The integrated pathway of care for people with stroke in Torbay & Southern Devon Rhoda Allison March...
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Transcript of The integrated pathway of care for people with stroke in Torbay & Southern Devon Rhoda Allison March...
The integrated pathway of care for people with stroke in
Torbay & Southern Devon
Rhoda Allison
March 2014
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’
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
Typical stroke pathway of care
Acute stroke
unitStroke rehab unit
Social Care
services
GP provides medical
care
Work and
leisure
Voluntary sector
Health and social care
reviews
ESD or community
team
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
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
Tracy’s pathway
Acute stroke
unit
Stroke rehab unit
Home to live with her parents
Stroke Association
Hub
Community team, social
care, GP
Peer Support
Swimming twice each
week
Enabler for social
inclusion
Respite services
Stroke rehab unit
Longer term plans
Community team, social
care, GP
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
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
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