Transcript Document

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
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
ASI 6 Psychological care within 6 months
of stroke
National Update
Multiple examples of good practice on the SI
website:
Evidence paper:
Kneebone & Lincoln (2010) Stroke Improvement programme.
Psychological support: State of knowledge.
National Update
Specific guidance:
Screening for emotional disorder
Screening for cognitive deficits
Does the patient have a communication difficulty?
No
Yes
Flow chart for people under 65 years
Administer the DISCs
Scored 2 or more?
Yes
invalid
No
Administer the HADS
Staff concerns?
Yes
Score 9 or more on D scale?
No
Yes
Administer SADQ H10
Administer suicide question from BASDEC
6 or more?
Yes
Suicide question
from BASDEC
No
Respond with true?
Non-depressed range
Respond with true?
No
Yes
Report to nurse
in charge
No
Yes
Report to nurse
in charge.
Depressed range
Non-depressed range
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 RBANS
OT to administer RCPM
What cognitive domains are affected?
Scores less than 19?
No
Informs team of results
Yes
Assess cognitive problems further
Week 6 onwards. Review.
Interfering with rehab?
using functional assessment.
No
No
If impaired, discuss treatment
Interfering with rehab?
Yes
options with psychologist
Yes
Review further assessment
Review further assessment
/treatment options
/treatment options with SALT
with psychologist
6 month review.
and psychologist.
Any cognitive problems reported?
Yes
No
Monitored by GP, refer for
Stroke Association
support etc
Is patient going back to work or
do they have cognitively demanding
lifestyle or responsibilities (e.g. childcare)
No
Yes
Comprehensive neuropsychologic
assessment by clinical
neuropsychologist
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)
ASI 6 Psychological care within 6 months
of stroke
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
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)
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)
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)
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”
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
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
SSNAP Organisational audit
2012
Percentage of stroke units with access to psychology
services by year
120
100
80
Percentage 60
40
20
0
2006
2012
2034
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
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
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
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)
The economic case for a
clinical psychology
led service
NHS savings from provision of
psychological care over two years
Savings
around
£59,000 year 1
Savings
around
£98,000 year 1
• 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