Joint care planning
Accelerating Stroke Improvement Measure
ASI 7: Joint health and social care management Proportion of patients and carers with joint care plans on discharge from hospital.
Quality marker 12 of the National Stroke Strategy refers to the need for 'A workable, clear discharge plan that has fully involved the individual (and family where appropriate) and responded to the individuals particular circumstances and aspirations, is developed by health and social care services, together with other services such as transport and housing’
This quality marker sets a clear standard that individuals and their families should have a discharge plan, fully involving them in the design, and which takes into account their heath and social care needs.
Recent audits of this part of the stroke pathway by the National Audit Office (NAO) (2010) and the National Sentinel Stroke Audit Round 7 (2010) showed some progress still needed to be made in achieving effective joint care panning and transfer of care from hospital.
The NAO report of stroke services, Progress in improving stroke care (2010) included a national patient survey of over 600 stroke survivors and carers (see page 31, point 3.2). The third most frequently cited comment about patients’ experience of their stroke care expressed dissatisfaction with their transition of care from hospital. To summarise patient feedback: 'More co-ordination is needed between sections of the NHS, and between healthcare and social services / a single named professional is needed as a coordinating point of contact'
The NAO found that in 2009, nearly one-third of patients were not given their discharge summaries, and that only two-thirds of hospitals had a policy of giving patients a named contact upon transfer of care from the hospital to the community. This is consistent with the National Sentinel Stroke Audit Round 7 (2010) which found that 40% of patients were not given a personalised discharge rehabilitation plan and 29% were not given a named point of contact on discharge.
Improved joint care planning was recognised at the Public Accounts Committee in 2010 as being an essential component of good care after stroke and one which warranted greater focus. It has been included as one of the nine components of Accelerating Stroke Improvement.
The Royal College of Physicians (RCP) National Clinical Guidelines for Stroke (2008) recommend:
- Transfer of care protocols should be developed to include the patient, family and all services involved in post hospital care
- Patients should be involved in decision making about transfer of care
- Patients should be offered copies of their discharge documentation and information
- Patients should have access to specialist stroke services and further support and know how to make contact
Carers of stroke survivors are key in the process of the transition from hospital to the final place of residence. Their involvement in the process and their need for support and information is recommended in the National Stroke Strategy and in the RCP National Clinical Guidelines for Stroke. In addition, the National Institute for Clinical Excellence (NICE) Stroke Quality Standards include a standard for involving carers: Standard 11 – Carers of patients with stroke are provided with a named point of contact for stroke information, written information about the patient’s diagnosis and management plan and sufficient practical training to enable them to provide care.
Fair Access to Care Services (FACS) was introduced in 2003 to address inconsistencies across the country regarding the allocation of social care support. This document summarises what FACS is and how it applies to social care for stroke survivors. Further information:
Information about relevant studies in discharge planning and joint care planning for people who have had a stroke
Support for implementing joint care planning for accelerating stroke improvement
A workshop comprising carers organisations, The Stroke Association, social care, the Department of Health, the Care Quality Commission and representatives from cardiac and stroke networks interested in improving joint care planning was held in October 2010.
Outputs from the group were:
This page will evolve and develop as more learning is gathered from those who are finding new and creative solutions.
To let us know about your work or to get involved, please contact Sarah Gillham.