1. If the patient is discharged from the service before 6 months, can we discharge the patient on SSNAP or wait for 6 months?
The patient should be discharged on the webtool once they are discharged from the service or at 6 months after stroke, whichever is first.
If a patient is still receiving care at your team 6 months after their stroke, you should enter a discharge date for the patient so that their 6 month assessment can be completed. Community rehabilitation teams can select "Completed their SSNAP record at 6 months but continues to receive/treatment from this team" as the discharge destination in Q3.1.
2. If the standardised cognitive, mood and visual screens have recently occurred on the stroke unit prior to ESD pick-up, are we able to enter these assessment dates on the data tool?
No, prior dates should not be recorded as these would be recorded by the team(s) performing the screen(s). It is expected that a patient has a reassessment for mood in the community. For cognition, "Not clinically required" should be chosen if screening/assessment has already been completed and due consideration has been given regarding the value of repeating screens (as per national clinical guidelines). For vision screen, "Screened by previous team" should be chosen if the patient has been previously screened for visual impairment by a previous team.
3. Can initial assessments by non-registered members of staff, including students, be recorded as the first assessment?
Initial assessments can be completed by a student or apprentice (and collected as assistant as per help notes), under the supervision of a qualified member of staff as part of their training. Initial assessments should not otherwise be undertaken by unregistered staff.
4. Are the four week blocks unique to the patients (i.e. measured from when they start with the community team) or is it based on monthly blocks?
The four week blocks are unique to each patient. Once the first assessment date and time have been entered, the start and end dates for each of the blocks will auto-populate for that patient on the webtool.
5. If a patient receives no therapy in a given week, do we document this as zero or leave this blank?
If the patient was considered to require therapy and did not receive any therapy, this would be documented as 0 days and 0 minutes. Therapy/care is recorded in blocks of 28 days and so any other therapy received in the 28 day period should be recorded. If no therapy was received in the 28 day period, then this would be recorded as 0.
6. We do the initial assessment and will identify the need for Occupational therapy, but there may a be a 6-7 week wait for that patient to see an Occupational therapist. Do we document on SSNAP that for these 7 weeks there was zero input?
Please record 0 days for any blocks the patient did not receive any therapy and record any therapy they do receive in the next block(s). The blocks have been designed to help us understand and explain where gaps are.
7. Which version of Barthel should be used for SSNAP?
The 10-item version with total score ranging from 0 to 20 (Collin and Wade, 1988) should be used. A version produced by Greater Manchester is available here: https://gmnisdn.org.uk/wp-content/uploads/2024/02/Barthel-Index.pdf.
8. Regarding patient consent for inclusion in SSNAP, are there any resources to use in the initial assessment pack to go through with patients?
Patient information sheets are available here: Information sheets.
9. What should be entered if there is not an up-to-date Modified Rankin Scale (mRS) on discharge?
Although every effort should be made to record this accurately, if the mRS is not known then a best estimate should be entered based on clinical judgement. However mRS should be available for all patients and therefore a "not known" option is unavailable. mRS on discharge gives incredibly important data on outcomes.
10. As 4 weekly recording is from the first face-to-face contact rather than admission, will the new dataset record admission to ESD/CRT teams and how will response times be recorded?
This has not changed with the new dataset. The clock will start for community services from the date and time of first face-to-face assessment. Response times remain important and a key feature of early supported discharge is being able to pick up within 24 hours and we have standards around non-ESD patients being seen promptly. These will continue to be reported.
11. If the patient has been discharged within 1 month of their 6 month assessment on SSNAP, what do we record for the outcome measures from the community?
If discharge from community service is within 1 month of 6m review and you are the service providing the 6m assessment, then use the same outcome measure.
Active therapy that ends earlier but patient benefits from wider service, then take outcome measure at end of active therapy.
Please see some examples below:
1. Patients referred from hospital to your team include mild/resolved patients and those requiring therapy. All patients are assessed by your team. Those patients who are deemed not to require motor, psychological, communication/swallowing or vocational therapy but will benefit from healthy lifestyle and management and/or social care needs and care delivery from your team should still have a SSNAP record open with your team and relevant minutes recorded. Complete outcome assessments at discharge (T2) and at the 6 month review (T3) and if these time points coincide, use the same data for both time-points.
2. Patients that are referred to your service and following initial assessment are deemed to require ESD/CRT. Therapy delivery (motor, psychological, communication/swallowing or vocational therapy domains) changes over time. This therapy then stops (e.g. at 3 months) but the patient would still benefit from healthy lifestyle and management and/or social care needs and care delivery (e.g. key worker support, driving review, open gym, leisure centre group, peer support group). In this instance, complete outcome measures at the end of active therapy and use this data for T2 (discharge timepoint). Keep SSNAP record open until patient not deemed to require any further input. Complete outcome measures again at T3 at the 6 months review.
3. No therapy needed but stroke social worker in your team involved to review packages of care and nurses reviewing medication compliance. Keep open on SSNAP and capture healthy lifestyle and management and social care needs and care delivery via your service. Complete outcome assessments when discharged from the service (T2) and at the 6 month review (T3). If patient is still with the service at six months, use same data for T2 and T3.
4. Patient seen in clinic every 4 months for spasticity injection and splinting. Occasional review in nursing home for education and postural review with nursing home staff. Keep open on SSNAP capturing periodic incidents of contact with service (spasticity management would come under motor therapy). Complete outcome measures at T3 six month review if patient is still with the service and use same data for T2.
5. Patients who are mild, or are deemed to have resolved impairment, have assessment with no needs identified. Register on SSNAP and record date initial assessment completed. Those identifying no needs or goals at this time, should be discharged from SSNAP if that concludes your team’s involvement (with no OCMs or minutes entered)
12. How do we record those patients that never have a face-to-face assessment? We triage patients with a holistic assessment over the phone and some patients will decline therapy, not require therapy or only require a high level rehabilitation programme that does not require face-to-face intervention.
All patients should be assessed. If a patient has not been assessed and there is no assessment date and time, then these patients should not be recorded on SSNAP. If the record has been transferred to your team on SSNAP, please revoke the record back to the acute team and ask them to amend the discharge destination. Hospital and community teams should liaise to ensure a coordinated transfer of care and ensure only appropriate records are transferred on the SSNAP webtool.
The first assessment on SSNAP needs to be a face-to-face assessment. This has been maintained in SSNAP to reflect best practice and evidence. There are some examples where the patient may be appropriate to have an initial video consultation that is recorded on SSNAP, but this should only be an option if it is categorically known that no environmental or physical issues exist. In the event of video assessment being completed, the clinician must be satisfied that the definition of a comprehensive assessment has been completed for this to be used as first assessment.
If a patient has not received a face-to-face assessment or in exceptional cases an initial comprehensive video assessment, the patient should not be recorded on SSNAP.
It remains that only those patients with a confirmed stroke diagnosis should be added to the SSNAP dataset.
13. How should patients be recorded if they only have an initial assessment and then have no goals and are discharged?
Patients who are assessed and subsequently decline therapy or do not require therapy should be added to SSNAP. The dataset can then be completed. The therapy or care a patient is considered to require can be recorded in Q2.5, and any therapy/care not considered can be recorded as “No”.
It remains that only those patients with a confirmed stroke diagnosis should be added to the SSNAP dataset.
14. When starting a record in the community, does “not seen by an acute team” only refer to an acute stroke team?
“Not seen by an acute team” refers to a patient who has not been seen by an acute stroke team. If they have been receiving acute care for another condition and now are referred to you for stroke rehabilitation you can select this option.
15. If a patient is readmitted to hospital (not for a new stroke) and the community team pick them up again once discharged. How do we record this as there will be a large gap in care?
This decision should be made at a local level but how you record this depends on the duration and impact of their hospital stay, as a guide:
- Short hospital stays (up to ~2 weeks): If the patient’s function remains largely unchanged and they can continue therapy as before, keep the record open to avoid losing data on their episode of care.
- Longer hospital stays (over ~2 weeks) or significant functional decline: If the patient’s condition changes substantially due to their hospitalisation, discharge the record. If the patient returns to your team within 6 months, you can start a new record for the patient in the community and select re-referral within 6-months. You can then complete a record from the beginning.
16. At discharge for question 3.1 what is the difference between discharged “from this team” and discharged “somewhere else”?
“From this team” should be selected when the patient has stopped receiving care from your service and has left the stroke pathway (so is not being transferred on to another team for further stroke care).
“Somewhere else” should be used when no other option applies.
17. If we put therapy 'on hold' whilst a patient needs a break, should we leave the record open, and will this dilute the minutes?
Yes, you should leave the record open until the patient is discharged from your service.
Gaps in therapy minutes will not dilute the data but will instead reflect the actual therapy pattern over time. The data is collected in four-week (28 day) time blocks, so you will be able to see when a patient has received intensive therapy, when there has been a gap, and when therapy resumes. There may be slight dilution within a single four-week block, but overall, the data will accurately represent the patient’s therapy journey. This approach ensures that SSNAP captures the full pathway rather than just the intensive initial phase.
18. When a patient DNA/cancels repeated sessions is there anything that should be recorded on SSNAP?
Only the minutes that are actually delivered to the patient should be entered onto SSNAP, however, you are able to use the comment function on SSNAP to keep a local record of DNAs and cancellations for internal analysis. This can help teams identify patterns, such as high DNA rates, and address any underlying issues.
19. When should we complete the outcome measures for patients who complete their intensive therapy after 12 weeks but remain with the team for a further nurse review?
If therapy stops at three months but the patient remains with the service for nursing review, the team needs to decide whether to close the record at the end of therapy or keep it open for the full six months. If the record is closed at three months, the final outcome measure should be recorded at that point, capturing the impact of therapy.
A local decision should be made however it is our recommendation to close the record at three months to more accurately represent therapy outcomes. Keeping the record open would include additional nursing data but might lose clarity on when intensive therapy ended. Once discharged from the team on SSNAP there is no ability to reopen the record.
20. If a patient has died before being seen for an initial assessment in the community how do we take them off the webtool?
If you have not seen the patient for an initial assessment, you should reverse the record transfer on SSNAP to the inpatient team and inform them of the reason. If the patient dies after initial assessment but before any therapy has been provided you should enter the initial assessment details and complete the record.
21. If no hospital number known you cannot progress with section 1 if starting a new record?
If you are starting the record in the community, please enter the unique identifying number you have for identifying the patient across all departments at your service and continue to enter the record. If you do not have this please enter 0.