Dudley Social Prescribing

Dudley High Intensity User Social Prescribing Service continues to achieve excellent results

Keeley Leave a comment

Vulnerable patients are continuing to benefit from the High Intensity User (HIU) project in Dudley, which is now entering its third year.

Year one saw a 33% reduction in A&E attendance and a 41% reduction in inpatient admissions saving the NHS over £492,995. Our second annual evaluation report for year two has seen a 75% reduction in A&E attendances and a 78% reduction in inpatient admissions saving the NHS over £546,540. New data has shown a 66% reduction in West Midlands Ambulance Service call outs with an additional saving of £230,193.

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.

The two Link Workers have continued to work in a flexible non-clinical way providing tailored support to frequent users of emergency services. The service has benefitted from being able to spot purchase groups, activities and services from our Voluntary Sector Fluid Floating Fund. So far we have been able to commission five different organisations to deliver creative activities, counselling, peer support groups, outdoor learning and housing and benefits support.

In addition to this we have been able to allocate personal health budgets up to the value of £100 per client. This has been a really positive intervention enabling Link Workers to work in a person centred way. Personal health budgets have been used to pay for transport to peer support groups which was previously a barrier and also items such as tablet computers to enable isolated clients to connect with the outside world.

A local service user said, “I needed more than a worker, I needed a friend, someone who could help me get in touch with the outside world, I felt so lonely and isolated. When I first met Kelly I had been in hospital several times, I was suicidal, and had given up, whereas now I enjoy life and am reconnected with friends.”

Another said,“This service has been extremely helpful, from the first visit from Danielle I was put at ease, she listened to me and I truly felt my issues were understood, which in turn enabled her to help me identify new avenues to explore. I am looking forward to starting my new volunteering role and giving something back”

Dudley CVS are delighted with the positive outcomes that the project is achieving. You can read the full evaluation report below:

“It all starts with a phone call and a cuppa”

kellydudleycvsorguk 1 Comment

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

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