Psychological care after stroke: A national update
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Transcript of Psychological care after stroke: A national update
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?
Yes No
Administer the HADS
Score 9 or more on D scale?
Yes No
Non-depressed range
Administer suicide question from BASDEC
Respond with true?
No Yes
Depressed range
Report to nurse in charge.
Administer the DISCs
Scored 2 or more?
Yes invalid No
Administer SADQ H10
6 or more? No
Non-depressed range
Yes
Suicide questionfrom BASDEC
Respond with true?
No YesReport to nurse
in charge
Flow chart for people under 65 years
Staff concerns?Yes
Weeks 1-3 (or before discharge if <3weeks) OT to administer MOCA or ACE-R + Star CancellationInforms team of results – rehab planning
Week 4 Does patient have communication problems?Yes No
OT to administer RCPM
Assess cognitive problems further using functional assessment. Interfering with rehab?
Scores less than 19?
Review further assessment/treatment options with SALT and psychologist.
Review further assessment/treatment options with psychologist
Interfering with rehab?
What cognitive domains are affected?
Informs team of results
OT to administer RBANS
Comprehensive neuropsychological assessment by clinical neuropsychologist
Monitored by GP, refer for Stroke Associationsupport etc
Week 6 onwards. Review. If impaired, discuss treatment
options with psychologist
6 month review.Any cognitive problems reported?
Is patient going back to work or do they have cognitively demanding lifestyle or responsibilities (e.g. childcare)
Yes
YesYes
No Yes
Yes
No
No
No
No
National Update
Screening for emotional disorder2006 55% (RCP 2007):
2012 88% (RCP 2013)
Screening for cognitive deficits2006 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
0
20
40
60
80
100
120
2006 2012 2034
Percentage
Percentage of stroke units with access to psychology services by year
Sentinel Stroke National Audit Programme (SSNAP)
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 SetEnsuring 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