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

July 13, 2020July 13, 2020Keeley 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:

Airtime: A friendly space to meet other people living with COPD and related conditions

November 20, 2019December 2, 2019Helena Leave a comment

At the Dudley CVS Annual Awards and AGM this year we spotlighted some of the amazing groups and individuals we supported during 2018/19. One of those groups was Airtime, a weekly group for members of the community with COPD and related conditions, developed by Integrated Plus and Healthwatch Dudley. Our work with the group over the last year has helped them to become independent and sustainable.

Dudley now has a sustained peer support group for individuals with chronic lung conditions which helps to improve confidence and quality of life. The group have now taken on leadership responsibilities and contribute to the health and wellbeing of its members. They are now looking to expand and find others with similar conditions who may like to join their group.

Members of Airtime understand how important it is to have the opportunity to meet with others experiencing similar challenges in a safe and caring environment. One of the groups main aims is to combat the feeling of isolation by giving people a chance to meet like-minded people with similar lung conditions in social surroundings. It’s a space to relieve stress, to laugh and feel the camaraderie. You can get involved in many activities including arts and crafts, bingo and quizzes, gentle exercises such as seated yoga, tai-chi and meditation. There are informative and educational talks, films, and musical performances.

We caught up with Angela, Dave and Jean at DY1 Community Building on Stafford Street, where the group is held each Thursday from 1pm, to find out how more about their conditions, the impact that Airtime has had on their lives and their exciting plans to develop the group for the benefit of members.

Angela has been coming to Airtime since 2016, she has emphysema, a condition that causes shortness of breath,

“Suddenly I had somewhere to go where there were people with the same problems as me. Everybody understands how you feel and we help each other, so you’re not trying to deal with it on your own.

Airtime has given me another interest. With my husband at work all day, I was at home on my own a lot. If you’re sitting at home looking at four walls you can get quite depressed. It doesn’t start until 1, but you’ll find most people turn up in the café at 12 just to have a chat. Suddenly you are not so isolated, you’ve got a friend at the end of the phone. Your mental and physical health improves. It’s like a family.

We talk to each other in a language we can all understand. We can learn things from each other that a consultant might not talk to you about.

There is a core of 20 people that come frequently and others occasionally. It’s just good to come out, talk to somebody and have a laugh. We like the group to bring ideas forward so everyone is involved in planning what we do.

Since joining Airtime, I’ve actually gone on to join many other groups. I’m a Healthwatch Community Reporter, I’m also a part of a research group. It gives you the feeling that you count again as a person, suddenly you are not just a patient.”

The group also have a Christmas party meal with entertainment where they have a raffle to help them to raise money for the group’s activities.

Jean has long term bronchiectasis which she developed when she was 10. “My condition is progressive, but very slowly. You can live with it, but if you get an infection it’s a struggle. You get through it, but it limits your life.

I love coming to Airtime, I’ve met some really nice people. You build some really good friendships. I met Dave at Airtime, and he’s now one of my best friends. The main thing is to get up off your settee and get out! Every Thursday, I think, it’s Airtime today, and I love it.

The respiratory nurses that come have been massively helpful, although it’s stuff we’ve all been through before, sometimes it goes out of your mind and for them to come in and refresh your memory is massively helpful.”

Dave has had Bronchiectasis for 25 years, he holds the position of Treasurer and also likes to organise quizzes for the group, “I lost my wife about 7 years ago, and when she went, I was completely lost. After 2 years of lying on the settee, I thought, I can’t carry on like this, I’ve got to do something. That’s when I found out about Airtime. For the first time I went dancing, and I met Kathy, who I’ve been with ever since. It’s given me the confidence to go out and meet new people and it’s also something to look forward to.”

The group have been running independently for 6 months now, they are planning activities and making their own decisions. Dudley CVS supported them to look at the frameworks within which they could operate, and the implications of running the group independently. Together they developed a simple constitution and elected the first committee to run the group democratically. Airtime was one amongst 200 hundred not-for-profits we supported last year.

Dave said, “Looking after Airtime now and being part of the committee has given me an extra lease in life. Now I do extra things for the group which I really enjoy. It’s brought me out of myself. Being treasurer also gives me something to do at home.

We ask new people to take a survey when they join Airtime, after 6 months we ask them to take the survey again to see if coming to the group has made a difference to their lives. Nearly everybody has commented about being able to get out of the house, most people were isolated. For some people, Airtime is the only thing they do. You can see people improving, it helps them to manage their condition.”

After our chat, we went to meet the rest of the group who were busy getting creative carving pumpkins and making Halloween crafts. The group also had a special visit from Chief Superintendent, Sally Bourner, who presented them with their Dudley CVS Spotlight certificate, a surprise for the benefit of those who weren’t present at the awards evening.

So, what can you expect if you dropped by Airtime? A warm welcome that’s for sure! A place to meet new people, take part in fun activities and listen to talks from respiratory experts and other guests. The chance to mix with other people living with respiratory conditions and to make friends. A lovely afternoon out for free with a superb supply of tea and biscuits of course!

If you are interested in joining Airtime Dudley, it’s free and runs each Thursday from 1pm – 3pm at DY1 Community Building, Stafford Street, Dudley, DY1 1RT and is open to anyone suffering from chronic lung conditions such as COPD, pulmonary fibrosis or bronchiectasis.

New members are very welcome.

For further information please feel free to contact Angela Rea angela2ree@gmail.com or Dave Taylor on axnfel@talktalk.net

Dementia is not a natural part of ageing

July 9, 2019July 22, 2019Keeley Leave a comment

Bingo? Knitting? Wartime songs? Nope!

This certainly wasn’t what I experienced when I visited the Alzheimer’s Society Working Age Dementia Café.

Dementia is not a natural part of ageing is 1 of 5 key messages promoted by the national Dementia Friends campaign. It is indeed true that dementia can affect younger people. I had the pleasure of meeting Patrick, John and Steve who are all living with dementia.

The group meets at The Oakfield Centre, Brettell Lane in Brierley Hill. It takes place on the last Wednesday of every month from 7pm till 9pm. Anyone who has been diagnosed with any form of dementia under the age of 65 is more than welcome. The group would love to see some new friendly faces!

When I popped along to meet the group I received such a warm welcome. Led Zeppelin was playing in the background and the group told me they were known as “The Rockers.” This was so refreshing. Patrick and John were having a go at a rock music themed word search and Steve was amazing us all with his musical knowledge. Later in the evening the group got creative and made different models out of clay which they all seemed to enjoy. Even the less creative amongst us found it quite therapeutic!

What struck me the most was the bond between the group members, not just the gents but also their wives and daughters. Maureen, Louise and Sandra all told me that they enjoyed attending the group and found the element of peer support invaluable. When I asked the guys what they liked most about the group John said that he loves the company, Steve agreed and Patrick said he liked the biscuits! I love his honesty, a man after my own heart…

I’d definitely recommend this group to any younger people living with dementia and their carers. I really enjoyed myself and I’m sure that others would too. Patrick, John and Steve all met one another on Alzheimer’s Society’s Living Well With Dementia Course and have since become great friends. You can find out more about the course and the café by contacting the local branch on 0121 521 3020 or by visiting the website.

Before I came to work for Integrated Plus, I worked for Alzheimer’s Society as a Senior Dementia Friends Officer. I had the pleasure of training up volunteer Dementia Friends Champions who delivered Dementia Friends Information Sessions. These Sessions help the public gain a basic understanding of dementia and learn some of the small things that they can do to help people with dementia living in their community. Awareness raising is so important as with the right support and understanding people with dementia can have the opportunity to live well.

Within Integrated Plus, my colleagues and I have supported 140 people living with dementia to access the support that they need and to help them remain active in their communities. The Working Age Dementia Café was a great example of a group of friends who are living well and enjoying one another’s company. To find out more about how you can become a Dementia Friend please visit the website.

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

May 29, 2019May 29, 2019kellydudleycvsorguk 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

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

March 26, 2019April 2, 2019Kate 1 Comment

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

March 14, 2019May 28, 2019Kate 1 Comment

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

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 3^rd 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