The High Intensity User (HIU) service (developed by NHS Blackpool CCG) has been rolled out across Dudley borough by the Integrated Plus social prescribing team as part of Dudley CVS. The service offers a robust way of reducing avoidable frequent user activity to 999, NHS 111, A&E, and hospital admissions, freeing up front line resources to focus on more clients and reduce costs. It uses a flexible and innovative non-clinical approach, targeting high users of services and supports the most vulnerable people within the community to flourish and find purpose in their lives.

With information given from the Blackpool HIU service, the Integrated Plus team were able to adapt the approach and develop a HIU service in Dudley, match-funded by Dudley Clinical Commissioning Group and the Department of Health.

Danielle and I (Kelly) have been working on this service from its inception in 2018.

Before taking on the role of Urgent Care Link Worker at Integrated Plus, I worked as a substance misuse worker across the Sandwell Borough for 13 years where I developed a good understanding of the skills and attributes needed to work with some of the most vulnerable and complex members of the community. Within that role, I gained experience working across the criminal justice system, child protection, safeguarding adults and children, mental and physical health and domestic abuse. Prior to this, I worked in the community as a carer for the elderly with mental health needs.

My colleague Danielle comes from a background in NHS and private mental health services. For over 10 years Danielle worked in the occupational therapy department within the male and female psychiatric rehab units, working with patients with complex mental health needs, substance misuse, and learning disabilities. From this, Danielle went into hospital discharge learning the pathway patients go through when they are being discharged from hospital and following them through the process. She was then able to use these skills to work alongside GPs in the community co-ordinating patient care, ensuring their discharge from hospital had been completed correctly and they had returned home with all relevant services in place.

In my current role in the HIU team, it all starts with a phone call, from which I am able to actively listen and find out the full extent of the problem/issues that they are facing in their lives. 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.

From here I give my direct work contact details, agree an action plan with the client and liaise with other agencies involved to ensure that a non-clinical holistic and person-centred approach is taken. The service I then provide is bespoke to that individual, for example, accompanying them to groups, shopping trips, lunch, coffee and medical appointments. I keep my approach relaxed, initially; this may start with speaking to the client two or three times a day as well as out of hours to de-escalate situations that could result in either a 999 call or an A&E attendance.

I will continue to work with a client for up to 6 months intensively with the aim that the support will come to a gradual end and the client no longer feels in crisis. At the end of the service, the client is informed that should they require any further support I would give assistance.”

One 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”.

If you would like to find out more about the Integrated Plus service visit www.integratedplusblog.com