Celebrating Integrated Plus as part of International Social Prescribing Day – Connecting and supporting for wellbeing and a sense of purpose

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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 and 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 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

 

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Voluntary Sector Multi-Community Specialty Provider (MCP) engagement session

On 7th November 2017, Dudley CVS hosted with Dudley CCG a session with voluntary organisations and community groups across Dudley borough on Dudley’s new MCP.

Purpose of session

Following the launch of the procurement process for Dudley’s Multispecialty Community Provider (MCP) in June, Dudley CCG recently announced the bidder that has made it through to the next stage of the procurement process.

Since September 2017, Dudley CCG has been going through a dialogue process with a consortium involving four local NHS Trusts and local GPs. The four trusts are – Birmingham Community Healthcare NHS Foundation Trust, The Dudley Group NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust and Black Country Partnership NHS Foundation Trust.

The new Multispecialty Community Provider (MCP) will bring together services in an integrated manner and will:

  • hold a contract of up to 15 years’ duration;
  • manage a single, whole-population budget;
  • transform the access to and delivery of community health and care services with Primary Care at the centre, and meet a defined set of outcome and performance measures.

As part of the dialogue phase, Dudley CVS hosted in partnership with Dudley CCG this engagement event for the voluntary sector with the potential consortia. This event enabled the voluntary sector to learn about proposed plans for the MCP and an opportunity to observe and engage in discussions on pre-set questions about how the potential bidder intends to engage with the sector over 10 – 15 years to meet the outcomes of the MCP.

For detailed notes from the meeting view the document below:

Exploring opportunities for the voluntary and community sector in supporting peer led activities and informal networks

Thursday 11th May 2017, 9:30am – 11:30am

DY1 Building, Stafford Street, Dudley

Background information and context

The NHS Five Year Forward View highlights the importance of the following in transforming health and social care services to meet to demands of an aging population:

  • Supporting people to manage their own health better
  • A need for radical upgrade in prevention and public health
  • The NHS becoming a better partner with the voluntary sector and local communities
  • Encouraging self-management for people with specific conditions and peer to peer support
  • Health related community volunteering

Dudley’s MCP commissioning and procurement document states that the MCP will:

  • Work effectively and efficiently with the voluntary and community sector ensuring there is parity of esteem between sector-led activities and initiatives and traditional health and care services.
  • Work with partner organisations in helping to build community capacity and resilience
  • Promote education, self-management and peer support

Aims of session

  • Explore with voluntary and community sector organisations opportunities for stimulating and nurturing peer to peer support informal networks for people living with a long term condition, people with drug and alcohol dependency, people who care for children with a learning disability or physical disability, older people that care for other older people, young people with mental health issues.
  • Explore ideas for co-designing a model to support and enable such activities (some  small levels of financial resource will be made available if required to kick start activities).
  • Explore how the voluntary and community sector can gather evidence of the value of peer-led activities to help people self-manage their health and wellbeing

Who the session is aimed at: voluntary organisations, charities, social enterprises, faith based organisation, community groups.

Book a place through the Eventbrite link here:  https://www.eventbrite.co.uk/e/exploring-opportunities-for-the-voluntary-sector-in-supporting-peer-led-activities-social-networks-tickets-33459223438

Are Link Officers the missing link?

Dudley multispecialty community provider vanguard aims to improve health and wellbeing for local people through more closely linked health and care services, based around GP practices, which allow easier access to care that is consistent and better co-ordinated. In October 2014 they created Integrated Plus, a service based on a social prescribing model that supports people who frequently visit their GP and who are at high risk of hospital admission. Kate Green manages the service and discusses the important role that Link Officers play in the supporting patients.

The aim of the Integrated Plus service is to look at the whole needs of a person, regardless of what those needs might be and jointly find solutions to problems faced and identify opportunities for people to become more involved and active in their community. We help to ensure people are accessing services and activities appropriate to their needs.

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