5th Edition July 14th, 2020 Neil Brownlee

The development of a discharge transition service: Countering the impact of Covid 19 in neuro rehabilitation

The impact of moderate to severe brain injury on individuals and their families is often catastrophic. The lives of the brain injury survivor and their loved ones can be changed in an instant. The road ahead for the person is often one of lengthy periods of neuro rehab in hospital and community settings in an attempt to regain previously achieved emotional, physical, cognitive and behavioural milestones.

The journey faced by families and friends of people with brain injuries is often traumatic for them too as they try to make sense of this new medicalised world of disability and recovery that has been thrust upon them. At a time when they are trying to manage their fears about how much recovery their loved one might make, and how they are going to cope, they suddenly find themselves in multi-disciplinary meetings with a range of health and social care professionals trying to learn a whole new language of subdural haematomas, CT scans and mental capacity assessments.

It would be wrong to view neuro trauma and the subsequent rehabilitation process within a medical context alone. We must look toward the social model of disability to help us gain a more holistic understanding of the impact brain injury on individual and their families. Failure to do so will result in a failure to understand the realities and priorities that the family face, and in turn this could negatively impact on our ability to affect positive change. As a qualified social worker I understand the impact of the attendant social issues, which often mean that families are hit with a double whammy of concerns: the medical and the social. In many cases the brain injured survivor provides income to the household and is responsible for dependents. This leaves families with additional social concerns such as rent or mortgage payments, living on reduced income, child care support and how to explain to their children that Mum/Dad might be different than before.

The medical and social impact of brain injury can be minimised if the person has access to a Major Trauma Centre immediately after the injury, a specialist neuro rehabilitation unit once medically stable and a specialist community neuro rehab team to ensure they continue to make rehab gains long after the hospital doors have closed.

Unlike many parts of the Country, in the Northeast of England these pathways are well established between the Royal Victoria Infirmary Hospital (Major Trauma Centre), Walkergate Park (Centre for Neuro Rehabilitation and Neuro Psychiatry) and a range of community teams such as Northumberland Head Injuries Service, Sunderland & Gateshead Community Acquired Brain Injury Service and the Regional Disability Team to name a few.In normal times the person would flow from one service to the next on their rehab journey back to the community. By early April 2020, signs were present that the flow was being halted by series of log jams and bottlenecks as a result of COVID 19.In normal circumstances the Ward staff and therapists would complete home environmental visits to assess the suitability of a property. They would order and fit grab rails, make adaptations and arrange handovers with families and care teams to ensure a smooth transition took place. The person would be given a period of home leave prior to discharge. This period was used to identify any unforeseen needs as well as being used to help the family become accustomed their new life post injury.

As a result of COVID 19, Walkergate Park could not risk ward staff and therapists continuing with their usual discharge practices due to the risk of them bringing COVID 19 back onto a ward. Unless a solution could be found Walkergate Park would be unable to safely discharge people to the community and by the same token would have no available beds to take new people from the Major Trauma Centre.

A timely solution had to be found to keep the pathways moving and to ensure people did not stay in hospital a day longer than they needed to. On April 13 2020 work began drafting a ‘changes to service’ plan. This was written up and submitted to our Trust’s senior management team responsible for all COVID 19 operations  and within the space of just one week the Discharge Team went from concept to reality.

The team was built utilising staff from community services who found their workload decreased due cancellation of non-essential appointments in order to minimise the risk of virus-spreading. The team was led by me, a qualified social worker and the team manager of Northumberland Head Injuries Service, and an Occupational Therapist/Team Lead from the Regional Disability Team. The core team was made up of the two Discharge Co-ordinators from Walkergate Park, both nurses with invaluable knowledge of the staff and therapist working in the rehab centre as well as the established systems and processes in place at Walkergate Park, two Occupational Therapists and a Physiotherapist from specialist driving assessment service Northeast Drive Mobility and an Occupational Therapist  from the Community Neuropsychiatry Team. We also had input from a case manager from NHS England to assist with any commissioning issues that may otherwise have delayed the discharge. Additional staff were drafted in as required from two local head injuries teams; Northumberland Head Injuries Service and Sunderland & Gateshead Community Acquired Brain Injury Service. These staff would work alongside the core team on the day of discharge and provided some of the follow up support which allowed the core team to focus their energy arranging the next discharge from the Centre.  

The plan was designed to ensure ward based staff would remain on their wards to look after inpatients so that those environments remained COVID secure. This new Discharge Team would not set foot on the ward but would take responsibility for the person’s transition to the community. This involved making sure that all the practical tasks to ensure a safe discharge were in place, providing two week follow up support to manage any teething problems and to ensure appropriate longer term support was in place from local services.

Technology played a key role. Using video conferencing technology, the Discharge Team were present at the person’s discharge planning meetings and multidisciplinary meetings which were held on the ward. They were given a full hand over by the Multi-disciplinary therapy staff working on the wards and received copies of the discharge packs developed on the ward, a comprehensive document consisting of reports from the consultants, nurses and therapists who have been involved in the person’s rehabilitation. It includes recommendations for rehabilitation strategies that can be continued in the community and a summary of the achievements gained as an inpatient.    

Using online technology the discharge team made contact with the patients and their families. They arranged environmental visits, sometimes using virtual technology where a family member would use a smart phone to show the team the layout of the house. Sometimes they would carry out a home visit wearing PPE.  The factors considered when deciding on home visits included whether the person a had complex physical health needs, whether  a family member was shielding and the location of the property. Staff completed various risk assessments as required, and they collected and installed mobility and other aids and adaptations which had been ordered by the Ward based therapists.

A weekly socially distanced team meeting was arranged for Discharge Team members with some staff calling in on MS Teams. During this forum the team would receive updates on patient’s rehabilitation progress from the discharge co-ordinators and ward based therapists so that proposed discharge dates could be firmed up and worked toward.

People ready for discharge in the coming weeks would be allocated amongst the team so that equipment lists could be checked off, referrals could be made to longer term support services and hospital transport arranged. The team would also use the forum to discuss the previous week’s discharges, with regard to any ongoing support needs or problems that needed to be overcome.

Another forum that was introduced was a reflective practice session every two weeks. In addition to the forum allowing staff to reflect on patient care, due to the rapid development of the team, sessions focused on operational issues as well. For example it came to light that when the Discharge Team escorted a person home on discharge they took much longer to hand over to families than the regular therapy staff did as they were less familiar with the person and their needs. This was proving difficult for people transport as the ambulance bookings had not accounted for the extra time.

A solution was quickly found: as three of the team came from Northeast Drive Mobility (NEDM) they had access to NEDM’s fleet of vehicles. One member of the team would escort the person home in the ambulance while the other followed in a fleet car from NEDM. Once the person was dropped off the ambulance could return to the hospital leaving the Discharge staff to take as much time as they needed for the handover as they had their own means of getting back to base.

Once the discharge took place the team remained involved with the person and their families for two weeks. In spite of this being a short window, the team found themselves dealing with some big issues. These included supporting families who were much more anxious about looking after their loved ones than they disclosed previously, supporting housing applications for major adaptations, making safeguarding alerts and sharing information with one person’s social worker so they could update  the Multi Agency Risk Assessment Conference (MARAC) who were monitoring concerns about the person being subject to coercion and control

As Service lead I found myself in the privileged position of supporting and supervising a great team of professionals who were put together to do a difficult job in challenging circumstances. I recall one debrief after two of the team experienced a particularly challenging encounter with the wife of a discharged person resulted in us having discussions about the need for the person’s wife to have support in her own right. When I caught up with staff the following week, they had liaised with social services, the care package had been increased immediately to allow the carer to have a few hours to herself each day and a carer’s assessment was pending. This shows the value to practitioners and the people they support of preserving and maintaining regular reflective supervisory forums in times of crisis, when things are moving quickly and services need to respond creatively and flexibly.

Despite the challenges, the team remained operational for ten weeks. During that time the team supported 20 people to return to their own homes, or to new homes,  or if that was not currently possible, to supported living or residential care.

We learned a lot from undertaking this project.We discovered that when we dispense with tight criteria we have fewer restrictions and are better able to fit support around the person’s needs, wishes and feelings. This fosters a solution focussed ‘can do’ attitude to resolving problems and removing barriers.

The shorter, two week follow up time frame focused person’s minds on what needed to be done. This led to more efficient working and reduced the risk of creating over-dependency on professionals and services which helped us better support people’s wishes to be independent.

We also discovered on going back to our respective community teams that we were now far better geared towards working more collaboratively with our inpatient colleagues.

The pandemic has caused devastation and disruption to people’s lives everywhere. It has presented major challenges to the provision of health and social care. These are likely to continue for some time yet. What is encouraging as we begin to reflect on the impact of COVID 19, is the way in which teams and professionals spanning health and social care rapidly adapted to meet the challenges in a dynamic, rapidly evolving set of circumstances. We intend to take these new discoveries forward with us into a post COVID world in order to continue to improve, adapt and shape services so they work to the fullest advantage for the people we support. 

Neil Brownlee, Long Term Conditions Lead, Cumbria, Northumberland Tyne and Wear NHS Foundation Trust