In comparison to service one, at service two the review team visited stroke survivors at six weeks, six months and annually for three years and observations were performed of each type of review. The review process performed at service two was in line with the recommendations of the National Stroke Strategy to a greater extent than at service one. However, stroke reviews had been provided in the local area for more than ten years, as the service funded three practitioners specifically for this purpose. Administrative support was also provided to help manage their large caseload e.g. to correspond with service users and organise their case notes. The provision of reviews for up to three years post-stroke was in line with, but also extended beyond the recommendations of the National Stroke Strategy, as the service manager (S2SM) commented.
S2SM: ‘We’re doing over and above that actually [recommendations in the National Stroke Strategy], but just due to resource issues and that we’ve made sure that we do that as a minimum and if we can, if somebody needs a three month review, if, you know, if someone who’s perhaps more complex we’ve left that for the nurses to make professional judgement as to whether they feel that review or not and they make a decision. Some people can’t wait. In fact, what we’d like to do is keep that as a permanent but we’ve had to respond to sort of pool our resources in another area, so, but yeah we do the minimum that is outlined in the Stroke Strategy, but we’d like to do more than that ‘cos I presume they’ve told you that we review up to three years....so that’s over and above but we’re gonna have a look at that again and maybe think well rather than review it at year three, maybe stop at year two or something and then concentrate more on the first twelve months, so bring back in the three month review but
take off the three year review. We haven’t made any final decisions on that.’
The three-month review, to which the manager refers, was previously provided as standard practice in the context of service two. Due to restraints on local resources and the publication of the Stroke Strategy (which recommended less frequent reviews) the three-month review was removed. However, the team were keen to re- introduce this and occasionally still provided it to individuals that had complex needs. The service manager’s remarks indicate how the provision of stroke reviews was also subject to change in the context of service two and the system of care was implemented in line with the decisions of local stakeholders.
The patient pathway at service two was slightly different to the one followed by individuals at service one. The Stroke Liaison Nurse (S2LN) identified stroke survivors prior to their hospital discharge through attendance at MDT meetings held on the acute stroke unit. These meetings were observed during fieldwork and revealed that the Coordinator had knowledge of all individuals admitted to the stroke unit, their progress during their period of inpatient rehabilitation and their discharge destination, as these were the areas discussed during the meeting. Stroke survivors were discharged to either the Intermediate Care Team (ICT) where intensive rehabilitation in an inpatient setting was provided, Early Supportive Discharge (ESD) where intensive ongoing rehabilitation in a community setting was provided, or directly home and to the care of the community stroke team. The Liaison Nurse contacted individuals discharged to the community within two weeks to ensure that they were coping in their home environment, and to inform them of their six-week review. A service letter including the HADS and the checklist was then administered. At the six week visit the Liaison Nurse completed the LoTS care assessment and provided specialist-nursing input (as described in chapter five). A copy of the care plan documented was sent to the individual with a letter providing contact details for the service. The Specialist Nurse repeated this process at six months, and the Generic Worker annually for three years. Service users were discharged from the team’s active caseload at their three-year review.
The intervals in which the stroke reviews took place indicate when service users had contact with a Coordinator, and consequently the system of care. The number of reviews performed in the context of service two was markedly different to that at service one. These differences are depicted in table 15 below for clarity.
Table 16: Coordinators contact with service users
Although not stipulated, a review of service users’ needs was expected as part of the system of care. A stroke review would enable the Coordinator to identify and address new problems as they emerged over time. Pilot work had suggested that this was a necessary process (Murray et al., 2006, Dowswell et al., 2000). However,
Service one
Referral accepted - checklist administered to service user
LoTS care assessment within 8 weeks of receiving referral, care
plan developed
Service user reviewed if re-referred to the service, or their needs
substantially change
Service two
2 week phone call to service user
Checklist and HADS administered to service users (administered
before each review)
6 weeks post-discharge: LoTS care assessment and care plan
developed
6 months review: LoTS care assessment, new care plan
documented 12mth review: LoTS care assessment, new care plan
documented
Reviews continue annually for three years
the review process employed at each service was shaped by local policy, which resulted in two distinct applications of the system of care. In the context of service one the Coordinators performed one LoTS care assessment when stroke survivors entered their service. Stroke reviews were being piloted in the local area, but locally developed tools were used for this purpose. At service two individuals were assessed three times within the space of a year (the duration of the trial) using the LoTS care structure i.e. stroke survivors had three opportunities to discuss emerging and ongoing problems with a Coordinator. These review processes adhered to the implementation principles to a greater extent than at service one, but this reflected a continuation of previous practice rather than an enhancement through the system of care.
The next point of inquiry became the monitoring processes performed i.e. what was the role of the Coordinator in ensuring the care plan was implemented after the initial assessment at service one, and between stroke reviews at service two.