Rapid Access Specialist Neurological Physiotherapy Service
NHS Greater Glasgow and Clyde
The Neurological Rapid Access Physiotherapy (NRAP) service in Greater Glasgow and Clyde is a discharge to assess model that provides specialist outpatient neurological physiotherapy for those who were medically fit for discharge, or were in crisis and risk of admission. This allows for people with Functional Neurological Disorder (FND) to experience a better and timely transition from acute to community care.
People with FND often remain in acute care longer than necessary while waiting for community rehab services to take over their care. Typically, people are admitted to the acute neurology wards for specialist management as there is a lack of coordinated support in communities. This is a very expensive model of care and is often not the best environment for successful progression and management of this group.
The NRAP service partnered with local community services to optimise care and provide seamless transfer of care when required. The service aims to deliver rehabilitation services that would normally be offered within a hospital setting at home. This transitional support can maximise independence, promote self-management and support a return to work and activity, while looking at changes in service delivery and the benefits for people.
Through this service no-one remained in an acute service bed when their needs could be met by the Neurological Rapid Access Physiotherapy (NRAP) service.
- What was the approach?
Key activities included
- rapid appointments,
- initial assessment including baseline outcome measures,
- up to 10 sessions of treatment provided with clear identifiable goals,
- tools and strategies for self-management,
- open option to re-contact within four weeks,
- onward referral to alternative services, and
- follow up phone call offered at three months.
The NRAP centred on close links with community services, including community rehab teams and neuro physiotherapy outpatients. The Allied Health Professional (AHP) lead was directly involved in overseeing the project and leading regular joint working activities such as:
- peer training
- shared case discussions, and
- joint working sessions.
Neurology Consultants were onsite and in regular contact with the team, supporting joint sessions with people, reinforcing diagnosis and eliminating the need for onward referral.
Two physiotherapists provided the treatments. The service ran from Monday-Friday for 1 year. A total of 104 people were referred in to the service. Of these, 95 were accepted and provided with treatment.
Referrals received came from different sources:
- AHP colleagues and medical staff from neurology wards, medical wards, stroke wards and outliers for early discharges,
- neurology clinics for those at risk of being admitted or deteriorating, and
- community physiotherapists with those requiring more specialist input, or needing an increase in intensity for maximum gain.
The Model for Improvement was used to monitor the project along with Plan, Do, Study, Act (PDSA) cycles to observe trends and guide change. Data was collected continuously to monitor functional outcomes and quality of life. Supplementing this data was two focus groups (administered by a third party) using standardised questions, open discussion and emotional touchpoints.
- What was the impact?
No-one remained in an acute service bed when their needs could be met by the Neurological Rapid Access Physiotherapy (NRAP) service.
There were two focus groups, hosted by a third party to anonymise results. People were happy with the level of input received and felt it was a seamless service between ward/clinic to their first appointment in NRAP. A common theme throughout the groups was that people felt more equipped to self-manage their symptoms and felt a reduced need to seek medical advice for the same problem.
Although a rapid access service, and being able to offer ‘next day’ appointments, it emerged that most people did not want these. After discharge home, people wanted a few days to orientate themselves and acclimatise to the home environment before commencing an outpatient programme. Those who had been referred from clinic often needed time to reorganise other life commitments e.g. work commitments, childcare, transport etc. The average uptake between contact and first appointment was about a week, which is still far less than other existing services.
By supporting early discharges and preventing admission, the project saved an estimated 203 bed days at a cost of £56,028.
Quotes from focus groups:
- “physio kept in touch via telephone while (I was) attending the pain service, then was allowed to come back again”
- “telephone contact to check in really helpful”
- “… (Melanie) contacted me a month later – I was so excited to tell her (what I’d achieved) – it’s good to have that ongoing
- What was the learning?
Key learning form this project is that there is evidence to support the need for an additional service. This is particularly true of support for people with Functional Neurological Disorder. They require timely input delivered by therapists with appropriate knowledge and skills to address these complex issues and aim to minimise accruing impairment and disability. There is a large number of this group who have recurrent hospital presentation and admissions. The current evidence shows that moving away from a medical model of care and toward self-management aided by physiotherapy is likely to have lasting benefits and better outcomes.
Learning already shared:
- Article in local online publication for Greater Glasgow and Clyde – Physiotherapy Focus
- Local training and updates to staff within the Institute of Neurological Sciences including medical staff.
- Training for community rehab teams.
- Presented at Independent Living Conference at SECC, Glasgow.
- Participated in Scottish Access Collaborative – Neurology Group about forward planning for equitable services across Scotland in advance of Scottish Governments National Action Plan for Neurology being published.
- Spent time in London at St Georges Hospital with clinical leaders in FND who have a different existing model, benchmarking against other services- sharing peer experiences.
- Poster presentation at Regional Development Day.
Sharing learning going forward:
- Link with Managed Service Network (national group for Neurosurgery, maintaining links across Scotland and sharing best practice.
- Article publication for Chartered Society of Physiotherapy (CSP) in their Frontline journal.
- Presentation at Physiotherapy Best Practice Day 2020 and share experience/learning
- Consider formal publishing in external journals.
- Consider attendance at the 4th International Conference on Functional Neurological Disorders, being held In Boston, MA in June 2020.
- Continuous peer training and presenting within local physiotherapy groups.
Advice for similar projects
- continue to review and audit your service, even for small changes
- use PDSA cycles to look for trends and make changes where needed
- explore options for funding and different ways to tackle projects
- don’t be too ambitious, even small changes can make big impacts, and
- allow adequate time for setting up, and to analyse at the end.
- What are the next steps?
There are present discussions with hospital management to discuss new models of care. Data from the project is being analysed in order to build a business case for continuation. In addition to this, there is work on constructing alternative pathways for people with neurological conditions to optimise care and provide a more cost effective model. This may also include a specific pathway for people with FND.
There is current research being carried out which is likely to influence future treatment models for people with FND. This will be incorporated into the business plan to support benchmarking against other services out with Scotland and provide the best person centred care.
The project could be reproduced in other rehab settings, e.g. stroke, medical – anywhere where you may be able to shorten length of stay without compromising medical treatment or care.