Integrated Plus Evaluation Reports – April 2020 – March 2021

It’s been a far from normal year of delivery for both Integrated Plus projects. The team spent a large proportion of the year leading 6 Covid-19 Community Support Networks and arranging crisis support for over 900 local residents. In addition to this, they continued to support existing Integrated Plus clients and receive a further 814 referrals for social prescribing support.

Due to Covid-19 crisis support work taking precedent this year, both evaluation reports are based on a smaller sample of data compared to previous years. However, findings continue to demonstrate positive social outcomes for the people we support, significant reductions in hospital admissions and A&E attendances and a strong combined cost avoidance figure of over £1million for both services.

I am proud of how hard the team have worked, not only sustain the day to day service, but also to provide essential crisis support for local people, with the help of Dudley CVS colleagues, local volunteers and partners.

Please click on the images below to read the full evaluation reports:

High Intensity User Social Prescribing Service – Year 3 evaluation
Integrated Plus Social Prescribing Service – Year 7 evaluation

Creative Arts therapy sessions help SC to better manage mental health

SC was identified from the High Intensity User (HIU) list due to being a frequent user of West Midlands Ambulance, West Midlands Police and A&E department. SC was very dependent on emergency services and was being admitted to hospital via ambulance every week due to poor mental health.

SC has a mental health diagnosis and struggles with her day-to-day activities. This puts a strain on her relationship with her family and friends.

I befriended SC and we formed a good therapeutic relationship, she explained how she was struggling, and I was able to offer her a range of groups to attend at Arts of Change (AOC) in Dudley. The Creative Orchid Project (AOC) consists of a series of creative arts therapy sessions which cover topics as body image, anxiety, self-esteem, depression and anger.

SC began to attend the groups, at first, she struggled in a group setting and at one point felt she may not be able to carry on. However, through her determination and persistence, she continued and completed the first group. SC has expressed how much she now enjoys the groups and as each group has finished, she has decided to attend the next one to continue to build her confidence and learn to better manage her emotions and feelings.

SC feels she can be open at AOC and has expressed how she feels comfortable around the session facilitators and the other participants, SC feels she has developed new friendships and a result of attending.

SC is now on her sixth course and is engaging well, she attends each week on time and participates fully in each session. She is looking forward to the future and intends to apply the skills she has learnt to her daily life.

“The groups are amazing and it’s helped me a lot”

Client D says support provided by Integrated Plus has “changed her life”

D was referred to Integrated Plus in October 2020, due to feeling low in mood and anxious. The Senior Social Prescriber contacted D to explore things more and after talking for nearly 2 hours, there were many things identified for Integrated Plus to offer support with.

D is a nurse and lives with her young daughter. One of the things impacting D’s wellbeing was the impact of her physical health. D had various health conditions that made mobilising difficult at times. Integrated Plus liaised with Adult Social Care to put aids and adaptations in place for D, which made entering and leaving her property much easier. D also struggled due to high energy costs, as she needed to keep her heating on to help with her physical health. The Senior Social Prescriber worked with Winter Warmth to support D to reduce her energy costs and apply for energy discounts.

D disclosed that she had been through a lot of trauma when she was younger. Integrated Plus referred D for therapy through primary care. As the waiting list for therapy is quite long, Integrated Plus worked with Arts of Change to start therapy for D, so that she was not left without any psychological support whilst waiting for therapy through primary care to start. When primary care got to D, there was a seamless transition from one therapy provider to another.

Integrated Plus also supported D to access weight loss information, advice and support to make healthy lifestyle changes, which has helped D to manage her condition.

D reported that she found the initial conversation with Integrated Plus ‘really helpful and lifechanging’. D said that the support put in place for her by Integrated Plus had ‘changed her life’ and D knows she can come back to Integrated Plus in the future for more support if ever needed.

Lifecentral Church supporting residents with befriending scheme

Lifecentral Church has been supporting the local community by recruiting kind-hearted volunteers to provide much needed befriending support.

Mr A was referred to Integrated Plus via his GP as he was struggling with loneliness and isolation through the pandemic. The Senior Social Prescriber contacted Jo Gregory from Lifecentral Church to see whether a befriender could be allocated to Mr A. Mr A was allocated a dedicated befriender and has had several weekly conversations with him on the telephone, Mr A very much looks forward to these calls. Their friendship is blossoming, and they are planning on meeting in their local town for coffee and cake.

“We at Lifecentral have a heart to serve our local community and meet the needs where we can, and we came up with the idea of investing volunteer time into befriending through the pandemic. We were increasingly aware that folks were lonely and isolated at home, and we wanted to do something to help this. I have an amazing team of committed, warm hearted and generous people who are delighted to give some of their time to folks who are lonely and need some support in the community“ – Jo Gregory, Lifecentral Church

How Rebecca (Link Worker) has been supporting patients to regain their confidence post lockdown


As COVID-19 lockdown restrictions begin to ease Integrated Plus has been looking at ways in which we can adapt to meet people’s needs. A large percentage of the people that we work with have long-term health conditions, meaning that they have not left their home for several months due to shielding. Many live alone or do not have family and friends close by so their loneliness and need for social connection has been exacerbated by restrictions. 
As we are now in spring and the sunnier weather is approaching, we have seen an increase in people wanting to leave their homes, for social connection, exercise and sunshine, however they lack the confidence to walk out of the front door. Integrated Plus staff have been supporting these people by doing supported walks aimed at supporting both physical and mental health. Here are some recent examples: 
Mrs A is an elderly lady who lives alone and told me that she has not left her home independently in nearly 2 years. She told me that her goal is to be able to walk to her local corner shop, but she lacks the confidence to go on her own. Following this conversation, I accompanied Mrs A to her local corner shop on two occasions. Since those two walks Mrs A has been on a further two walks to her local shop with her gardener and cleaner. Being able to walk to the shop means that Mrs A has reconnected with the shop assistants and is gaining confidence to go back groups that she attended prior to lockdown. 
Miss B is a young girl who has autism, since the start of the pandemic she has not left her home independently. During a telephone conversation Miss B expressed to me that she wanted to walk into her local town but lacked confidence. I accompanied Miss B on a supported walk into her local town and visited several book shops and showed her where her local library was based. Miss B has since walked independently into her local town and has visited the local library to enquire about joining a book club. 
Mrs C is a recently bereaved lady with multiple health conditions. Due to her health and restrictions, she has not been able to leave her home in several months. Mrs C expressed to me that she is keen to start exercising by walking around her small carpark. I met Mrs C for a walk around her carpark and she said she enjoyed getting out of the house for a chat, exercise and some vitamin D! We are still working with Mrs C and hope to connect her with a volunteer befriender who can offer long-term walks and companionship. 
As we emerge from COVID-19 into what feels like a different world, social prescribing plays an important role in supporting the governments COVID-19 mental health and wellbeing recovery action plan (April 2021) and interventions such as connecting people with their community, physical activity and access to outdoor spaces play a key role in improving people’s physical and mental health.   

Rebecca Woodall – Senior Social Prescribing Link Worker (Halesowen PCN)

Client X supported to maintain independence and improve wellbeing

X was referred to Integrated Plus in June 2020. At the time, X was living in a B&B and had mobility and physical health needs that could not be met, due to having to use shared facilities such as a bathroom and kitchen area. X was also having issues with his memory and was extremely isolated.

When the Senior Social Prescribing Link Worker first contacted X, X gave consent for them to speak to his daughter in law, as he was struggling with memory. The Senior Social Prescriber talked to the daughter in law to learn more about X’s struggles and challenges and a plan of action was developed.

The Senior Social Prescriber referred X to Adult Social Care and to Housing Support. Due to X’s support needs, X was allocated a worker from Housing Support. Adult Social Care, Housing Support and Integrated Plus supported X to find appropriate housing in an age exclusive setting with other residents of a similar age. For the first time in years, X had access to his own kitchen, bathroom, living room and bedroom.

X was given some hours of care to help him to maintain his independence. Integrated Plus and Housing Support worked together to obtain a new cooker and fridge freezer for X and supported the family with setting up direct debits for his bills. Integrated Plus also supported with access to a memory assessment with the doctor’s surgery and X’s memory issues are being monitored on an ongoing basis.

The Senior Social Prescriber also supported X to apply for Attendance Allowance, which made a huge different to his ability to pay for the extra help he needed e.g., someone to help with cleaning his flat.

X’s daughter in law reported that the difference she had witnessed in X was ‘astounding’. Due to X feeling happier with his living situation, his daughter in law commented that his relationship with his family had ‘improved, as it’s more enjoyable to spend time with him in his own flat’.

X’s daughter in law said:

Integrated Plus have been amazing. Their help and advice have been valuable and most appreciated. As a family who never claimed benefits or applied for council housing, we would have really struggled without their help. They have been fantastic easing the pressure on us and they offer an invaluable service to the community. We cannot thank them enough! Thank you so much for your help, support, and guidance.

Dudley CVS commission Riverside Stourbridge CIC to deliver new outdoor social prescribing activities

Riverside House is a beautiful and ecologically diverse site in Stourbridge which runs alongside Stourbridge canal. Riverside House is in the process of transforming the 19th century ironworks area into a heritage centre with gardens, a restaurant, crafts shop, woodland and workshops but also a place where people feel included and bespoke opportunities are provided.

Much of this work is now well underway. Our capacity building team at Dudley CVS initially helped Riverside Stourbridge to get set up as a CIC, supported them with planning, building their vision and securing funding and it is fantastic to see the progress being made. The project works with a wide range of individuals from diverse backgrounds and supports them to learn new practical skills through the conservation and preservation of the estate.

In the winter of 2020, Clare and Lloyd at Riverside Stourbridge CIC applied for funding from our voluntary sector social prescribing fund. The fund makes it possible for new activities and services to be set up and delivered to meet the needs of our Integrated Plus High Intensity User social prescribing clients, who frequently attend A&E or call 999. Their application was successful and they’re now delivering three different workshops including copper & willow weaving, blacksmithing and green woodwork.

Ami is a client accessing the High Intensity User social prescribing service, after hearing about the workshops she was keen to try blacksmithing as she enjoys being outdoors and learning new skills. Ami attended the six week course and thoroughly enjoyed every session, she showed her Link Worker how she had made a plaque for her home to hang her keys on and how she has personalised it. Ami was able to recognise within herself how the workshop had built her confidence and helped her overcome her fear of new places.

“I attended the Blacksmithing course at the Riverside House Project and I loved it! Not only did I get expert and friendly tuition in a totally new skill I had never tried before, but the guys shared their vision and dreams for the Riverside House site during the sessions and got me excited for the future of the project. All the volunteers and leaders were friendly and welcoming, always encouraging and helped me feel confident in something I had never done before! Looking forward to joining with more projects and seeing the way the RHP develops and expands in the coming years.” Ami

To find out more about the other fantastic work that Riverside Stourbridge CIC deliver, click here.

To find out more about our voluntary sector social prescribing fund please email

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Carving spoons at a green woodwork session
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Making copper bowls