After experiencing an acute stroke, patients come to the 20-bed Oxfordshire Stroke Rehabilitation Unit at Abingdon Community Hospital as part of their care pathway. They normally stay at the service, run by Oxford Health NHS Foundation Trust, for around four weeks before they’re discharged home or to other locations in the community.
Follow-up rehab is usually provided by the county’s community therapy service, but with the Covid-19 pandemic in March came a national focus on patients being discharged from hospital, and rehab services were put on the backburner.
“At the same time, two of our allied health professionals were shielding, and couldn’t work face-to-face, and we had patients discharged without being followed up,” says Emma Garratt, clinical lead physiotherapist and interim ward manager at Oxfordshire Stroke Rehab Unit.
The team decided to set up its own follow-up service, aiming to provide advice and support, and ongoing rehab. They have since followed up almost 80 patients who have been discharged from the service.
Garratt says they have seen some ‘brilliant’ success stories so far, with patients who have made great progress, including getting back to driving and work.
“Covid forced a lot of services to innovate and look at how they work. This was an idea one week and put into action the next. We thought, ‘We have staff who can’t work on the ward, and patients who need support, so let’s find a way to do that’.”
The follow-up starts with a phone call, then remains either telephone follow-ups or transfers to video calls. Garratt says there’s an effort to move on to video calls for as many patients as possible, although for some this isn’t feasible.
“For some patients, it’s been more about advice and support, acting as a signposting service, answering queries that have cropped up, that they’re not sure who else to ask.
“For other patients, it’s been very much a rehab-focused process, with one or two sessions a week to progress their exercise programmes, mobility and independence” she says.
“It very much feels like the service meets a need, and it does different things for different people.”
Now, Garratt feels the programme is at a point where it needs evaluating, and the team is collecting patient data with the aim of measuring its impact. Staff are also collecting feedback from patients, which Garratt says has been ‘overwhelmingly positive’. A patient discharged home during lockdown said: ‘The remote sessions have given me exactly what I need, and I feel that I am making steady and good progress towards my aim of a very good recovery to a pre-stroke situation’.
There isn’t a specialist community neurological rehab service in Oxfordshire, so before the pandemic, patients leaving the stroke rehab unit would be followed up by a generic community service that doesn’t necessarily specialise in stroke.
The new service allows patients to be followed up by clinicians who normally work in the rehab unit, and who are familiar with the patient pathway, the service and its staff. This allows good continuity of care, Garratt says.
Garratt, who also has a good knowledge of the patients, has been having weekly meetings with the therapists working in the follow-up service, giving them advice where needed.
“Continuous care is really valuable for patients. It helps them feel like they’re not being passed from one group of people to another, and that the whole process isn’t starting again. Ideally, we would like the process of people moving through the stroke pathway to feel quite seamless for them, even if we’re juggling things behind the scenes,” she says.
“Simple things, like a therapist having access to a patient’s admission notes and having direct links with that service, helps with this. The programme isn’t currently using any extra resources, it’s simply making use of staff who are shielding, who otherwise would have been at home or redeployed.”
They’ve had a locum filling in for this on the ward, Garratt says, but otherwise, the service hasn’t had any additional funding. In order to run the service long term there would need to be extra resources, which Garratt is currently looking into, as staff will be needed on the ward to maintain quality of care.
One challenge with community services is the time-consuming nature of travel, Garratt says. There is potentially a group of patients that could be supported through such a remote service, and this may free up capacity for face-to-face community teams to meet other patient’s needs.
“Being optimistic, I’d like to think this is longer term than the virus, as it’s meeting a patient need. A lot of research shows us that, when patients leave in-patient services they feel ‘abandoned’ and like they ‘drop off a cliff’.
“They feel unsupported – often because community support post-discharge is lacking, due to insufficient resources.
“We’re seeing that this project helps bridge that gap a bit. There is definitely a cohort of patients who need face-to-face input as well, so it doesn’t solve everything, but having someone to talk to proactively, to get advice from, and guide ongoing recovery, is helping our patients with the transition from hospital to home” Garratt says.