Community rehab: a common sense approach

They say the best ideas are the simplest and the common-sense approach behind a new rehabilitation programme is being credited for slashing emergency bed days and improving patients’ quality of life.

Instead of focusing on a single condition, physiotherapists at NHS Ayrshire and Arran are offering a tiered rehabilitation programme which embraces the fact that many of today’s patients have multiple morbidities.

Patients who have suffered one specified acute condition (such as cancer, angina or a stroke) and have at least one other long term condition are being welcomed onto the Healthy and Active Rehabilitation Programme (HARP).  Its aim is to encourage users to embrace activity, self-management and lifestyle change, and because its approach is based on treating common symptoms such as breathlessness or persistent pain, classes can include patients with a variety of diagnoses.

A typical patient is George, whose health conditions included heart problems and recent treatment for bowel cancer. He said: ‘I thought my exhaustion would have disappeared [after chemo] but it hadn’t. I felt so depressed, I felt everything was getting worse and the end was near.’

He was referred to the ten-week HARP course by his specialist nurse. Three months on, he has joined a gym, walks the dog again, and is enjoying playing with his granddaughter, for whom he has just built a wooden doll’s house.

Like other patients, George didn’t care what conditions the other patients in his rehab classes had been referred with. What mattered was their common goal: ‘The big difference was the talks and meeting others. We all felt the same; we needed something to get us going and get our lives back. HARP gave me control of my body and my mind.’    

HARP is a product of cooperation between NHS Ayrshire and Arran and the three local authorities’ leisure services teams. The integrated care approach means patients can move between its four tiers seamlessly – from specialist evidence-based rehab programmes at the top, through evidence-based rehabilitation health and wellbeing programmes, to local leisure programmes and community exercise groups, as part of one service. 

Individuals’ wellbeing

Patients who are referred receive a multidisciplinary assessment from a specialist physiotherapist and nurse who recommend they access one of the tiers. Movement between tiers doesn’t require further referrals, so associated waiting times are avoided. And because so many disciplines are involved, specialist support is available to the practitioners at all levels. 

MSP Jeane Freeman, the Scottish government’s cabinet secretary for health and sport, is among those impressed by the programme. She told Frontline: ‘The key focus for the integration of health and social care services is the wellbeing of the individual and this requires a different

approach to partnership working.

‘HARP is one such example – by starting with what’s important to the person, rehabilitation is provided in a collaborative approach which includes health professionals, leisure services and the third sector. As a result, people using the service are supported to get back to as full a life as possible and their need for the use of other health services is reduced.

By starting with what’s important to the person, rehabilitation is provided in a collaborative approach... As a result, people using the service are supported to get back to as full a life as possible and their need for the use of other health services is reduced

‘HARP is an excellent example of integrated services that I expect to see working across Scotland’

Everyone agrees the approach is very much based on common sense. But what makes it special is the evidence that proves this new way of working has been a success. 

Tier 4 of HARP, which offers specialist rehabilitation programmes, treats the most acute patients with multi morbidities.

Tier 3 offers the new approach of rehabilitation health and wellbeing programmes for people with multi morbidities. This consists of a 10-week course of 90-minute classes which incorporate exercise led by physiotherapists and wellbeing talks centred not on a particular condition but the commonality of living with long term conditions such as fatigue, or sleep hygiene. 

Every year, 450 patients are funded through Tier 3, and in the 12 months post-referral, there was a 72% drop in emergency bed days among patients in year one of the programme and a 79% drop in year two. The potential cost avoidance during year one was calculated at £122,841. 

Tier 2, the local linked leisure programmes for people with multi morbidities, offers new classes for patients which are led by leisure services staff with physiotherapy input. 4,106 additional people are recorded as exercising over the programme’s initial three years’ operation to 2018. 

Tier 1, exercise groups and activities held at leisure centres and other community venues, gives service users lifelong activity options. Because these are now integrally linked to HARP, patients have access to wider experiences, such as walking football, and support groups they might not previously have heard about.

The improvements in HARP patients’ cardiovascular risk factors are also impressive, among them physical activity (86% improvement); blood pressure (79%); alcohol (55%); smoking (44%) and waist circumference (44%). 

A win-win model 

Common sense it may be, but the success of HARP is down to a canny targeting of available funds, an inclusive approach among the project leaders and some robust evidence gathering.

Jane Holt, physiotherapy team lead at Ayrshire and Arran, said: ‘The key is to utilise current drivers for change and its associated funds. Our speciality is cardiac rehab and we also wanted to have the capacity to treat people affected by angina, atrial fibrillation and similar risk factors.

We spotted an opportunity to change the way we worked to create a win-win model where if we broadened our expertise, we could include the people we wanted to see.

The team benefitted from the formation of health and social care partnerships in Scotland, statutory bodies bringing together the NHS and local authorities to provide health and social care for adults, backed by an integrated care fund. 

Holt’s colleague, Dr Janet McKay, consultant nurse for cardiology, led the bid for funding, along with local AHP service lead Elaine Hill, with the support of local leisure services. The bid was evidence-based, taking into account the local authority areas it would cover - a mixture of urban and rural, plus two islands - and the high levels of deprivation, high incidence of long-term conditions and unscheduled hospital admissions among its population.

Once they had secured the cash they established a steering group with wide local and national representation to put HARP into action.

The buy-in of leisure services and physiotherapists with different specialities was vital, Holt says: ‘We made a point of being inclusive at every step. Everybody was invited to training days: the AHPs, nurses, physios, people from all the localities of leisure, and third sector groups such as the British Heart Foundation and Ayrshire Cancer Support, so we had a real variety of knowledge being shared with the teams.’

This also built relationships so that, once HARP was up and running, Holt’s cardiac team had a wide range of additional expertise available to them. ‘We now have access to the cancer and diabetes teams, for example, plus psychological support. It all goes back to the training and devising the tiers… everyone played a part in the discussions and that’s made the resulting programme more inclusive.’ 

A crucial element of HARP’s continued funding is building a solid evidence base. ‘We know quantitative data is always valued and there’s been a real drive for the patient’s story, too, so we planned to be able to deliver that. We also planned for focus groups across the board.’

Incorporating feedback

The steering group took the cardiac rehabilitation programme as the basis of HARP programmes and gradually built in training from other specialities, incorporating ‘the best of’ them.

‘Pulmonary rehab has really led the way in terms of self-management going forward, and peer support; cancer rehab is fantastic at using the power of volunteers,’ says Holt. ‘We incorporated the best bits but very much in consultation with people who had expertise in these other areas.’

All feedback was incorporated going forward, and an issues log was circulated, with each concern addressed by Holt or McKay.

Consultant physiotherapist Dr Aynsley Cowie gathered the evidence of HARP’s impact among patients, nursing staff, physios, occupational therapists and leisure staff who were delivering the programme.

Not all staff bought into HARP at first, Cowie says: ‘People were apprehensive. There were worries about the quality and safety of care, of diluting the specialised service. Some said they felt as though they were losing their whole identity. But as time went on they realised the benefits of HARP, gained confidence and felt better able to promote it.

‘Our specialist physiotherapists also realised that many of the patients they had been dealing with had always been multimorbid. They now had extra training, plus access to extra help as part of a structured programme which offered a more holistic, seamless approach to care.’

People were apprehensive There were worries about the quality and safety of care, of diluting the specialised service. some said they felt they were losing their whole identity.’ Aynsley Cowie

Pooling staff resources

One of the reasons physiotherapy staff were bowled over long before the statistics became available was the obvious improvements in patients, who emerged much more aware of their capabilities, with the confidence and motivation to do more.

Staff comments included: ‘The changes we’ve made to people’s lives! Some of the individual journeys have just been amazing... I’ve had people saying ‘I wouldn’t be here today, if it wasn’t for this class’’ and ‘The whole thing is more like a community now’

Cowie adds: ‘Our staff realised that what sounded like a huge change at first actually wasn’t so different. They’re just pooling their resources and expertise and gaining strength by working side by side.’

McKay is also delighted with the impact of HARP: ‘The big thing for me is the flexibility - that people can move through depending on what their illness is at that point in time. It’s also reassuring for leisure staff if they’ve got someone that they’re struggling with; they know they can just pick up the phone. 

‘From a nursing perspective, nurses who’ve worked with HARP bring back greater knowledge from the cardiac side. Because a lot of our patients are multimorbid the wider experience they’ve gained means they’re more likely to tackle issues that they would have passed on before. They also get really good support from other specialities in terms of training.’

Volunteers, who have all have been through physiotherapy rehab themselves, have played a vital role in HARP’s success by helping out across the programme. Class participants value their support and view them as role models. The fact they’ve been through the process also helps patients feel more secure in attempting exercise after an acute health event.

Holt says: ‘Our aim is to give patients the confidence to self-manage and volunteers have made a huge contribution to this. They acknowledge, as we do, that our patients often have real fears about exercise but they reassure them that not only can they do it, but they can go on to do it without our help.’ 

David’s story

‘In 2016 I suffered from heart failure. I was in intensive care and in bed for 16 days. I left hospital in a wheelchair… I was short of breath during easy activities and didn’t have any help or advice. I lost all my confidence. I tried to join my local leisure centre but they wouldn’t see me due to me having heart failure.

When I was referred to HARP I was unsure and scared. But I wanted to improve. I wanted a teacher and a group. I needed other people to help with encouragement, motivation and having a purpose.

Now after HARP I can physically do more, am stronger and walk further. I know my limits and all the staff support us to have a go at doing more. Their training, knowledge and experience made me feel safe. I would not have done this on my own. 

The classes are valuable because you see the progress of all the other people, which helps. Before I thought I was in the worst position, but meeting others made me realise I was not alone. The volunteers have a great attitude – bright, enthusiastic, sociable and encouraging.   The talks give you hints and tips. Now, after HARP, I’m joining classes at my local community and leisure centres. I’ve started doing more work around the house again to improve my flat. I’m getting out of my flat now and I want to thank the team. It’s due to them I’m in a better place mentally.’

Jane’s top tips

Jane Holt’s tips for other physiotherapists looking to develop a similar programme:

1. Look for a win-win situation that you can influence
2. Utilise current drivers for change/associated funds
3. Appreciate the diversity of knowledge in a multidisciplinary team
4. Allow role blurring but appreciate everyone’s unique skill set
5. Target evaluation, balancing qualitative and quantitative data
6. Use social media
7. Embrace volunteering – people with lived experience – they will be the icing on your cake
8. Produce posters and submit abstracts for conferences, locally and nationally – what have you got to lose?

Email: Jane.Holt@aapct.scot.nhs.uk; Twitter  @AAA_HARP Facebook  NHSAyrshire&ArranCardiacRehabandHARP

Jenny’s story

Jenny came to the HARP following a nursing referral. She is 30 years old, has a learning disability and is affected by under-developed kidneys, thyroid problems and long-standing type 1 diabetes, which is complicated by the fact that her veins shut down and she requires general anaesthetics to have blood tests. A non-invasive blood scanner helps monitor blood sugar levels and this has helped transform her independence. 

But before joining HARP Jenny gained two and a half stone, developed joint pains, loss of energy and had low self-confidence. There were days she didn’t get dressed and she made that her initial goal. HARP worked with Jenny and her dad Bill to turn things round and help with solutions. Jenny soon trusted and had confidence in the nurse and physiotherapist in class.

After HARP, Jenny’s weight gain has stabilised, she has started using an exercise bike at home and can now negotiate stairs without breathlessness. She gets dressed every day, has the confidence to go into town and to the shops and use her phone. She has more social media friends, including her class volunteers, and has joined a local healthy heart exercise class and weight loss group.

Jenny says she can’t thank her physiotherapist enough for helping find so many solutions and helping her realise that new options could be found by working together.