Author: Kate

High Intensity User Social Prescribing Service helps reduce demand on emergency services in Dudley

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Vulnerable patients are benefitting from a new High Intensity User (HIU) project in Dudley.

A one year evaluation of the project commissioned by Dudley CCG and Dudley CVS has shown a 33% reduction in A&E attendance and a 41% reduction in inpatient admissions saving the NHS over £492,995.

Delivered by the Dudley CVS Integrated Plus social prescribing team and match-funded by Dudley CCG and the Department of Health, the service offers a robust way of reducing avoidable frequent user activity to 999, A&E, and hospital admissions, freeing up front line resources to improve care for all patients and reduce costs.

Working together with partners, the HIU team uses a flexible and innovative non-clinical approach with the voluntary sector, to target high users of services and support the most vulnerable people within the community to flourish and find purpose in their lives.

This is in line with the Right Care Programme, which is part of the NHS Long Term Plan’s focus to better understand the needs of patients who are frequent users of emergency departments. Both will work to improve waiting times and response in emergency departments for those patients with the highest care needs is a priority.

Kelly Rea, (Urgent Care Link Worker), HIU Team said: “It all starts with a phone call, from which I am able to actively listen to understand the needs of patients accessing A&E departments. I like to arrange a face-to-face appointment as soon as possible to gain a better understanding of their situation. On the first visit, I try my best to make it very relaxed to allow them to tell their story.

It’s surprising how many people say after the visit it’s the first time they have been really listened to.

A local service user said, “This service, in my opinion, is vital to help other people from utter despair, I cannot explain in words what this service has done for me.

After another attempt to end it all, I was given a lifeline, introduced to my link worker from Integrated Plus, always at the end of the phone, caring and understanding, non-judgmental who listens to my every need in my recovery. My link worker takes me out for coffee and shopping and has enabled me to laugh again and understand a future without pain. I look forward to her visits helping me to feel normal again”.

Sarah Knight, Commissioning Manager, Dudley CCG, “We are really happy that the service is benefiting people in Dudley, we are always looking at new and innovative ways to meet the needs of our local population, and this is one way we are doing this”.

The programme initiated by NHS Blackpool CCG has also been rolled out in a number of other CCGs across the country.

The full impact report is available to read below:

Integrated Plus delivers a successful peer learning programme for staff delivering social prescribing schemes around the East and West Midlands

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During January – April 2019, Dudley CVS’s Integrated Plus service delivered a social prescribing peer learning programme for link workers around the country. The programme enabled existing link workers from across the East and West Midlands to connect with each other, share learning, successes, challenges and access training in areas such as motivational interviewing, mentoring and solution focused therapy.

25 staff from 9 organisations delivering social prescribing projects around the country attended the 10 day programme delivered over 3 months.

Participants shared that they had learnt:

  • More about what social prescribing is
  • Each other’s social prescribing models
  • Different approaches to supporting people
  • New techniques and coping strategies when working with vulnerable people

“Brilliant, invaluable, interesting and overall a fantastic and worthwhile training package” (participant who attended the programme)

“Spending time offering each other peer support has been incredibly invaluable” (participant who attended the programme)

For more information about the Integrated Plus service, please contact Kate Green on 01384 573381.

For National information and updates on social prescribing visit: https://www.socialprescribingnetwork.com/

Integrated Plus Service – evidencing the value of social prescribing for people living in Dudley borough

Kate 1 Comment

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During late 2018, Dudley CVS appointed an external consultant, David Waterfall, to work alongside the team to collate and analyse data regarding the Integrated Plus social prescribing service, and to use this information to produce an evidence-led evaluation report.

Dudley CVS has been delivering a social prescribing service for the nearly 5 years. In early 2014, Dudley CVS with support from Dudley Clinical Commissioning Group (Dudley CCG), identified an opportunity to develop and deliver an innovative, flexible and complementary service called ‘Integrated Plus’.

The service was set up to trial a different approach to supporting people in their own homes to ensure the non-clinical needs of patients are taken into account at the GP-led Multi-Disciplinary Team meetings (MDTs) established in 2014. Integrated Plus offers 1-2-1 social prescribing support to patients aged 16 and over who are:

  • At high risk of hospital admission;
  • Frequently visiting their GP;
  • Vulnerable and in need on non-clinical, social support.

Key findings from the report:

  • 2,720 out of 3,756 clients have connected with the service during September 2014 – August 2018.
  • In terms of a typical patient referral to Integrated Plus; 60% are aged 64 and over, 37% are aged between 24 – 63, 58% are female, 71% have no caring responsibility, 25% are referred due to feeling isolated, 17% because of a long term health condition and 16% due to feeling that they have mild to moderate depression. There is a high correlation between clients feeling isolated and feeling that they have mild to moderate depression.
  • 94% of clients rate the service as 4 or 5 stars (out of 5), 96% consider Integrated Plus has had an impact on them (of which 28% consider this to be significant), and 79% feel that Integrated Plus has helped connect them to services and activities suitable to their needs.

 Performance

Following Integrated Plus, client change for each of the seven core outcomes was:

  • Finance; an 81% reduction in those patients that were not managing, and also an increase of 48% for those who were managing. The greatest enhancement in an indicator was “I have enough money to meet basic needs”
  • Physical Health; an 82% reduction in those patients that were not managing, and also an increase of 29% for those who were managing. The greatest enhancement in an indicator was “I am managing long term conditions well”.
  • Mental Health; an 76% reduction in those patients that were not managing, and also an increase of 58% for those who were managing. The greatest enhancement in an indicator was “Feeling optimistic about the future”
  • Social Contact; an 80% reduction in those patients that were not managing, and also an increase of 35% for those who were managing. The greatest enhancement in an indicator was ““I regularly have face to face social contact with people who are not family members”
  • Housing; an 82% reduction in patients that were not managing, and also an increase of 24% for those who were managing. The greatest enhancement in an indicator was “I feel able to keep up with my rent”
  • Safety; an 83% reduction in those patients that were not managing, and also an increase of 24% for those who were managing. The greatest enhancement in an indicator was “I feel I have people I can contact”.
  • Learning; an 72% reduction in those patients that were not managing, and also an increase of 10% for those who were managing. The greatest enhancement in an indicator was “I feel happy in my retirement”

In broader terms, following the intervention 46% fewer clients report poor quality of life, and 45% fewer clients report poor wellbeing.

  • For hospital data, there are significant reductions in A&E attendance after Integrated Plus with a 14% reduction after 6 months, increasing to a 17% reduction after 12 months. Regarding inpatient admissions, after Integrated Plus there is a 14% reduction after 6 months, increasing to a 15% reduction after 12 months. In terms of hospital cost avoidance, data shows £751,400 for reductions in Inpatients, and £58,305 in reduced A&E admissions; totaling £809,705
  • For GP data, of the 43 surgeries engaged; 34 had a decrease in surgery consultations, 21 had a decrease in telephone consultations, and 26 had a decrease in home visits. In terms of GP cost avoidance, data shows £73,115 in fewer GP Consultations, and £16,400 for fewer GP Home Visits; totaling £89,915. The surgery with the greatest extent of cost avoidance was Wychbury Medical Centre/Cradley Road Medical Practice, with a cost avoidance of £11,135 (from 306 referrals, of which 189 supported)
  • Through surveying of GPs, 100% of surgeries rated Integrated Plus as good or excellent, and 89% felt that the Link Officers added value to the current Multi-Disciplinary Team meetings. All surgeries agreed that Integrated Plus had helped to reduce inappropriate GP consultations, and most surgeries felt that “Reduces isolation and loneliness” was a key benefit for patients. Wider benefits included, “Our main Link Officer has an excellent rapport with our patients, nothing is too much trouble for him and he is literally only a phone call away. He attends all MTD meetings and has good input from the patients he sees.”

For more information you can read the full report here:

For more information, please contact Kate Green. Tel: 01384 573381.

Email: buildingblocks@dudleycvs.org.uk

Celebrating Integrated Plus as part of International Social Prescribing Day – Connecting and supporting for wellbeing and a sense of purpose

Kate 1 Comment

 

Dudley CVS has been delivering a social prescribing service for the nearly 5 years. In early 2014, Dudley CVS with support from Dudley Clinical Commissioning Group (Dudley CCG), identified an opportunity to develop and deliver an innovative, flexible and complementary service called ‘Integrated Plus’.

The service was set up to trial a different approach to supporting people in their own homes to ensure the non-clinical needs of patients are taken into account at the GP-led Multi-Disciplinary Team meetings (MDTs) established in 2014. Integrated Plus offers 1-2-1 social prescribing support to patients aged 16 and over who are:

  • At high risk of hospital admission
  • Frequently visiting their GP
  • Vulnerable and in need on non-clinical, social support

Our support is about enabling and facilitating connections with others, nurturing new friendships and helping people to find purpose in their lives. We focus on the whole person’s needs whatever they might be, to jointly find solutions to challenges faced. Our approach is about spending quality time with people, actively listening to their needs, goals and aspirations. We explore what is important to the person and help them to identify, amplify and reflect on their strengths, passions and skills. 99% of people we have connected with stated that spending quality time with them actively listening and exploring what they want to achieve as the most valuable component of our service.

Other key facts and stats

  • 4,326 referrals from GPs and at the MDT meetings. Of 4,326 we have connected with 3,132 people.
  • 81% reduction change in people that were not managing in the areas of finances but who are now getting appropriate support or now managing ok
  • 82% reduction change in people that were not managing their physical health but who are now getting support or now managing ok
  • 80% reduction change in people that were isolated and lonely but who are now accessing services/activities or no longer feel isolated or lonely
  • 8,719 outward referrals to organisations, 60% to the voluntary sector
  • Avoidable A&E attendances have reduced by 17% over a 12 month period after Integrated Plus interventions, cost avoidance totalling £58,305
  • Avoidable hospital admissions have reduced by 15% over a 12 month period after Integrated Plus interventions, cost avoidance totalling £751,400
  • Overall GP consultations have reduced by 15%, cost avoidance totalling £73,115

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Karen supported to find time for herself and regain her confidence

Karen was referred to Integrated Plus by her GP. She was diagnosed with depression and finding life difficult to cope with.  Karen is selfless and spends most of her time caring for others.  She has caring responsibilities for her mother, an aunt and a son who is disabled.  Despite her busy schedule, Karen is regarded as being positive and upbeat about herself and her life but while looking after everybody else her own mental health was deteriorating and she became unwell.

When Karen met the Locality Link Officer for Stourbridge, Wollescote and Lye she said she felt “Lost and exhausted and didn’t know what to do.” The Link Officer listened to Karen and discussed options for her to have some time concentrating on herself, regaining her confidence and doing something she would find helpful and worthwhile.  The Link Officer asked Karen what hobbies and interests she had and if she would like to do some activities. Karen said yes and the Link Officer agreed to accompany her to her first activity until she felt comfortable with her surroundings.  They went to the University of the 3rd Age in Stourbridge (U3A) and Karen enjoyed it and settled in a lot quicker than she thought she would.

Karen now has the confidence to attend on her own and has been to the U3A several times and is going to join the group as a member. She is looking forward to enrolling on a diverse programme of classes in the New Year, including, lace making, walking and tap dancing. She was surprised and pleased to find that the lace making course is taught by a neighbour and this has rekindled their friendship.

The Link Support Worker met Karen a couple of months later to do a follow up review and she said her mental health has significantly improved and that she is feeling much better. Karen has also grown in confidence and has attended some Carers Coffee Mornings and said this has been important in reducing the isolation and loneliness felt by many carers.

Karen has reconnected with neighbours and her wider community and has made new friends since being referred to Integrated Plus. She said she was very grateful for the “…impartial support from Integrated Plus.”  And without this support she said she would probably be “sat at home rocking back and forth in her chair not knowing what to do next.” With support from Integrated Plus and Karen’s desire to make changes she is looking forward to the future with renewed confidence and hope.

For more information contact: Kate Green. Email: buildingblocks@dudleycvs.org.uk

 

Voluntary Sector Multi-Speciality Community Provider (MCP) engagement session

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On 7th November 2017, Dudley CVS hosted with Dudley CCG a session with voluntary organisations and community groups across Dudley borough on Dudley’s new MCP.

Purpose of session

Following the launch of the procurement process for Dudley’s Multispecialty Community Provider (MCP) in June, Dudley CCG recently announced the bidder that has made it through to the next stage of the procurement process.

Since September 2017, Dudley CCG has been going through a dialogue process with a consortium involving four local NHS Trusts and local GPs. The four trusts are – Birmingham Community Healthcare NHS Foundation Trust, The Dudley Group NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust and Black Country Partnership NHS Foundation Trust.

The new Multispecialty Community Provider (MCP) will bring together services in an integrated manner and will:

  • hold a contract of up to 15 years’ duration;
  • manage a single, whole-population budget;
  • transform the access to and delivery of community health and care services with Primary Care at the centre, and meet a defined set of outcome and performance measures.

As part of the dialogue phase, Dudley CVS hosted in partnership with Dudley CCG this engagement event for the voluntary sector with the potential consortia. This event enabled the voluntary sector to learn about proposed plans for the MCP and an opportunity to observe and engage in discussions on pre-set questions about how the potential bidder intends to engage with the sector over 10 – 15 years to meet the outcomes of the MCP.

For detailed notes from the meeting view the document below:

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Dudley CCG has launched a public consultation to help shape the development of Dudley’s Multi-Speciality Community Provider (MCP). The consultation is to ask peoples views to help ensure that the new Dudley MCP is organised in the best possible way to meet people’s needs. Consultation is taking place on four key areas including:

Details of services included in the MCP contract (scope)

  1. The targets and outcomes expected to be achieved for Dudley people
  2. A description of the way the MCP is expected to operate (its characteristics)
  3. An expectation on how technology will be used to improve access (for example easier telephone/online access system)

How to get involved

You can share your views any time between Friday 15th July up until midnight on Friday 9th September. Take a look at Dudley CCG’s consultation document. You can return completed questionnaires free to the following address (just write this on an envelope):

FREEPOST RTGH-YKLH-AZXZ Dudley Clinical Commissioning Group Brierley Hill Health & Social Care Centre Venture Way BRIERLEY HILL DY5 1RU

Events taking place across Dudley borough:

Join in with one of 5 public meetings:

  • Monday 1st August at the Zion centre Halesowen – 1pm-3pm
  • Tuesday 2nd August at The Beacon Centre, Sedgley – 10am-12noon
  • Wednesday 3rd August at Stourbridge Town Hall – 1pm-3pm
  • Thursday 4th August at Brierley Hill Civic Hall – 5.30pm-7.30pm
  • Friday 5th August at DY1 in Dudley Town centre – 11am-1pm

To book a place at one of the above sessions please email Keren.Hodgson@dudleyccg.nhs.uk or call 01384 321730

Jump on the campervan between 1st and 5th August and leave your views in the video diary room. Dates and venues to be confirmed.

Come along to more focussed sessions to understand more detail on the following areas:

  •  Diabetes – Tuesday 19th July 4pm-6pm at DY1, Stafford St, Dudley, DY1 1RT
  • Primary Mental Health -Tuesday 6th September, 12pm-2pm, DY1, Stafford St, Dudley, DY1 1RT
  • Respiratory – Thursday 8th September, 2pm-4pm, Bank St Methodist Church, Brierley Hill, DY5 3DA
  • Outcomes, Characteristics and Scope – Monday 5th September 2016 10am-12.30pm, DY1, Stafford St, Dudley, DY1 1RT or Wednesday 7th September 2016 4.30pm-7pm, Brierley Hill Civic Hall, Brierley Hill, DY5 3DH

Alternatively you can:

Combating Loneliness and isolation conference

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Integrated Plus Link Officers attended a Westminster Briefing conference on 9th March in partnership with ‘The Campaign to End Loneliness’ to understand this largely unreported issue and what is currently being done to tackle it. The conference provided an opportunity to learn about the causes and consequences of loneliness and more importantly solutions to combat it.

Loneliness and isolation have a profound impact on the health and wellbeing of older populations and vulnerable people. There is a growing evidence base around the complex challenge of loneliness.

Here, is a summary provided at the conference from research undertaken.

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