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Case studies > 2022 case study competition > A Seamless Pathway: Putting the patient needs at the foremost of their rehabilitation journey.

A Seamless Pathway: Putting the patient needs at the foremost of their rehabilitation journey.

Midlands Partnership NHS Foundation Trust

Quality improvement aims: To improve patient quality and experience though embedding new ways of working within the stroke rehabilitation pathway

Clinical challenge
The NHS long term plan raised stroke care as a focus and priority in response to the changing population demographics, the increased number of people having strokes and the predication that the number of stroke survivors living with disability will increase by a third.

At the Haywood Hospital, Midlands Partnership Foundation Trust, we provide specialist inpatient rehabilitation to complex stroke patients who have multiple needs, physical, social, cognitive and psychological. We work as part of an MDT to ensure the needs of individual patients are met, working to achieve their goals and to maximise their independence in order to reach a level where they are medically stable and their rehabilitation and care needs can be safely and adequately met in an alternative setting. In keeping with the findings nationally, the Staffordshire Stroke rehabilitation SSNAP report 2021 highlighted the increase demand for stroke care services within Staffordshire, the increase in dependency of patients requiring rehabilitation which ultimately resulting in the increase in length of stay in our specialist inpatient and community rehabilitation service.

The National service model for an integrated community stroke service highlights the importance of a seamless and timely transfer of care for patients from an inpatient stroke unit setting into the community and that there should be cross team working between stroke units and community rehabilitation to ensure this.  In response to this and the evidence of an increase in service demand from our SSNAP report it has led ask to ask these questions;

  1. Can we enhance patient’s experience, their quality of care through making their transfer of care between bed based and community services seamless?
  2. Can we expedite the discharge of more dependent patients by being able to support their rehabilitation needs in the community through a bridging service: a collaborative approach between bed based and community based services?

A quality improvement initiative has been commenced starting with a scoping period of 12 months. The initiative is following a Planning-Do-Study-Act (PDSA) model and to include primary and secondary outcomes which will form a part of the service improvement methodology.

The planning/scoping phase commenced in July 2022, which the following has been tested:

  • Identify patients who would benefit from a ‘bridged’ discharge through collaborative discussions between bed based and ESD/CSRT prior to discharge.
  • Electronic referral for the ESD/CSRT team made following negotiated date for discharge, admission and joint ‘bridging’ approach. This will entail joint handovers, continuous assessments and / treatments to enable patient to be transferred between services more seamlessly and reducing duplication.
  • Workforce and time management initiatives to reduce negative impact on either service to provide collaborative approach.
  • Cross team working between the ward therapy team and ESD/ CSRT team results in a seamless referral system for patients on discharge without duplication.
  • Cross team working fosters peer to peer learning resulting in improved quality of care for patients
Impact so far
“Following my Mums stroke in February, Mum was at Haywood for several months (and Cheadle) with NHS staff on the ward leading therapy sessions with Mum. Mum has been in a local nursing home since August. As you can imagine the last few months have been very stressful and continue to be so. A thing that can reduce that stress, I feel helps mum to feel a bit happier, more comfortable and help with her rehab. One of those things is Mum having continuity of therapy and staff in general, so mum can feel more comfortable and feel confident to push on with her rehab. Having support from the ward team has helped Mum, with both the community and ward therapists being very caring, friendly and professional. In my opinion, if this way of working was to continue going forward, it would be a huge positive and I feel would help the rehab of any future stroke sufferers. Finally a huge thank you from Mum and me.” (Haywood hospital, Sneyd ward Service user JH’s son)

This scoping project of ward therapists forming a discharge bridging service is an ongoing project with the aim for the above evidence and further evidence to be collated and used to make changes to service provision on a permanent basis. We have already seen the impact of using our current resources differently to respond to the SSNAP findings, and to respond to the needs of the individual patients through patient’s feedback, facilitation of a faster discharge for complex patients, efficiency in the referral process to ESD/CSRT.

With the changing population demographics and the predicted of continued increase in service demand we need to provide a seamless stroke pathway and a seamless referral system. We need to support patients in the community who are more dependant and support the ESD/CSRT team with the increased service demand.     

Next steps
  • Ongoing work between ward therapy team and ESD / CSRT to develop the stroke pathway and collect patient feedback and review SSNAP audit data for ongoing impact
  • Submit bids for future investment funding. This will look at building on this quality improvement initiative by bringing together the expertise of clinicians and care experts with commissioners and stakeholders in determining the future shape of stroke services across the Staffordshire system.

Find us

Sentinel Stroke National Audit Programme
Kings College London
Addison House
Guy's Campus


0116 464 9901