Development of psychosocial care pathways in stroke services

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Services should develop a screening pathway that is fit-for- purpose for their patient group, service structures, and available supports.

Components of a comprehensive approach to psychosocial care

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Screening pathways should enable comprehensive screening, assessment, and support processes. These should incorporate a variety of screening approaches, mechanisms for supporting team conversations about well-being, processes for reviewing well-being, clear identification of psychosocial supports within and external to the team (including pathways for referral to specialist service providers), and processes for promoting communication as people transition through services, including information about how people can access specialist psychosocial services after discharge.

Services should develop a screening pathway that is fit-for-purpose for their patient group, service structures, and available supports. In developing a pathway, it will be important to connect with mental health teams within the locality, and with mental health support services in the NGO/volunteer sector.

Rangatiratanga and oritetanga should be at the heart of service development.

Pathways for whānau Māori should be Māori led and developed, and ideally, be Māori delivered. Rangatiratanga can be expressed through Māori leadership or opportunities to ‘take charge’ over the direction and shape of their own organisations, communities and development [9]. At the very least, there needs to be consultation with Māori health services and Māori providers, and proactive monitoring of service provision, experience and outcome (e.g. through audits, feedback from whānau for new services or resources) to ensure equity is achieved.

Stepped Care model

Universal psychosocial support should be provided to all people with stroke, with more complex, specialist interventions provided if required.

This reflects the Stepped Care Model, a model of care that is widely used in mental health and in psychosocial care after stroke [10,11].

It has three levels:

Level One: Care that is offered to everyone and can be provided by all team members

Level Two: Care that is offered to those whose needs are impacting on engagement and everyday life. This can be provided by clinicians with advanced knowledge of stroke and well-being.

Level Three: Care for those experiencing persistent and/or severe psychological difficulties. This is provided by psychologists and psychiatrists.

Not all patients will progress through these levels in a sequential manner. Over the course of their recovery, people may move through the layers several times.

The Stepped Care approach makes best use of best use of the skills of the multi- disciplinary team and utilises more specialist staff for the patients with complex problems that require specialist help [11]. The diagram below shows the Stepped Care model for psychosocial care after stroke.

Stepped Care model for psychological care after stroke

(Gillham & Clarke, 2011)

Sub-threshold’ mood changes at a level common to many or most people with stroke.

This can include normal expressions of grief and loss, stress, mood and anxiety, which are mild, fluctuate during the day, and have little impact on engagement in rehabilitation and daily tasks.

Level One support can be provided by whānau, peers, and all of the healthcare team

Mild to moderate psychosocial symptoms or difficulties that interfere with rehabilitation or daily tasks.

This may include depressed mood, anxiety and panic, emotional lability, agitation, apathy or loss of motivation, which may contribute to sleep and appetite difficulties and impact on rehabilitation and daily life.

Support with screening, education, brief interventions, goal-setting and problem-solving should ideally engage whānau, and can be supported by non-psychologist stroke specialist staff (with support/supervision by psychologists with stroke expertise) or by clinical psychologists.

Severe/persisting psychological difficulties.

These are diagnosable and require specialised intervention, pharmacological treatment and suicide risk assessment, and for which treatment at Level 1 and 2 are not sufficient.

Intervention of clinical psychologist, neuropsychologist and/or psychiatry, ideally with specialist expertise in stroke. Whānau should be involved wherever possible.