Upper limb rehabilitation in the community: improving patient experience

The primary aim of the project was to develop a local approach to improve the therapeutic experience of patients with functional difficulties due to upper limb disabilities. Whilst improving their ability to engage and participate in their care. This all needed to occur whilst managing the wider caseload and waiting times.

Long term the aim is to prevent patients requiring further medical intervention such as operations and increased medication. Overall this would have an impact on the wider multidisciplinary team by reducing appointments.

From the patients perspective the aim was to reduce the waiting times and improve their experience accessing the service. Functionally patients wanted to notice a decrease in the difficulties experienced in daily activities by appropriate intermediate care and rehab whilst working towards the patient centred goal; for example to hold a cup, prevent pain, return to work/ hobbies or improved appearance of their upper limb. Whilst improving patient experience the therapists were able to upskill their knowledge specific to this rehabilitation process. As a consequence to these actions the team were more likely to achieve the Trust’s target waiting time for a therapy assessment.

All of this work needed to be completed whilst continuing to provide our standard service provision so as not to impact on other patient care and experiences.

Despite a high percentage of the local population having neurological conditions there is no dedicated neurological rehab team nor funding for the rehabilitation. To meet the demand of local service provision we decided to review how the service was provided and if this could be changed to improve patient experience whilst continuing to meet the expectations/ requirements of the other caseload.

Specifically we noted (via patient feedback (verbal and written) and outcomes of therapy provision) the patient’s experience of rehabilitation was poor and they often didn’t receive the goals they had hoped. The aim of improving patients’ functional abilities would long term prevent dependence on other services for example care needs and nursing needs due to contractures and wounds etc. The team would feel more in control of the caseload management: aiming to prevent the build-up of large caseloads.

Often those needing longer term rehabilitation would have appointments changed or cancelled due the demand of rapid response referrals. The aim of the work would be to reduce these cancellations. There would be a reduction in waiting times due to improved caseload management, ideally within the trust target time of three weeks from referral. By having a focus on upper limb the therapists would have the opportunity to upskill in this specialism and then share these skills with each other. These skills would also be transferable across to other patient groups.

A gap in service provision was identified by reviewing patient feedback (achieved through formal feedback forms and informal verbal feedback) and outcomes (no outcome measure was being used so this was observational and feedback). The team spoke with a variety of patients with upper limb difficulties and discussed their expectations at key points of their rehab journey:

• Transfer between acute trust and community services (if appropriate).
• Initial contact from the community team.
• Treatment options offered and location.
• Benefit of therapy from their perspective.
• Timeliness of discharge.

As a team we then decided to continue to see the patients within the usual therapy pathway (but with improved skills and community resources) for those needing to be seen at home and to operate a group for those able to attend the hospital. The group initially ran weekly but was reduced to fortnightly as the demand was not as high as expected.

Over time we found a group setting was not the right avenue and a clinic was formed instead. To upskill team members we identified gaps in knowledge. For training either one therapist attended a study day and disseminated the knowledge to the team or informal learning was completed within the team. Upskilling remains an ongoing process. Once the adaptation to the service was implemented we shared the information with local GPs and hospitals.

Over time patients shared our approach with the local neurologists and spasticity clinic which spread our reputation. Resources were purchased within the team budget, but costs were kept to a minimum. The focus for resource has been that they need to be suitable for taking to patients homes so that all can access the service. Resources were purchased for outcome measures, splinting, sensory and fine motor activities. As far as possible resources were used from within the patients’ environment to save on costs. The service has implemented two assessments which are used as outcome measures, both specifically link to upper limb function. Qualitative review of patient feedback also remains a key to monitoring the benefits of the service. The adaptation to the service is constant but we plan to review the service thoroughly every six months to see how it needs adapting.

The largest unexpected finding has been the cost savings to the trust by purely changing how a service is delivered. It has been calculated that the service creates a cost saving of over £1600 per year for the department. This has primarily occurred by reduced duplicate visits referrals. But also as we now have access to making splints in the patients’ home rather than relying on 'off the shelf' splints. Previously we were spending a minimum of £2200 per year on off the shelf splints, now we are spending approximately £500 to make same amount of splints.

Other findings have included:

• Increased efficiency of treatment available; previously had to wait at least four weeks for off the shelf splints to arrive in the meantime patients tone and contractures would increase and the damage was often irreversible. Often now the team are able to fabricate splints on the day when the need is identified.
• Overall there appears to have been a reduction of patients requiring treatment from other services. For example attending the GP for analgesia or nursing visits due to wounds from contracted fingers. A specific example is a patient with a contracture that was prevented from worsening by efficient and effective splinting, preventing deterioration rather than having to undergo Botox, tendon release operations or taking expensive medication.
• Staff have higher skill level and competency level, meaning better care and treatment for patients.
• Referrers asking us to see patients outside of our working area/patch due to the treatment we can provide. Unfortunately we cannot provide an out of area service but are working with commissioners on service specification and the benefits and cost savings long term.
• The team have seen a reduction in re-referrals for new splinting needs. Prior to this project when off the shelf splints were used or patients were waiting longer for rehabilitation the team were experiencing a high number of re- referrals as patient needs had not been met.
• Reduction in community nursing referrals for pressure sores/ wounds from contracted fingers or deformity.
• Over half of our patients have had a reduction in care package needs due to improved upper limb function.
• There has been improved liaison with neurologist, spasticity clinic and other specialists which has improved the patients’ experience of the pathway.
• Patient feedback has improved. The majority of patients report the service meets their needs and expectations.

The key learning for the team has been the upskilling of clinical skills. This has improved in patient assessments and then treatment outcomes.

 If this study was to be replicated I would have looked into funding options for more formal study as this would have implemented the learning quicker than by research and internal training. The service ran a group setting for approximately one month but patient and therapist feedback indicated this was not the correct avenue.

Patients found they did not benefit from the social element and felt they were ‘hanging’ around to see a therapist. The therapists felt the range of upper limb conditions and needs were too diverse to see everyone at once and they needed to see patients on a one to one basis. Therefore the group was converted into a clinic. This continues to give protected time for patients needing upper limb rehab preventing these appointments being cancelled for rapid response work. In order to manage the demand between rapid response and rehab patients the team has a ‘duty’ therapist whose role is to respond to the rapid response referrals.

Having changed the pathway for patients with upper limb difficulties we now plan to review the pathways for other conditions and to see if this system can be replicated.