Maximising potential and achieving goals

For young mother-of-two Kelly who had already been through a rehabilitation programme after a devastating stroke, being referred to Woodlands became a life-changing move for her.

While Kelly still had profound needs after her initial rehab had finished, the referring team realised there may still be some potential for her - and identified the specialist Level 2 neurological rehabilitation site in

York as the ideal setting for that to happen.

“Kelly was using a hoist when she initially came to the unit. She had a very dense right sided weakness, requiring assistance from two people for all of her activities of daily. Her speech, language and communication were impaired, as was her swallow,” recalls Sari Teasdale, head of therapies at Woodlands (pictured above).

“This was a young woman with two young children, so being able to get home was a really big focus of her rehabilitation. To ensure the best outcomes for Kelly, all therapy disciplines and nursing and care teams worked with her, taking every opportunity we could to help her recovery.

“And 24 weeks later, she was discharged back home to live with her husband and children.

"Kelly no longer uses a hoist, she is able to get around the whole of her property with the use of a stick and transfer into a car to allow her access to the community. She is able to manage a normal diet and fluids and her speech and language improved, meaning she is able to interact with her family.

“This is so far from where she was when she came to us, and had Kelly not had the opportunity to continue with intensive rehabilitation, her options for returning home would have meant very limited access around her property, with the need for large pieces of equipment and an extensive care package, which is absolutely not appropriate for a young mother-of-two, and not what she wanted.”

These kinds of outcomes are routine for the specialist centre, which has helped so many individuals and families rebuild their lives, despite the many obstacles that may present.

“We will work with the patient and their family from the outset to identify what matters to them, set achievable goals and devise patient-centred therapy to support them to get there, which enables our patients to achieve outcomes like this,” says Sari.

“There are so many examples over the years, where the outcome we have supported people to achieve is so different to what it could have been, had they not come to Woodlands, and we’ll always work with the patient and family to help someone regain the life they want and achieve their goals.”

Rehab-focused goal setting

In its tranquil surroundings in York surrounded by 3.5 acres of grounds and woodlands, 27-bed Woodlands

Neurological Rehabilitation Centre - part of Active Care Group - supports patients with brain injury, spinal injury, stroke and other neurological conditions in rebuilding their lives from the moment they are admitted.

“It’s of benefit to the patient to access rehabilitation as soon as possible, in a specialist rehabilitation environment and start the process as soon as possible, as long as the patient is medically stable,” says Sari.

“Not everyone comes to us at such an early stage, some patients may have gone home before coming to us, but as soon as they arrive, the work starts.” understands what the patient is working towards at any one time,” says Sari.

Arriving for an initial 12 weeks, each patient is assessed and the rehab process is commenced, looking at what will happen over the coming period. This involves both the patient, and crucially their family too.

“The whole situation is new to the individuals we support, and patients and families often report feeling quite worried, frustrated and anxious, so it’s really important we involve the family as much as possible and support them through the whole process,” says Sari.

“When we hold the welcome meeting within the first few days of admission to the unit, we establish the patient’s expectations for the period of rehabilitation and establish at their main objectives.

“It’s important for the therapy and nursing teams to understand what a goal is. For example, what ‘walking’ would mean for that patient in practice. Is it walking from the chair to the bathroom? Is it walking a short distance to the shop to buy a paper?

"For some people it may mean walking ten miles with a dog, but everyone is so different that we need to understand the patient, their background and who they are as a person to support treatment.”

For goals which may look particularly challenging, the team will devise a plan to break the goal down to make it achievable, with timeframes depending on the patient’s impairments with regular reviews to allow monitoring of progress.

“We’ll do the groundwork, map out where we are going, and manage expectations along the way.

“As part of the welcome meeting, we also use a values checklist, which helps us to better understand what motivates the individual we are treating. Is that person driven by independence, work, family, religion?

"Establishing a patient’s values helps the team to understand the person as much as possible, which is really important in rehab.”

Following a period of initial assessment, carried out by an experienced multi-professional team, a patient goals setting meeting is held.

“We ensure goals set are achievable during the period of time we have. Sometimes this involves managing expectations to ensure that everyone

"We will look at making the goals SMART so we can help to deliver them. We don’t want it to feel impossible, but we’ll also be realistic, honest and open,” says Sari.

The therapy and nursing team - supported by on-site clinicians - can then devise therapeutic plans of how to support patients towards their goals, which can change over the weeks ahead, depending on the response to treatment and level of progress being made. Therapy may be delivered in individual sessions, joint sessions with multiple disciplines involved and group therapy sessions, all with the patients goals at the forefront.

“Our focus is totally patient-centred and very holistic, we’ll be guided entirely by the patient.

"We ensure we educate our patients as families during the process,” says Sari.

“We’ve had some brilliant outcomes in terms of what patients have achieved, compared to where they were when they first came to us - but that is about team work and everyone, including the patient having the same focus.”

Collaboration and innovation

The multi-disciplinary team at Woodlands Neurological Rehabilitation Centre brings in physiotherapy, occupational therapy, speech and language therapy, psychology, music therapy and social work and working alongside the nursing team and rehab assistants - with a consultant in rehabilitation medicine and doctors on-hand when required – deliver specialist comprehensive therapy, care and support to patients.

“We do work closely as a whole team and involve the rehabilitation assistants in therapy sessions, as they are the team members who deliver the ongoing rehab across the 24-hour period,” says Sari.

“As part of their assessments, the occupational therapists may, for example, complete a washing and dressing assessment, and are able to advise the rehabilitation assistants on how to support that patient physically and cognitively on a daily basis. We all work together in achieving this.

“And then of course we have the domestic staff, who we couldn’t function without, and the kitchen staff too. All of our food is prepared on-site, and I think that’s a really big thing when you come from a hospital environment to then be able to enjoy home-cooked food.

“We all come to know the patients and all have a role to play, and we work really closely in achieving that.”

Woodlands also invests in technology to support its therapeutic work. In addition to the Guldmann Gait Trainer, to support patients as they recover movement, it encourages the use of remote tech which can be used in rehab sessions as well as encouraging self directed therapy where appropriate, to support a patient’s independence and maximise their progress.

“We use specialist apps for speech and language therapy, which can be accessed via a tablet by patients in therapy sessions, as well as away from sessions to further support the therapy the speech and language therapy team do,” says Sari.

“We also use GripAble, which works on the upper limb focusing on grip, hand and wrist movement and allows the patient and therapists to see outcomes on the activities. Again, this can be used in sessions and also by patients independently. “Like with the gait trainer, not everything will be appropriate for every patient, but we have a range of options available.”

Woodlands is also investing in RehaCom, a software system for computer-assisted cognitive rehabilitation which supports patients to recover abilities in attention, concentration, memory, perception and daily living activities.

“We are about to roll this out, our occupational therapists have attended training on this software and are ready to go with it. This brings even more to what we do and shows we’re continually developing ways in which we can support patients,” says Sari.

The route to independence

For most people when they arrive at Woodlands, their ultimate goal is to live as independently as possible, whether that is in their own home or a supported living environment. And for Sari and the team, that is a goal they are pleased to support. “Navigating what discharge looks like is part of the rehabilitation process, so we address that right at the start in the welcome meeting,” says Sari.

“For some our patients, they’ve been in hospital for weeks or even months before they come to us, so the idea of discharge from a 24 hour care facility must be really scary. It’s important we address that and reassure our patients and families and support them throughout the process.”

The Woodlands team work closely with local care teams - in localities where the patients live - to ensure their discharge and move back into the community is supported and sustainable.

“We will work with external services early on, once we know when someone is on the pathway to be leaving us.

"Not all patients will have ongoing care and support needs, however if they do, we’ll refer them to establish who would be funding their future care, to ensure packages of care can be set up,” says Sari.

“From a therapy point of view, we may refer to community teams to pick up where we finished with some continued input.

"We recognise that getting people back to their homes is extremely important. People do flourish in their own environments.

“We do a lot of work ourselves with patients in their own homes where possible and appropriate.

"For example, if a patient has cognitive deficits, we can work to orientate them to our kitchen in Woodlands or to the local shops, but that’s not reality for them.

"For some patients, we need to support that work within their own home and own local area for it to be meaningful when they are discharged.

“For other patients, we may refer this work to community neuro teams once they leave Woodlands. The therapy and nursing teams often support the patient on the day of discharge from the unit to hand over to care teams or families - it’s a big thing for us when one of our patients returns home, and we want it to be seamless.

“Our patients are supported by the extensive team at Woodlands, from the moment they arrive to when they leave and work in collaboration with all relevant parties externally to make sure they can return to their lives as independently as possible.

"That’s what we work towards and what we work with our patients and their families to achieve.”

Woodlands Neurological Rehabilitation Centre offers several different patient pathways within the service , including rehabilitation, long term complex nursing care and therapy maintenance management, Respite and Discharge to Assess. We are happy to discuss any patients that may benefit from our expert care and encourage our external colleagues to visit us, and get in touch with us on referrals@activecaregroup.co.uk