Frameworks

1
Frameworks Guidelines for Practice Recent
developments in the UK

• Andy Tyerman
• Consultant Clinical Neuropsychologist
• Community Head Injury Service
• Vale of Aylesbury Primary Care Trust
• andy.tyerman_at_voapct.nhs.uk

2
Recent national guidelines / standards

• Head injury Triage, assessment, investigation
  and early management of head injury in infants,
  children and adults (NICE, 2003).
• Rehabilitation following acquired brain injury
  (RCP, BSRM, 2003) .
• Vocational assessment rehabilitation after ABI.
  (RCP/Jobcentre Plus/BSRM, 2004).
• The National Service Framework for Long-term
  Conditions (Department of Health, 2005).

3
National Institute of Clinical Excellence Head
Injury - Clinical Guidelines (2003)

• Presentation and referral
• Transport to AE pre-hospital care
• Assessment/investigation in AE (eg CT scan)
• Admission to hospital
• Transfer from secondary to tertiary care
• Observation of admitted patients
• Discharge (incl. sample discharge advice cards)
• www.nice.org.uk

4
British Society of Rehabilitation Medicine

• National Clinical Guidelines for
• Rehabilitation following
• Acquired Brain Injury
• (TurnerStokes L, ed.)
• Royal College of Physicians / British Society of
  Rehabilitation Medicine, Dec. 2003
• (www.rcplondon.ac.uk/pubs)

5
BSRM Guidelines Content

• Principles and organisation of services
• Approaches to rehabilitation
• Carers and families
• Early discharge and transition to rehabilitation
• In-patient clinical care preventing
  complications
• Rehabilitation setting and transition phase
• Rehabilitation interventions
• Continuing care support

6
In-patient clinical care

• Optimising respiratory function
• Management of swallowing impairment
• Maintaining adequate nutrition hydration
• Positioning and handling
• Effective bladder bowel management
• Establishing basic communication
• Managing epileptic seizures
• Emerging from coma and PTA
• Prolonged coma and vegetative states

7
Rehabilitation interventions

• Promoting continence
• Motor function and control
• Sensory disturbance
• Communication language interventions
• Cognitive, emotional behavioural management
• 
  cont.

8
. cont. Rehabilitation interventions

• Optimising performance in daily living tasks
• Leisure recreation
• Computer and assistive technology
• Driving
• Vocational/educational rehabilitation

9
Identified need for guidelines on long-term
community rehabilitation, care support

• Possible content
• Rehabilitation interventions in the community
• Occupational, leisure and social activities
• Family sexual relationships
• Neuropsychotherapy provision
• Supported living (incl. aids/equipment)
• Driving other independent travel needs
• Support for family and friends

10
Inter-Agency Advisory Group on Vocational
Rehabilitation after Brain Injury

• Vocational Assessment Rehabilitation after
  Acquired Brain Injury
• Inter-Agency Guidelines
• Royal College of Physicians, Jobcentre Plus /
• British Society of Rehabilitation Medicine, 2004
• www.rcplondon.ac.uk/pubs

11
ABI Vocational Service Guidelines

• Guidance and support in returning to previous
  employment, education or training.
• Vocational/employment assessment to determine
  alternative avenues of employment or training.
• Vocational rehabilitation to prepare for return
  to alternative employment, education or training.
• Supported employment for those requiring ongoing
  support and/or additional training.
• Permitted work, voluntary work or alternative
  occupational / educational provision.

12
Brain injury vocational rehabilitation provision
ABI Team NP/OT
Occup.Health
DEA
Work Psychol.
Adult Educ.
Care Manager
Work Prep.
Access To Work
Shelt. w/shop
Vol. Work
Permit. Work
WORK STEP
Voc. Train.
New Job
Old Job
Day Activity
13
Inter-Agency Guidelines Implementation

• Development of local inter-agency protocols
• NHS, JCP, SSD, vocational/educational providers
• Key staff to establish ongoing service links
• (e.g. NP/OT regular consultation with WP/DEA)
• Development of ABI vocational training
• awareness vocational needs specialist skills
  training
• Need to review future provision for VR for ABI
• (NHS/SSD) NSF-LTC DWP Framework for VR

14
The National Service Framework for Long-term
Conditions (NSF-LTC)

• Specific focus on long-term neurological
  conditions in people of working age but also
  wider focus on issues common to long term
  conditions
• (Department Health, 2005)
• (www.dh.gov.uk/longtermnsf)

15
What are National Service Frameworks ?

• NSFs are blueprints for care which
• Set national standards and define service models
• Highlight current best practice
• Put in place strategies to support implementation
  and delivery
• Establish performance measures to monitor progress

16
The NSF for LTC aims to

• promote quality of life and independence by
  ensuring that people with long-term neurological
  conditions receive co-ordinated care and support
  that is planned around their needs and choices.
  
• transform health and social care across the care
  pathway, from symptom onset diagnosis through
  acute care rehabilitation to long-term
  community support and, when required, end-of-life
  care.

17
Quality Requirements Structure

• Aim
• Quality requirement
• Rationale
• Evidence based markers of good practice

18
QR1. A person-centred service

• Quality requirement
• People with long-term neurological
  conditions are offered integrated assessment and
  planning of their health and social needs. They
  are to have the information they need to make
  informed decisions about their care and treatment
  and, where appropriate, to support them to manage
  their condition themselves.

19
QR1 Markers of good practice outline

• timely integrated assessment by all relevant
  agencies leading to individual care plan
• covers current anticipated needs - holistic in
  nature
• held by person regularly reviewed (incl.
  self-assessment)
• named point of contact for everyone for complex
  needs named person responsible for co-ordinating
  input
• care assessment/planning for life transitions to
  provide continuity of care (e.g. transfer to
  adult services across geographical boundaries
  change in social circumstances).

20
cont. QR1 Markers of good practice outline

• Arrangements for providing information
• timely, quality assured, culturally appropriate
  information on service provision, on the
  condition and how to manage it and on wider
  social inclusion issues.
• professionals, people with LTNC and carers
  receive training on effective ways to provide
  use information.
• access to education and self-management
  programmes, tailored to individual need

21
QR2. Early recognition, prompt diagnosis and
treatment

• Quality requirement
• People suspected of having a neurological
  condition are to have prompt access to specialist
  neurological expertise for an accurate diagnosis
  and treatment as close to home as possible.

22
QR2 Markers of good practice - outline

• improved access to neurological expertise (e.g.
  through training, shared protocols, MD neurology
  clinics)
• diagnostic services effectively designed with
  sufficient capacity, consistent with NICE and
  other guidelines
• improved access to appropriate treatments
  guidelines, early integrated assessment/care
  planning information
• prompt access to ongoing specialist neurological
  advice and treatment including specialist nurse
  practitioners
• improved access to treatment review

23
QR3. Emergency and acute management

• Quality requirement
• People needing hospital admission for a
  neurosurgical or neurological emergency are to be
  assessed and treated in a timely manner by teams
  with the appropriate neurological and
  resuscitation skills and facilities.

24
QR3 Markers of good practice - outline

• complies with NICE other standards/guidelines
• local hospitals have resources for treatment
  review (ie. staff, facilities, links protocols)
  
• protocols comply with NICE guidelines (eg HI)
• transfer to neuroscience / SCI centres when
  needed (capacity - staff facilities) return
• local hospitals suitable wards, facilities
  staffing for ongoing care, supervision or rehab.

25
QR4. Early and specialist rehabilitation

• Quality requirement
• People with long-term neurological
  conditions who would benefit from rehabilitation
  are to receive timely, ongoing, high quality
  rehabilitation services in hospital or other
  specialist setting to meet their continuing and
  changing needs. When ready, they are to receive
  the help they need to return home for ongoing
  community rehabilitation and support.

26
QR4 Markers of good practice - outline

• rehabilitation complies with NICE guidelines
  takes account of other nationally accepted
  guidelines
• improved access ( re-access) to rehab. provided
  
• early, at appropriate intensity, by co-ordinated
  team
• trained staff support people carers in applying
  skills in ADL
• person, family and rehabilitation team work to
  agreed goals
• seamless transition of care through integrated
  working
• specialist rehabilitation for very severe /
  complex needs

27
QR5. Community Rehabilitation Support

• Quality requirement
• People with long-term neurological
  conditions living at home are to have ongoing
  access to a comprehensive range of
  rehabilitation, advice and support to meet their
  continuing and changing needs, increase their
  independence and autonomy and help them to live
  as they wish.

28
QR5 Markers of good practice outline

• access to flexible programmes focussed on
  individual goals beyond basic care which promote
  participation in life roles
• local multi-disciplinary rehab. and support in
  community by professional with the right skills
  and experience
• - joint working, access to specialist
  expertise available long-term
• support people and their family and carers to
• live with, develop knowledge and skills to
  manage condition
• achieve sense of well-being / long-term
  psychological adjustment
• maintain function prevent deterioration as
  condition progresses

29
QR6. Vocational rehabilitation

• Quality requirement
• People with long-term neurological
  conditions are to have access to appropriate
  vocational assessment, rehabilitation and ongoing
  support to enable them to find, regain or remain
  in work and access other occupational and
  educational opportunities.

30
QR6 Markers of good practice outline

• co-ordinated multi-agency vocational
  rehabilitation taking account of national
  guidance/best practice
• local rehab. services review needs work with
  agencies to provide basic vocational assessment,
  guidance support refer on to ..
• specialist vocational services for complex needs,
  providing specialist vocational assessment
  counselling, job retention and workplace support
  VR programmes advice for local services.
• routine evaluation/monitoring of long-term
  outcomes

31
QR7. Providing equipment and accommodation

• Quality requirement
• People with long-term neurological
  conditions are to receive timely, appropriate
  assistive technology / equipment and adaptations
  to accommodation to support them to live
  independently help them with their care
  maintain their health and improve their quality
  of life.

32
QR7 Markers of good practice outline

• assistive technology provided and maintained in
  accordance with agreed standards and guidelines
• integrated community assistive
  technology/equipment services work closely with
  neurology rehab. services
• equipment needs documented in integrated care
  plan
• specific funding arrangements for assistive
  technology
• social services work closely with housing /
  accommodation and Supporting People services

33
QR8. Providing personal care and support

• Quality requirement
• Health and social care services work
  together to provide care and support to enable
  people with long-term neurological conditions to
  achieve maximum choice about living independently
  at home.

34
QR8 Markers of good practice outline

• health and social services work together to
  provide full range of accommodation, care and
  support options
• care in all settings provided by appropriately
  trained staff who receive support / advice from
  specialist services
• health social services work together to help
  the person remain as independent as possible as
  condition progresses
• equitable access to services based on need and
  support for people in applying for funding, care
  and support

35
QR9. Palliative care

• Quality requirement
• People in the later stages of long-term
  neurological conditions are to receive a
  comprehensive range of palliative care services
  when they need them to control symptoms offer
  pain relief and meet their needs for personal,
  social, psychological and spiritual support, in
  line with the principles of palliative care.

36
QR9 Markers of good practice outline

• specialist neurology, rehabilitation and
  palliative care multi-disciplinary teams work
  together
• specialised generalised palliative care
  services at home or in specialised setting
  according to choice needs
• staff providing care and support in later stages
  of a long-term neurological conditions have
  appropriate training
• neurologists/neurorehabilitation teams in
  palliative care skills
• all staff in management of LTNCs and in
  palliative care

37
QR10. Supporting family and carers

• Quality requirement
• Carers of people with long-term neurological
  conditions are to have access to appropriate
  support and services that recognise their needs
  both in their role as carer and in their own
  right.

38
QR10 Markers of good practice outline

• carers have choice on extent of caring role and
  are offered integrated assessment, written care
  plan and contact person
• involving carers in care planning/delivery
  (partners in care)
• flexible, responsive and appropriate services for
  carers (emergencies children breaks), all
  culturally appropriate
• help with adjustment to changes (especially
  cognitive or behavioural) , when appropriate on
  condition-specific basis
• staff training in carer awareness, education and
  training which involves carers in planning and
  delivery.

39
QR11. Caring for people with long-term
neurological conditions in hospital or other
health and social care settings

• Quality requirement
• People with long-term neurological
  conditions are to have their specific
  neurological needs met while receiving care for
  other reasons in any health or social care
  setting.

40
QR11 Markers of good practice outline

• in other care settings integrated neurological
  care plan available to all staff close liaison
  with usual care team
• neurological needs met in all settings planned
  admissions (pre-admission interviews) emergency
  admissions (protocols for liaison) consultations
  between teams
• consultation with person ( families/carers)
  about care
• neuroscience, neurorehabilitation spinal injury
  services provide advice training for staff in
  other settings

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5. Next Steps Implementing the NSF-LTC

• Suggested early action for Primary Care
  Trusts
• Setting up managed neuroscience clinical networks
• (incl. leadership, financial accountability)
• Stakeholder event to agree local priorities
• Setting up a local implementation team
• Setting up integrated planning commissioning
  arrangements with Social Services other PCTs
• Influencing provision of housing-related support

42
Clinical neuroscience networks

• Key stakeholders might include
• PCTs specialised commissioning groups
• acute trusts foundation trusts mental health
  trusts
• neuroscience centre and spinal cord injury centre
  
• community and home care providers
• rehabilitation services
• local authority services (SSD, housing,
  transport, FE)
• voluntary and independent sector organisations
• people with neurological conditions carers

43
Other possible early actions

• Assessing/auditing services, skills training
  needs
• using LTC self-assessment tool for PCTs and SSD
• auditing local services across all local
  organisations
• analysing and profiling skills of local workforce
• identifying key training needs for all agencies
  
• Redesigning services
• redesigning services and considering new patterns
  of working and skills mix (e.g. integrating
  trust local SSD staff in specific
  multi-disciplinary teams).
• 
  

44
NSF-LTC Good practice guide

• Managing LTCs self assessment tool
• Tackling the issues - guidance papers
• Care coordination for people with LTNCs
• Local provision of information
• Service models for LTNC
• Evaluated examples of good practice
• (website guide - www.dh.gov.uk/longtermnsf)

45
NSF-LTC Implementation 2005/06

• Department of Health
• Project Team National Leads
• National Stakeholders Group
• Neurological Advisory Panel
• Professional groups
• Working parties / professional standards / audit
  etc.
• Regional / Local Action
• SHA Leads Neuroscience/Neurological Networks
• PCT Leads local implementation groups

46
NSF-LTC Neurological Advisory Panel

• Discussions have focused on
• Policy integration / differentiation
• Incorporation into inspection process
• Development of specific clinical indicators
• Putting the NSF-LTC on PCT and LA agenda
• Commissioning issues
• Development of an minimum dataset for LTNCs
• Development of models of service provision