Beyond the Bathboard: Work and Community Participation after Stroke

1. Beyond the Bathboard:Work and Community Participation after Stroke Yashashree Bedekar Occupational Therapist, Vocational Rehabilitation Tower Hamlets PCT Yashashree.bedekar@thpct.nhs.uk 0208 223 8841

2. Go shopping with my daughter Play cards Use my hair straighteners Go on e-bay Run a marathon Go back to work ‘What are your goals?’

3. Context of stroke • 25% strokes in those under 65 years • Most disabling condition with consequences in health, social services and benefits sectors • £1.8 billion in lost productivity and disability • Top three unmet needs reported by young people after stroke: provision of information; financial assistance and lack of intellectual fulfilment (The Stroke Association, Kersten et al)

4. Work- definitions • Employment: paid work in a formal setting • Work: a range of purposeful activities, which may or may not be paid • Volunteering • Study • Extended ADLs • Participation in community life

5. Work matters • Quality of life and work • Links between worklessness and poorer health • Representation of people with disabilities in workforce • DDA • Incapacity benefits and mortality

6. What is Vocational Rehabilitation? • “A process to overcome the barriers an individual faces when accessing, remaining or returning to work following injury, illness or impairment” which includes: • The procedures in place to support the sick individual and/or employer or others (e.g. family and carers), • Help to access vocational rehabilitation • Help to practically manage the delivery of vocational rehabilitation (DWP, 2004, p 14).

7. Vocational Rehabilitation for stroke • Close interplay of: • Core stroke rehabilitation- MDT working • Rehabilitation for work: retraining of skills, adaptation to disability, task analysis, workplace assessment • Knowledge and application of employment law/DDA • Knowledge and application of benefits system • Interlinked with family/carer needs

8. Key Documents: User views • Different Strokes ‘Work After Stroke’ (2002) • 74.8% respondents wished to return to work after stroke • 42% were able to return to work • Barriers for return to work included: • Lack of access to specialist staff • Pessimistic attitude of healthcare professionals • Rehabilitation goals aimed at minimal function • Insufficient scope or duration of rehabilitation • Enablers for return to work included: • Support and advice re: their condition and employment • Liaison between rehabilitation professionals and employers • Occupational therapists

9. Key Documents: Pensions and Health • Working for a healthier tomorrow: Black, 2008 • Vocational Rehabilitation Inter-agency Guidelines: BSRM/RCP/DWP, 2004 • National Clinical Guidelines for Stroke, 2008 • National Stroke Strategy, 2008

10. Putting guidance to practice: NCGS • 6.49.1 Recommendations • A Every person should be asked about the vocational activities they undertook before the stroke. • B Patients who wish to return to work (paid or unpaid employment) should: • have their work requirements established with their employer (provided the patient agrees) • be assessed cognitively, linguistically and practically to establish their potential • be advised on the most suitable time and way to return to work, if this is practical • be referred to a specialist in employment for people with disability if extra assistance or advice is needed (a disability employment advisor, in England). • C Patients who wish to return to or take up a leisure activity should have their cognitive and practical skills assessed, and should be given advice and help in pursuing their activity if appropriate.

11. Practical application 1: Part of rehabilitation pathway • NCGS- early identification of work issues • Occupational therapy core remit • MDT involvement in assessment process • Case Study: Elaine

12. Putting guidance to practice: National Stroke Strategy • Commissioners will want to consider engaging a wide range of provision, including provision from the third sector, to meet the needs of the local population. Services should also be appropriate for all ages; one quarter of people who have a stroke are under 65 and may have particular needs. • In 6 months post discharge, 50% receive the rehab they need… at 12 months 20% receive this.

13. Practical application • 2: Intensity of core rehabilitation by appropriate professionals, and long-term support • BSRM/NCGS/Stroke Strategy • Case study: Abdul • Seen by specialist community team following discharge (OT, SLT, Psych) • Local community centre for resources

14. Putting guidance to practice: An Inter-agency Framework

15. Practical application • 3: Interagency links with DWP, non-statutory organisations • Stroke Strategy, Inter-agency guidelines Case Study: Carl • Seen by community stroke team • In-reach and follow-up by specialist voc rehab OT • Referred to local disability gym- physio involvement

16. Meeting long-term needs • Timeliness of intervention • Intensive rehabilitation as well as long-term adaptation • Sharing of information across agencies • Understanding of stroke and consequences • Employers, families, social settings… • Routes ‘back in’ for review and top-up input • Retention of roles- not just acquisition • Opportunity for 3rd sector partnership working

17. Vocational Rehabilitation models • Specialist Vocational Rehabilitation Programs • Stroke Pathway Teams with extended rehabilitation • Local/ regional centre for long-term support- health and voluntary sectors • Inclusion into mainstream healthcare: • Intensive, specialist MDT stroke rehabilitation in the pathway • Specialist vocational rehabilitation staff (OT, psych) • Extended therapy input for meeting participation goals • Links with DWP/voluntary sector for long-term needs

18. Example of Stroke VR: THPCT • Specialist vocational rehabilitation for stroke and neurology client groups • 1 WTE OT, 8a • 1 WTE TA, 4 • Sessional neuropsychology • Based with stroke and neuro teams • Inreach/outreach at acute, inpatient and community • Developing partnerships with local voluntary group organisations: Volunteer centre, Tower Project etc • Promoting and developing voc rehab skills across relevant teams

19. Measurement tools/outcomes • LTC working group/HfL: standards for vocational rehabilitation- in progress • LTC/BSRM: Implementation guidelines for vocational rehabilitation for people with long term neurological conditions- in progress • Audit of casenotes- RCP/NCGS • Hierarchy of work outcomes • Retention of outcomes: 12, 24 months

20. The bottom line: • Vocational rehabilitation should be part of mainstream healthcare for stroke • Assessment and treatment of work issues begin at inpatient level: OT/psychology staffing levels to support this • Consider links with voluntary organisations for long-term social participation needs • There will be auditable standards for VR interventions

21. What are our goals??