Dementia is not a natural part of ageing

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”

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 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

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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

 

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