

The Therapy Clinical Lead in the Early Supported Discharge (ESD) Stroke Service at Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust (RBCH), led on a quality improvement initiative to improve carer support in their ESD services transforming carer experiences.

Where to look

Stroke is a major health problem in the UK. Each year, approximately 110,000 people in England have a first or recurrent stroke. More than 900,000 people in England are living with the significant morbidity following a stroke (NICE 2013). Despite improvements in stroke mortality and morbidity, people with stroke need access to effective rehabilitation services. Stroke rehabilitation is described and outlined here.

NICE (2016) describe Early Supported Discharge (EDS) as an intervention for adults following a stroke, which supports their care to be transferred from an inpatient environment to a community setting. It enables people who have a mild to moderate stroke with a resulting mild to moderate disability to continue their rehabilitation therapy at home beginning within twenty-four hours of discharge. EDS is linked to increased independent living at home six months after their stroke, with accompanied increased satisfaction with the services they received (Langhorne & Baylan, 2005).

The Clinical Lead at RBCH identified the vital role carers play in the discharge of stroke patients from hospital was potentially coupled with exacerbated strain for the carer, particularly when discharge is accelerated. Collaboration with the University of Southampton led clinicians to explore how extra provision of support for carers could benefit individuals on EDS and what this support would entail.

What to change

The RBCH ESD Team provides an early, intensive specialist rehabilitation service for stroke and neurological patients for approximately two weeks. The team support patients to leave hospital more quickly and return to their own homes, to maximise independence after their stroke. Rehabilitation is centred around their individual goals and delivered in a setting that is meaningful to their lives. Patients are referred directly from the stroke unit and are usually seen on the same day of discharge or within 24 hours of returning home. The service uses a multidisciplinary team model made up of stroke specialist staff that covers a 7 day a week service to provide specialist rehabilitation. Rehabilitation goals will depend on the individual but tasks may include mobilising, activities of daily living, shopping, memory strategies, emotional support and care givers support, teaching and education. After the 2 weeks of rehabilitation, referrals are made onto appropriate community services as needed.

Carer support included assessment of carer strain (using the Carer Strain Index) at the halfway point and the offer of a referral to social services for carer support. Education for carers was more informal and was planned as part of a patient session as indicated, but there were no stand-alone sessions for carers.

However, the clinical leads heard from carers that they themselves felt an emotional impact that was not being explicitly addressed. A pre-intervention audit with carers highlighted:

• 1/3 of carers would have liked more opportunity to ask questions
• 1/4 of carers reported concerns about adjusting to changes in their lives
• 1/2 of respondents reported concerns regarding emotional management
• 1/5 carers worried about leaving their family member alone after their stroke
• 1/5 of respondents wanted more information about rehabilitation and prognosis

How to change

To better meet carer needs, the team held a carer focus group which identified that carers wanted more information and felt that they would benefit from a session just for them. They asked for the following:

• Face to face session at the end of the two-week ESD – scheduled at the beginning of the process so that the support is clear from the outset
• Flexibility of location
• Open lines of communication so that the carer feels there is opportunity to highlight topics they would like to discuss
• Allocated time to ask questions and
• An open rather than structured format.

The Trust’s clinical psychologist provided the team with support and training on communication and dealing with distress amongst other emotional variables. In conjunction, an information pack was developed to cover 10 topics highlighted as crucial by carers and staff within the service, such as feelings of frustration, fatigue, medications and leaving your relative alone following a stroke.

Adding value

Better outcomes – The initial 3-month post implementation audit results demonstrated a significant improvement in carer satisfaction. All respondents (100%) now report having had the opportunity to ask questions and understand their relative’s care, an increase of 34%. This was paired with 33% increase in having their own needs met. It is likely that these improvements have made an impact on the increased confidence observed in caring for and supporting their relative.

Better experience – The new approach to provision of support for carers has not only been welcomed by carers and patients, it has also been a positive approach for staff – the signposting to appropriate services amongst other parameters is now observed as more inclusive and joined up – collaborative and all encompassing.

Better use of resources – Targeted support for carers and their individual needs has been valuable. Having time specifically earmarked for carers has streamlined the support offer. This has led to improved carer satisfaction.

Challenges and lessons learnt for implementation

Emotional management was the biggest concern for carers and this programme of work demonstrates the need to consider carers when discharge planning.

Working collaboratively with carers, patients and relatives was a real success of the programme and should be encouraged from the beginning of a change programme.

Find out more

For more information contact:

• Michelle Heath – Clinical Leader, Neurotherapy ESD Team, Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust, michelle.heath@rbch.nhs.uk