The integrated pathway of care for people with stroke in Torbay & Southern Devon

1. The integrated pathway of care for people with stroke in Torbay & Southern Devon Rhoda Allison March 2014

2. Stroke rehabilitation in Babylonia 1600 BC(Reynolds & Kinnier Wilson, 2004) • Massage • Hot poultices (flax seed, barley, beer, tamarisk) • Incantations • Quite a lot of bandaging • ‘If when he tries to bend or stretch out he howls with pain and saliva flows from his mouth an animal spirit has possessed him’

3. Stroke care in the 21st century • Acute care and thrombolysis • Start rehabilitation early • Emphasis on increasing the intensity of functional practice • Early supported discharge schemes • Recommendations about life after stroke • Management of long term disability • Self management • Health and social care checks • Access to further rehabilitation if there are goals

4. Typical stroke pathway of care Acute stroke unit Stroke rehab unit GP provides medical care Health and social care reviews ESD or community team Voluntary sector Social Care services Work and leisure

5. What is integrated care? Torbay & Southern Devon model of Mrs Smith (and her son Robert) • ‘Seamless care’ • No barriers between health and social care services • Joint health and social care teams aligned to GP practices- people only tell their story once, staff all in the same office using shared information • Pooled budgets • Close relationships with voluntary sector • No barriers between the acute hospital and community services

6. Tracy’s story • Tracy is a 44 year old woman • She lived in a flat on her own, relatively close to her parents and worked in Torquay as an administrator • She sustained a severe left sided stroke in June 2011 • This caused: • Complete paralysis of the right side of her body • Communication disability- difficulty receiving information and expressing herself • Reduced swallowing • This all had a huge emotional impact

7. Tracy’s pathway Home to live with her parents Stroke rehab unit Community team, social care, GP Acute stroke unit Longer term plans Stroke rehab unit Peer Support Respite services Swimming twice each week Enabler for social inclusion Stroke Association Hub Community team, social care, GP

9. Long term needs are incredibly complex • Stroke is the leading cause of disability in the western world • Not all young people are able to return to work • Carers provide so much support but also have their own needs • All agencies involved need to link together

10. How is technology helping? • Electronic discharge summaries Infoflex • Joint records (up to a point) PARIS, Windip • Entire community shares access to imaging, lab results and clinical guidelines; PACS, Cyberlab • Web based resources, education, TV Hiblio • Staff diaries managed on Outlook with smart phones- co-ordinated visits

11. What more could we do? Support integration further • Electronic notes!!!! Use technology to enable staff to be more efficient: • Collecting data • Arranging appointments Use technology to maximise rehabilitation opportunities- it’s all about practise: ‘I’m such a good lover because I practise such a lot on my own’ Woody Allen