Neuro Rehabilitation Project
Interim Report October 2014
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Executive Summary Our project aim is to work with our partners and patients across North West London to improve the lives and wellbeing of people who have sustained an Acquired Brain Injury in North West London. The purpose of this report is to provide a summary of Imperial College Health Partner’s (ICHP) neuro rehabilitation project and to provide some preliminary and interim recommendations, ahead of a final report in 2015, to help commission neuro-rehabilitation services for patients with Acquired Brain Injury in North West London. We have identified three work streams to help us achieve this:
- Develop a demand modelling tool. This tool will help us understand how and when current services are used by patients so we can identify bottlenecks and constraints in the system that need to be addressed. This will mean we can ensure that in the future the right services are available, and there are enough of them to meet the demand of patients in North West London, thus reducing waiting times and improving outcomes.
- Develop a web-based referral and waiting list system. This system will help clinicians refer patients to the most appropriate service, reduce the steps in the process, avoid duplication of referrals, and provide important feedback to clinicians on the time frame for patients being accepted on to a bed. Further, we will be able to monitor all patients that are waiting for neuro-rehabilitation services.
- Review and make recommendations on the pathway of care for
patients who have suffered an Acquired Brain Injury. Working with clinicians, patients and commissioners we will look at how patients who have received acute treatment for an Acquired Brain Injury then can access the optimal neuro-rehabilitation services. We will identify areas for improvement and make recommendations to clinical commissioners.
The following recommendations are based on discussions undertaken among stakeholders, mainly clinicians. It was noted in undertaking these recommendations the burden of ill health among patients living with an Acquired Brain Injury. For example, estimates suggest that 1 in 4 people aged between 16 and 64 years with a chronic disability have a neurological condition
Recommendations
Priority resource improvement proposals in North West London for patients with Acquired Brain Injury to improve patient outcomes
1. We recommend a further increase of Level 2 neuro-rehabilitation bed capacity for
NWL residents by approximately 5 to 6 beds.
a. This figure is an estimate, based on clinical experience of continued demand and waiting times for admission. It will be reviewed following the capacity modelling. The modelling will also need to consider where data allows the overall increase in Level 2 capacity through the additional provision of 16
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beds at the Alderbourne Unit, Hillingdon Hospital. These beds are available for all patients resident in North West London.
2. Undertake Multi-Disciplinary Team (MDT) reviews for patients with an Acquired Brain Injury who have cognitive deficits. Cognitive impairment is a risk factor for poor rehabilitation outcomes.
a. It is estimated that in North West London there are 23,719 patients who have an Acquired Brain Injury (activity data). The proportion of those requiring review will vary according to the type of Acquired Brain Injury. For example, even mild Traumatic Brain Injury can cause long-term cognitive problems that affect a person's ability to perform daily activities and to return to work. Estimates for stroke patients suggest that between 30-50% will have a cognitive impairment. It is likely that MDT meetings will be needed weekly. There is a significant unmet need for cognitive rehabilitation and neuropsychological treatment.
b. Increase access to neuro-psychology assessment and treatment, cognitive therapy and neuro-psychiatry provision for patients and carers to be available equitably across North West London and to ensure that sufficient provision exists in each area.
3. Increase provision of specialist nursing and residential care rehabilitation services together with introduction of specialist domiciliary care services to work with community rehabilitation services.
a. Approximately 50% of patients from the Royal Hospital for Neuro-disability (the largest Level 1 service complex physical disability unit in England) are discharged to a nursing home or residential placement.
b. 1/3rd of disabled patients living in a residential setting have a neurological condition.
c. Furthermore, there is a need to improve the clinical quality assurance among current providers
4. Pilot a Neuro-Navigator role (Senior Allied Health Professional) as a “pathway coordinator” for patients (as per the Barnet /Royal Free model) across all boroughs and acute trusts.
a. Proposal by ICHP to pilot and evaluate this model in North West London in one volunteer locality with the aim of quantifying the effect on delays in transfers of care.
5. Commission vocational rehabilitation for patients to return to paid or unpaid employment and improve provision of social or day centres for working age patients with ongoing impairments who are unable to return to work. This may be in association with the third sector such as Headway.
a. This will have wider impact on both health and social care budget, to enable patients where possible to return to work.
6. Develop a system for early supported discharge from hospital to home by jointly commissioning social and community care services with specific neuro-rehabilitation expertise and assistive/supportive technology.
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Priorities without resource implications
1. Simplified referral process between services.
o Current proposal of ICHP’s work stream B is to develop and pilot a web based referral/waiting list tool. Although, this may have resource implications, simplifying the process does not.
2. Develop standards for rehabilitation teams and refine metrics currently being collected across North West London.
Conclusions
A high percentage of the population who acquire a brain injury are of working age. The socio-economic benefits of improving rehabilitation among this group have long term implications for health and social care budgets. Imperial Partners Health Partners preliminary findings suggests that neuro- rehabilitation in North West London would benefit from integrating commissioning of health and social care for patients with Acquired Brain Injury due to their complex and varied needs. Our further work will include patient and carer engagement, developing links with North West London Whole Systems Integrated Care leads, to describe the current issues among people living with a long term neurological condition who need access to neuro rehabilitation services, and developing research questions and audit ideas.
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1. Introduction Our project aim is to work with our partners and patients across North West London to improve the lives and wellbeing of people who have sustained an Acquired Brain Injury in North West London.
The purpose of this report is to provide a summary of Imperial College Health Partner’s (ICHP) neuro rehabilitation project and to provide some preliminary and interim recommendations, ahead of a final report in 2015, to help the commissioning of neuro-rehabilitation services for patients with Acquired Brain Injury in North West London. We have identified three work streams to help us achieve this:
- Develop a demand modelling tool. This tool will help us understand how and when current services are used by patients so we can identify bottlenecks and constraints in the system that need to be addressed. This will mean we can ensure that in the future the right services are available, and there are enough of them to meet the demand of patients in North West London, thus reducing waiting times and improving outcomes.
- Develop a web-based referral and waiting list system. This system will help clinicians refer patients to the most appropriate service, reduce the steps in the process, avoid duplication of referrals, and provide important feedback to clinicians on the time frame for patients being accepted on to a bed. Further, we will be able to monitor all patients that are waiting for neuro-rehabilitation services.
- Review and make recommendations on the pathway of care for
patients who have suffered an Acquired Brain Injury. Working with clinicians, patients and commissioners we will look at how patients who have received acute treatment for an Acquired Brain Injury then can access the optimal neuro-rehabilitation services. We will identify areas for improvement and make recommendations to clinical commissioners.
By undertaking the three work streams identified, we aim to achieve the following:
Gain a better understanding of the current situation of how neuro-rehabilitation services are provided and accessed for residents of North West London to inform decisions and recommendations about how better to plan services.
Develop and implement an innovative tool to reduce waiting times for neuro-rehabilitation services.
Gain a better understanding of the current care pathways in place across North West London, identify areas for improvement and make recommendations to clinical commissioners.
This report is divided into the following:
background which details the reasons for undertaking this project; an outline of the project and associated work streams; and,
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recommendations for priority areas for action in North West London.
Further background and supporting information, for example, the current levels of neuro-rehabilitation service provision in North West London and existing neuro-rehabilitation pathways are included within the appendices. Other concurrent work is being undertaken nationally and locally, with the specific aim of improving the care of patients with neuro-rehabilitation needs. This includes work by the Triborough Councils and Clinical Commissioning Groups in North West London through the Better Care Fund which provides an opportunity to encourage integrated commissioning and integrated delivery and Whole Systems Integrated Care. Brief overview of Whole Systems Integrated Care (WSIC) and Better Care Fund (BCF)1 “The Triborough Councils and Clinical Commissioning Groups in North West London are one of the national pilot sites for the Whole System Integrated Care (WSIC).The vision of WSIC is about transforming and reshaping the local health and social care economy by integrating the models of care, operational delivery and funding more tightly for a cohort of patients. Across the Triborough health and social care environment, there is already a shared commitment that:
people are enabled and supported to stay as healthy and as independent as possible for as long as possible
people are supported to live in the most appropriate place according to their choice and needs and are able to maintain maximum control over their lives
The Better Care Fund is entirely compatible with the Whole Systems Integrated Care programme as it creates a pooled fund to catalyse integrated working, to deliver tangible multidisciplinary and integrated services and teams focused on delivering benefits to the population. Within the Better Care Fund Programme (A) there has been specific work on business case which proposes the way forward to develop a Triborough Integrated Community Independence Service which will integrate and enhance existing local models and delivery frameworks to achieve common and improved outcomes for the local population. Community Integrated Service provides a range of functions including rapid response services to prevent people going into hospital, and rehabilitation and reablement which enable people to regain their independence and remain in their own homes. The service is currently delivered by a multidisciplinary team of community nurses, social workers, occupational therapists, GPs, geriatricians, mental health workers, reablement officers and others.”
2. Background
Neuro-rehabilitation is a broad term that describes a wide range of interventions and treatments that are given to patients with a multitude of disease conditions, from Acquired Brain Injury (ABI) to degenerative disorders. Patient needs are usually multi-dimensional, including physical, cognitive, psychological and medical and may be very complex. For
1 Kindly provided by Rob Sainsbury and Ray Boateng
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example, head injury patients may find themselves in a spiral of decline revolving around the loss of their job, alcohol dependency, and losing their home. By breaking this cycle we can bring about long term health and wealth benefits through improving their independence (within the limitations of their significant disabilities) and avoiding social exclusion. In North West London there are challenges within the healthcare system for patients to access appropriate and timely neuro-rehabilitation services. In particular, current care pathways for patients with Acquired Brain Injury (ABI) rely heavily on accessing neuro-rehabilitation care from multiple providers. As a consequence of this, the pathway is fragmented and difficult to navigate for health and social care professionals as well as patients and carers, leading to long delays in accessing neuro-rehabilitation care.2 Additionally, there is a wider effect on the health economy, with patients with ABI experiencing unnecessarily long stays in acute hospitals, significant delays in transfers of care, and delays in receiving appropriate neuro-rehabilitation care. For example, preliminary audits of delayed transfers of care in the boroughs of Kensington and Chelsea and Westminster have shown that 50-60% of acute bed days lost are associated with delays in accessing neuro-rehabilitation care. Many patients with ABI are of working age with knock on effects for wider society if they are unsupported to return to work and gain their independence. They will require higher levels of community, social and health care for an extended time period.
It is difficult at any one moment in time, to specify precisely the number of level 1 and level 2 designated beds in the system. Patients from NWL are referred to rehabilitation facilities elsewhere in London, and patients from elsewhere in London are admitted to NWL facilities. Furthermore, there are a number of facilities which informally provide level 2 neuro-rehabilitation, without having been specifically commissioned as such. For example, at Imperial College Healthcare NHS Trust. The closure of the Brain Injury Rehabilitation Unit (BIRU) in 2011 has left a significant under capacity of inpatient and outpatient neurological and cognitive therapy services.
2 Imperial College Healthcare Trusts Discharge Database
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3. Aim of Project
Our project aim is to improve the lives and wellbeing of people living in North West London who have sustained an ABI North West London. To address the current challenges of neuro-rehabilitation services in North West London, Imperial College Health Partners is working with provider organisations, clinical commissioning groups, social services, patients and carers and the third sector to address the neuro-rehabilitation needs among patients with Acquired Brain Injury.
The following three work streams were identified:
To develop a demand modelling tool To develop a web-based referral and waiting list system To review and make recommendations on the pathway of care for
patients who have suffered an Acquired Brain Injury.
3.1 Develop a demand modelling tool The aim and outcome of this work stream is to gain a better understanding of the current situation of neuro-rehabilitation provision, demand and need in North West London, which will help inform decisions and make recommendations on how best to plan services. This work stream involves developing a:
A) Demand model. This model aims to predict patient arrivals at neuro-rehabilitation units and help plan for predictable changes, for example, increased pressures for beds over the winter months.
B) Queuing and delay model. This model will help determine whether the current number of neuro-rehabilitation beds meets present and future demands. It will be based on the proposed ‘demand model’ and performance measures such as mean bed delays, probability of waiting times greater than a set amount and bed occupancy levels.
C) Capacity management tool. This tool will help develop an effective policy for future bed allocation planning by determining how different levels of capacity will respond to current and future demands. Thus helping units to find an optimal solution.
D) Map of current bed provision for neuro-rehabilitation (Figure 1) Figure 1 shows a completed map of provision in North West London. There are: one Level 1 unit with 24 beds at Regional Rehabilitation Unit, Northwick Park
Hospital two Level 2b units with a total of 48 beds:
o 36 beds at the Alderbourne Unit, Hillingdon Hospital o 12 beds at the Robertson Unit, Willesden Centre
additionally residents of North West London access Level 2b beds at the Royal Free Rehabilitation Centre (13 beds) and the Albany Unit at University College London Hospitals (10 beds) in North Central London.
There are 63 Level 3 beds in total in North West London. These beds are mixed general and neuro-rehabilitation beds. The beds may be used by elderly patients, for example that require post-operative rehabilitation, or have progressive neurological
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conditions. Therefore utilisation in the demand model will need to take account of this. Furthermore, these beds are accessed by patients with Acquired Brain Injury according to where they live, or if they are registered with a General Practitioner in North West London. Each individual CCG commissions beds for differing population groups. Hence beds are not pooled across North West London residents. The exception to this is the Regional Rehabilitation Unit at Northwick Park and the Alderbourne Unit will accept any resident in North West London to their beds.
Figure 1 Map of neuro-rehab services (bedded), North West London
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Table 1 below illustrates the current national definition of neuro-rehabilitation services and who is responsible for commissioning each service level. Table 1
NATIONAL DEFINITION SETS FOR REHABILITATION
Level National definition service type Patient category – rehab needs
Level 1 needs and services:
Tertiary ‘Specialised’ Rehabilitation Services Provided by specialised rehab teams led by consultants trained and accredited in the specialty of rehabilitation medicine (RM) (and/or neuropsychiatry):
Category A needs
Serving a regional or supra-regional population and taking patients with Category A needs – i.e. severe physical, cognitive communicative disabilities or challenging behaviours, with highly complex rehabilitation needs* that are beyond the scope of their local specialist rehabilitation services, and have higher level facilities and skilled staff to support these. Collect and report full National Specialist Rehabilitation Dataset
Catchment: 1-3 million Predominantly highly complex caseload (e.g. 60-70% patients with RCS score ≥10)
These patients with category A needs would typically be those who require one or more of: 1, Intensive, co-ordinated interdisciplinary
intervention from 4 or more therapy disciplines, in
addition to specialist rehabilitation medicine/nursing
care in a rehabilitative environment 2, Longer programmes - typically 2-4 months,
but occasionally up to 6-12 months 3, Very high intensity input – e.g. 1:1 nurse “specialling”, or 2-3 trained therapists at one time 4, Neuropsychiatric care, including risk management, treatment under the Mental Health Act 5, Higher level facilities /equipment such as bespoke assistive technology Complex multi-agency vocational rehabilitation /support 6, Ongoing management of complex / unstable medical problems in an acute hospital setting
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Commissioned by NHS England
Level 2 needs and services:
Specialist rehabilitation services Provided by inter-disciplinary teams led/supported by a consultant in RM, and meeting the BSRM standards for specialist rehabilitation services
Category B needs
Patients with category B needs would typically be those who require: 1, Co-ordinated interdisciplinary intervention from 2-4 or more therapy disciplines, in addition to specialist rehabilitation medicine/nursing care in a rehabilitative environment 2, Medium-Longer durations of stay, i.e. usually >6 weeks – occasionally up to 6 months
3, Rehabilitation/support to return to productive roles, such as work or parenting. 4, Special facilities/ equipment or interventions They may also have medical problems requiring ongoing investigation / treatment during rehabilitation.
Level 2a
District level specialist rehabilitation services Led by consultant in RM. Serving an extended local population in areas which have poor access to level 1 services. Take patients with a range of complexity, including Category B and some Category A with highly complex rehabilitation needs* Collect and report full National Specialist Rehabilitation Dataset
Catchment: 600K-1 million
Mixed caseload (e.g. 50% RCS score ≥10)
Level 2b
Local specialist rehabilitation services Led/supported by a consultant in RM. Serving a local population, predominantly patients with Category B needs. Collect and report at least the minimum national dataset
Catchment: 250-500K Less complex caseload (e.g. 20-30% RCS score ≥10)
Level 2a is commissioned by NHS England Level 2b is commissioned by CCGs
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Level 3 is commissioned by CCGs Level 3:
Local non-specialist services. Includes generic rehabilitation for a wide range of conditions, provided in the context acute, intermediate care and community facilities, or other specialist services (e.g. stroke units)
Category C and D needs
Level 3a
Other specialist services led or supported by consultants in specialties other than RM - e.g. services catering for patient in specific diagnostic groups (e.g. stroke) with Category C needs. Therapy / nursing teams have specialist expertise in the target condition
The majority of patients have category C or D rehabilitation needs. These individuals will travel satisfactorily down the path from injury/illness to independence with the help of their local rehabilitation and support services.
However, a small minority of patients will have more complex needs requiring specialist rehabilitation, and a few will have very complex needs or profound disability, requiring a tertiary specialised rehabilitation service.
Level 3b
Generic rehabilitation for a wide range of conditions, often led by non-medical staff, provided in the context acute, intermediate care and community facilities, for patients with Category D needs
In addition, it is important that we consider that neuro-rehabilitation needs among patients may be best met through out-patient based
services or in the home setting and that this may represent a larger proportion of the burden.
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Figure 2 shows the care and service pathway for rehabilitation beds that exists from hospital into the community. Measures that are
commissioned in the community helps any blocks in acute care
Figure 2. Care/Service pathway for rehabilitation beds from hospital to community
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The funding arrangements for neuro-rehabilitation are complex and Table 2 shows preliminary work that has been undertaken to
understand the costs that are incurred. Further, more detailed financial analysis to enable a programme budgeting approach would
involve new financial data collection to be requested of care providers and currently sits outside the scope of this project.
Table 2. Financial data
Level 1 & Level
2a
Commissioned by NHS England not sought
Level 2b Commissioned by North West
London CCG (Inner)
10 Level 2b beds (approximately £1.4 million)
Additional costs incurred include activities at other London units.
Approximate costs are between £3k to 4k per week and varies
dependent on the level of care. Accurate activity data is missing.
Commissioned by North West
London CCG (Outer)
Pending
Level 3 Commissioned by North West
London CCG
Funding arrangements for Level 3 services are included within a
block budget for community services and are not readily
disentangled.
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In summary
- Level 1 NHS England commissioned neuro-rehabilitation services/spinal services bedded intensive Multi-Disciplinary Team (MDT) input with access to specialist medical interventions
- Level 2 CCG commissioned neuro- rehabilitation services bedded intensive MDT input with
some access to specialist medical interventions - Level 3 CCG commissioned community based neuro- rehabilitation and general
rehabilitations services, which include the following:
Local bedded units with neuro-rehabilitation trained staff available to support with 24 hour nursing care
Domiciliary MDT home based MDT input with specialist care agency staff Out-patient neurotherapy services in community Out-patient neuropsychology services Vocational Rehabilitation services
Navigator support to access appropriate services Specialised support activities and leisure options Long term care placement in specialised nursing homes
A limitation to work stream A and the proposed modelling is that the routine data being used is historical and may not exactly reflect the current true need for rehabilitation services among the North West London population. To address this potential limitation, work has been undertaken to examine the incidence and prevalence of long term neurological conditions in the North West London population by borough as an estimate of likely need. Two sources of data have been used: first population data, as identified by the Public Health Observatories i and, second, activity data provided by the Clinical Strategic Network for Neurology for London (Tables 3 & 4). The work stream will explore the potential to link the estimates of population incidence and prevalence of long term neurological conditions to current work on demand modelling. This along with proposals to address current knowledge gaps and need for prospective data collection is being considered within the current project time frame.
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Table 3. Estimates of incidence & prevalence of long term neurological conditions, North West London population
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Table 4. Estimates of incidence & prevalence of long term neurological conditions (using activity data) among North West London population
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3.2 Develop a web based referral and waiting list tool
The aim of this work stream is to develop, pilot and evaluate a web-based interactive referral and waiting list tool that will help effectively manage neuro- rehabilitation beds in North West London. This system will help clinicians refer patients to the most appropriate service, reduce the steps in the process, avoid duplication of referrals, and provide important feedback to clinicians on the time frame for patients being accepted on to a bed. Further, we will be able to monitor all patients that are waiting for neuro-rehabilitation services. Current work is being undertaken London wide by London Specialist Commissioning and Level 1 specialist units to develop and pilot a web based tool (two years) to manage neuro-rehabilitation patients that are referred and discharged from their units. They have proceeded with using the developer CleverMed that has developed clinical platforms for UK Neonatal units. Imperial College Health Partners is presently investigating the feasibility of extending this to Level 2 and 3 units in North West London and piloting this over a shorter time frame with the same developer (CleverMed). 3.3 Review and make recommendations on the pathway of care for patients
who have suffered an acquired brain injury
The aim of this work stream is to describe what a clinically effective set of service options and pathways would look like for patients with an Acquired Brain Injury. It is recognised that any recommendations will take place within a wider need to develop a cost effective and integrated model of neuro-rehabilitation care. Members of the work stream consisted of a wide range of expert clinicians and therapists, especially in North West London that have helped to provide the context and proposals to improve neuro-rehabilitation care (Appendix 6). The members summarised the current environment in which services are delivered and the potential this has on the delivery of care. These include the following factors:
Patients were mobile with variable family support High volume of homeless and vulnerable people suffered brain injury Multicultural Patients and families experienced difficulty navigating the system and were
disempowered by this Complex health and social care funding and restrictions which act as barriers
to transfers of care
Limited access to integrated mental health/health/social services Access to services vary depending on which borough is providing them Mobile work force with high turn over
Current pathways and effective neuro-rehabilitation service model Appendix 4 shows the current service pathways and options for patients with Acquired Brain Injury that require neuro-rehabilitation services in North West London. There exist a number of key care providers in the wider London region; a consequence of the complex needs among this patient group.
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The work stream went on to identify the key components of an effective and efficient neuro-rehabilitation service model. The components include:
Appropriately skilled staff to deliver support for cognitive, behavioural and emotional needs, who can make decisions and deliver on rehabilitation pathways and services.
Acute services that can support effective assessment periods with acute rehabilitation input and avoid unnecessary referrals to Level 1 or 2 beds.
Multi-disciplinary group assessment of needs within the acute and community setting.
Simple referral process for all services with access to an on line referral systems aligned to existing forms, for example, as used for stroke services
Rapid screening of patients for bedded services with standard response times that are met.
Access to appropriate range of service options (e.g. vocational rehabilitation, short term rapid response, cognitive rehabilitation in transitional living environment with 24 hour supervision) within a standard waiting time.
A standard minimum dataset agreed by the whole system using internationally standardised and validated tools and patient reported outcome measures.
Flexible funding streams between health and social services to fund individual patient needs where required.
Access to follow up and review; either a patient or GP led model. Access to equipment and accommodation that enables the individual Access to good voluntary services and charities such as North West London
Headway, Different Strokes, Stroke Association, Neurological Alliance, Back up, Multiple Sclerosis Society, Parkinson’s Disease Society
SWOT of delivering an effective pathway in North West London The National Service Framework for Long Term Neurological conditions published in March 2005 identified 11 quality requirements to support the needs of people living with neurological conditions. Table 5 summarises the strengths, weaknesses, opportunities and threats to delivering an effective pathway and appropriate service options for patients with Acquired Brain Injury in North West London, as measured against the quality requirements of the National Service Framework for Long Term Neurological Conditions. The members also discussed lessons learnt in managing current patients in existing pathways through use of case histories. Each case history illustrates a case for change to improve patient care with Acquired Brain Injury and as a result be more effective.
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Table 5. SWOT analysis of National Service Framework for Long Term Neurological Conditions and Quality Requirements for
North West London population
QUALITY REQUIREMENTS
STRENGTH WEAKNESS OPPORTUNITY THREAT
QR 1 Person Centred care
Staff who understand patient centred care
Variable waiting times for services & Variable services
Improve referral processes Improve access to information via a Navigator
Multiple providers
QR 2 Early recognition, prompt diagnosis and treatment QR 3 Emergency and acute management
Neuroscience Centre Major Trauma Centre Trauma network
Delays in transfer of care from acute setting to rehabilitation services
Integration of services Reduce delays in transfers of care Faster access to a wider variety of options, especially community based Extend assessment periods in acute settings to enable appropriate service options to reduce inappropriate care
North West London undergoing significant redesign/shaping healthier future
QR 4 Early and specialist rehabilitation
Access to Level 1, 2 & 3 beds Access to community neuro- rehabilitation services Occupational therapy/Physiotherapy/Speech and Language Therapy/Dieticians domiciliary services Access to experienced Rehabilitation consultants, nurses & therapists
Long waiting times Complex referral processes; duplication of assessments Delays in transfers of care from acute and poor flow through beds Limited exit routes for severely affected individuals High administrative burden of metrics, not directly associated with patient care
Stream line referral process Reduce duplication of assessments Reduce metrics requested Use resources better by sharing resources and skills
Historical patterns of referrals and ways of working Strongly held personal beliefs Poor feedback mechanisms As demand for neuro-rehabilitation increases there will be increased pressure for non-
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specialist units to accept patients requiring specialist input.
QR 5 Community rehabilitation and support
Neurological rehabilitation MDT’s in the community in most boroughs
Lack of neuropsychology input. Lack of links and support from mental health services Time limited Limited OPD services Time limited access to reablement carers with neuro rehabilitation skills and training. Lack of Early Supported Discharge services across North West London
Integration with social services and mental health Integrated roles in Acute, primary and social care
Historical patterns of referrals and ways of working Strongly held personal beliefs Poor feedback mechanisms Cost
QR 6 Vocational Rehabilitation
Some access to vocational rehabilitation at QS and Edgware community hospitals
Insufficient services to meet patient needs Poor identification of people who would benefit and when from vocational rehabilitation
Learning from services already set up To develop and use skills within services to provide vocational rehabilitation
Funding of new services
QR 7 Provision of equipment and accommodation
Joint equipment stores and delivery services Governance of equipment Shared budget social services, acute, primary care in the sector Some availability of appropriate accommodation
Limited flexibility in access to funding non catalogue equipment Waiting times for powered wheelchairs Limited up take of technology Complex process of accessing accommodation with waiting
Explore pooling budgets further and making flexible arrangements on funding specialist equipment Simplify process and support accommodation requests
Funding issues and
resource issue
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in boroughs times for adaptations/housing
QR 8 Providing personal care and support
Social services with reablement or skilled teams
Neuro-rehab skills of work force is variable
Integration and redesign Historical patterns of service delivery
limited access to specialist navigator & psychological support
Limited numbers of highly skilled cross boundary posts developed
QR 9 Palliative care services
Training opportunities provided by QS on neuro-palliation
Limited access to specialist nursing home beds if required
Integration and redesign Time/effort
Some specialist nursing home placements
Minimal integration of palliative care with neuro-rehabilitation services
A number of ‘specialist’ nursing home beds across North West London without any clinical assurance of quality.
Palliative care services & Co-ordinate My Care well developed for cancer patients
QR 10 Supporting family and carers
Navigator roles for complex patients
Limited access to navigators access NWL
Training opportunities Time
Headway Brain Injury Nurse specialists Neurological alliance
Developing services from Headway
Integration and redesign
Skilled community teams Limited access to full MDT teams for prolonged periods of time
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Integrated mental health services and access to neuro psychology, psychology
GP engagement regarding the ongoing care of patients with neuro rehab needs
QR 11 Caring for people with neurological conditions in hospital or other health and social care settings.
Key acute care providers with access to neurological services and support
Sharing information across boundaries
System re-design and integration
Knowledge, skills and time A number of ‘specialist’ nursing home beds across North West London without any clinical assurance of quality
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3.4 Case studies
Case histories A and B illustrate the case for change to improve access to complex case
managers and develop care co-ordinator roles with care plans and the importance of access
to neuropsychology and psychiatric support.
CASE HISTORY A Judith, 18 years old was admitted to a Neuroscience Unit following an assault where she sustained a severe Traumatic Brain Injury. She underwent neurosurgery and was on ITU before being transferred to a neurology ward. She had a tracheostomy and was tube fed. She received a period of acute rehabilitation, medical, nursing and therapies and was weaned from her tracheostomy and started to feed 4 months post hospital admission. Judith was transferred to specialist Level 1 Neuro- rehabilitation services at Putney for specialist seating and disability management for 6 months. Her family identified that they would like to manage her at home. There was no complex case worker with Neurological Rehabilitation expertise. She was transferred to the community, rehoused in adapted housing, received four care calls per day and support from community neuro rehabilitation services and Social services. She remains at home requiring ongoing support from carers with intermittent review and input to reassess and manager her needs. Mother struggled to get re-housing; Judith’s room was too small for hoisting equipment to be used effectively therefore was cared for in bed with limited access. There was no review of the tube feeding 18 months on when eating and drinking. Judith developed significant behavioural issues influenced by frustration at lack of activities.
CASE HISTORY B People with changes in brain function who require intermittent access to neuro rehabilitation to prevent secondary impact of brain injury over time such as reduced physical, cognitive, behaviour function, social isolation, financial crisis and depression/mental health. Emily sustained a head injury, was admitted to a Major Trauma Unit and identified to have cognitive impairments and behavioural changes. She was discharged after 2 days as she had sufficient function to manage independently. She was reviewed at 3 months in outpatients. She had been made redundant and hence as financial challenges. She was low in mood, withdrawn and anxious and experiencing relationship issues with her partner. No services are currently in place. She is being followed up in neurology out- patients. At point of hospital discharge, she was referred but was placed on a low priority waiting list. She is now frustrated and not able to engage in the physical and cognitive therapy that has been provided due to her emotional state. The services available do not have access to a neuropsychologist or psychiatric support to assist in enabling Emily.
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Case history C shows the case for change to improve access to vocational rehabilitation services in North West London for people with changes in brain function, who require short term physical, cognitive, behavioural and emotional support to enable them to return to previous levels of independence.
Case history D sets out the case for change for early access to community neurological rehabilitation teams that can deal with cognitive and behavioural symptoms, or a short term transition unit for people with changes in brain functions that effect their cognition and behaviour but not their physical function.
Table 6 outlines the interventions reviewed by the work stream, specifically examining how it effects delayed transfer of care for patients requiring neuro-rehabilitation. Members considered best practice and the evidence and identified key services for patients with an Acquired Brain Injury. Furthermore, the work stream went on to identify interventions and make recommendations that distinguished those that could be achieved without significant investment of resources and those that do require on-going investment. This is outlined in Section 4.
In the next phase of the work the expert clinical group will work in partnership with patients to further explore the issues and opportunities identified, seek to understand in more detail the user perspective and ensure that recommendations for improvement are co-designed with service users and carers.
CASE HISTORY C Julian, 22 years old was admitted to a Major Trauma Centre following a Road Traffic Accident. He was admitted to ITU following neurosurgery and then transferred to the Major Trauma Ward for two weeks. Assessed by Rehabilitation Medicine Consultant and was transferred to Regional Rehabilitation Unit (Level 1) for three months. He was discharged home to a supportive family but there was a delay in starting community neuro-rehabilitation. He required help from his family to gain access to services. He received 1 year of community based therapy with a focus on cognitive and speech strategies and was supported in a vocational rehabilitation program. He returned to work 2 years later.
CASE HISTORY D Asha, 36 years old, male was admitted to a Major Trauma Centre following a Road Traffic Accident. He sustained frontal contusions to the brain. He had orthopaedic surgery for fractures of his left arm. He was confused and aggressive following surgery. He usually worked full time in the family business. Post injury he had poor understanding of risks of driving and lack of insight into the impact of his behaviour on relationships. He was transferred to an elective orthopaedic ward for his own safety and self discharged with friends who he had previously lived with. He was referred to local community services for management of behaviour and cognition. Asha settled in the community and is attending outpatient rehabilitation facilities.
Table 6. Interventions to reduce delayed transfer of care for patients requiring Neuro-
rehabilitation
Barriers to patient flow
Interventions: cost neutral
Interventions: will incur costs
Evidence base
Complex & cumbersome referral pathways with multiple data requests
Stream line referral systems & reduce information required
Train and trust acute assessors
Better information exchange
Web based tool development
OT TBI guidelines NSF for Long Term
conditions. MS guidelines Stroke Guidelines NICE trauma
guidelines ( in development)
NICE guidance on pressure sore management.
Research specific etc.
Historic referral patterns and practices with preferences and different areas of expertise among units
Clearer guidelines on criteria for patient admission to bedded units
Develop training materials
Achieve better skill mix among units
Differences in clinical reasoning and rationale, different thresholds of triggers for inpatient rehabilitation vs community
Reduce differences between units to make the systems clearer, as Level 1 and level 2 differentiations are not straight forward
Lack of awareness of current services
available
Better communication of current services
Inflexible budgets and reluctance to utilise budgets with holding onto funding, to see if can be funded from another pot
Discussion between budget holders and education about CCN and support for panel discussions. Innovative use of budgets.
Pooled budgets
Lack of services and options available in the community
Explore cross boundary working between acute and community services; outreach and inreach.
Vocational rehab services.
Support discharge teams
Skilled carers workforce
OPD therapy services
Day centres/support. Specialist nursing
home beds
Prolonged stays in rehab units due to lack of placements for individuals who cannot be managed at home.
Define standards for length of stay
Develop case coordinator and manager role
Poor utilisation and development of 3rd sector in NWL
Discussion and exchange of information
Headway West to develop with occupational therapist staffing.
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4. Recommendations
The following recommendations are based on discussions undertaken among stakeholders, mainly clinicians. It was noted in undertaking these recommendations the burden of ill health among patients living with an Acquired Brain Injury. For example, estimates suggest that 1 in 4 people aged between 16 and 64 years with a chronic disability have a neurological condition.3
Priority resource improvement proposals in North West London for patients with Acquired Brain Injury to improve patient outcomes
1. We recommend a further increase of Level 2 neuro-rehabilitation bed capacity for
NWL residents by approximately 5 to 6 beds.
a. This figure is an estimate, based on clinical experience of continued demand and waiting times for admission. It will be reviewed following the capacity modelling. The modelling will also need to consider where data allows the overall increase in Level 2 capacity through the additional provision of 16 beds at the Alderbourne Unit, Hillingdon Hospital. These beds are available for all patients resident in North West London.
2. Undertake Multi-Disciplinary Team (MDT) reviews for patients with an Acquired Brain Injury who have cognitive deficits. Cognitive impairment is a risk factor for poor rehabilitation outcomes.
a. It is estimated that in North West London there are 23,719 patients who have an Acquired Brain Injury (activity data). The proportion of those requiring review will vary according to the type of Acquired Brain Injury. For example, even mild Traumatic Brain Injury can cause long-term cognitive problems that affect a person's ability to perform daily activities and to return to work. Estimates for stroke patients suggest that between 30-50% will have a cognitive impairment. It is likely that MDT meetings will be needed weekly. There is a significant unmet need for cognitive rehabilitation and neuropsychological treatment.
b. Increase access to neuro-psychology assessment and treatment, cognitive therapy and neuro-psychiatry provision for patients and carers to be available equitably across North West London and to ensure that sufficient provision exists in each area.
3. Increase provision of specialist nursing and residential care rehabilitation services together with introduction of specialist domiciliary care services to work with community rehabilitation services.
a. Approximately 50% of patients from the Royal Hospital for Neuro-disability (the largest Level 1 service complex physical disability unit in England) are discharged to a nursing home or residential placement.
b. 1/3rd of disabled patients living in a residential setting have a neurological condition.
3 Neuro – numbers http://www.neural.org.uk/store/assets/files/20/original/NeuroNumbers.pdf
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c. Furthermore, there is a need to improve the clinical quality assurance among current providers
4. Pilot a Neuro-Navigator role (Senior Allied Health Professional) as a “pathway coordinator” for patients (as per the Barnet /Royal Free model) across all boroughs and acute trusts.
a. Proposal by ICHP to pilot and evaluate this model in North West London in one volunteer locality with the aim of quantifying the effect on delays in transfers of care.
5. Commission vocational rehabilitation for patients to return to paid or unpaid employment and improve provision of social or day centres for working age patients with ongoing impairments who are unable to return to work. This may be in association with the third sector such as Headway.
a. This will have wider impact on both health and social care budget, to enable patients where possible to return to work.
6. Develop a system for early supported discharge from hospital to home by jointly commissioning social and community care services with specific neuro-rehabilitation expertise and assistive/supportive technology.
Priorities without resource implications
1. Simplified referral process between services.
o Current proposal of ICHP’s work stream B is to develop and pilot a web based referral/waiting list tool. Although, this may have resource implications, simplifying the process does not.
2. Develop standards for rehabilitation teams and refine metrics currently being collected across North West London.
5. Conclusions
A high percentage of the population who acquire a brain injury are of working age. The socio-economic benefits of improving rehabilitation among this group have long term implications for health and social care budgets. Imperial Partners Health Partners preliminary findings suggests that neuro- rehabilitation in North West London would benefit from integrating commissioning of health and social care for patients with Acquired Brain Injury due to their complex and varied needs. Our further work will include patient and carer engagement, developing links with North West London Whole Systems Integrated Care leads, to describe the current issues among people living with a long term neurological condition who need access to neuro rehabilitation services, and developing research questions and audit ideas.
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Project Board Membership
Ronke Akerele Imperial College Health Partners
Liz Bruce Tri-borough
Adrian Bull Imperial College Health Partners
Lorraine De Souza Brunel University
Daniel Elkeles CWHHE CCG Collaborative
Leigh Forsyth CWHHE CCG Collaborative
Shamini Gnani Imperial College Health Partners
Nicola Grinstead Imperial College Healthcare NHS Trust
Yi-Ke Guo Imperial College London
Sue Harman Headway
Nick Loseff
Strategic Clinical Network London
Kathryn Magson Ealing CCG
Charlie Nyein London North West Healthcare NHS Trust
Phil Porter London Borough of Brent Council
Davina Richardson Imperial College Healthcare NHS Trust
David Sharp Imperial College London
Kai Sun Imperial College London
Helen Tilley NHSE London
Lynne Turner Stokes London North West Healthcare NHS Trust
Chao Wu Imperial College London
Geralyn Wynne North West London CSU
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Appendices
1 Summary of definition of Levels of neuro-rehabilitation services
3 Incidence and prevalence figures for long term neurological conditions in NWL London
Population figures Public Health Observatory
Neurology Clinical Strategic Network
4 Map of different referral pathways and services in NWL
Triborough pathway
Ealing pathway
Hillingdon NHS Trust pathway
Neuro-psychology pathway
Barnet pathway – recommended model
5 Job description for Neuro-navigator
6 List of contributors to interim report
