Client X supported to unlock artistic talent and reduce hospital admissions

Client X was highlighted as a potential person that we could support, within the last 12 months he had been admitted to hospital on 19 separate occasions. During the Covid-19 pandemic I made contact with him over the telephone, built up a rapport and carried out a holistic assessment.

Client X is an older male and he had become extremely lonely since his wife had been taken into a care home. He lives in supported housing but due to Covid-19 all the activities had stopped.

I identified that Client X was really struggling with loneliness and this was not helping his long-term health issues, this resulted in his admissions to hospital increasing. I needed to look into how social prescribing and the HIU service could help alleviate the pressure on the hospital, especially during the pandemic but most importantly help and improve the health and wellbeing of Client X.

During our many telephone conversations, Client X told me that he is artistic and loved painting but could not afford to buy supplies. I was able to allocate Client X a personal health budget in order to purchase some art materials such as paints, canvas’s etc.

I’m pleased to say that over the last few months this has given Client X a sense of purpose, he now paints pictures and gives them away to his carers and to other residents, improving his social life. His hospital admissions have dramatically reduced.

I feel that something as simple as being able to allocate client X a personal health budget has made a huge different to his mental and physical wellbeing and he no longer has a need to go to hospital.

Here is a photograph of a recent painting that Client X sent to me:

Kelly Rea – HIU Link Worker

Tea Time Treats for Halesowen residents

In 2015, Halas Homes took over the running of a local café called Coffee Cups in Halesowen. The cafe was a social enterprise where people with learning disabilities could learn and develop skills in a real, commercial working environment. Coffee Cups quickly became a very important part of the local community and was considered to be a ‘community cafe’.

Coffee Cups was a much loved place to visit by local residents (including one of our clients, Mr X). Mr X is in his 80s and was referred to Integrated Plus by his GP due to long term health conditions and loneliness. When the Link Officer (Sue Bloomer) visited Mr X she realised that he could no longer easily manage to walk to Coffee Cups unaided, and asked the Link Support Worker (Becky Woodall) to take Mr X to a local mobility centre to help him look at mobility scooters. After looking at what was on offer Mr X decided to buy a mobility scooter there and then! He used it to visit Coffee Cups regularly and got to know all the staff and customers there. It has also enabled him to be more independent and visit other local shops.

Unfortunately, due to the Coronavirus outbreak early in 2020, Coffee Cups was forced to shut its doors, leaving Mr X with little social contact with others, less chance to get out and about, and reliance on his own cooking.

However, Halas Homes has now received some funding to use to benefit local people and has used this to set up ‘Tea-Time Treats’. The staff deliver free tea, coffee, soup and sandwiches to those identified as elderly and isolated. Integrated Plus has worked with the Project Coordinator to identify people who would benefit from the new project, and Mr X is delighted to receive support from this new initiative. 

Quote from Jo Bennett about how the project is going:

We have had a positive response and fabulous feedback from the residents we are supporting so far. It is great to see the project continuing to grow week by week.

Meeting the residents and having the opportunity to have a chat with them when we deliver their refreshments is a fabulous way to keep all our spirits up. The warm welcomes we get are heart-warming, especially during these difficult times.

Staff on their team time delivery rounds

Jenny receives support with her finances, mental health and enjoys a brighter Christmas

Our client, Jenny, lives with her partner and 3 children. She is a full time teacher at a local secondary school and her husband currently works part time due to the coronavirus. Her husband was made redundant a day before her youngest was born a few years ago – the stress of this resulted in him having a breakdown and struggling to get re-employed. Since then, they have acquired debts that equal into their thousands and have had trouble paying them off. Jenny was referred to Integrated Plus initially for support with their financial situation and the crisis point that was nearing.

At the time of our support, Jenny was off sick from work due to the stresses of the above. Jenny agreed for a referral to the Arts Of Change for counselling, as she felt that she was on the edge of her own breakdown with having to care for her children, her father and her husband. We also sent information on the Debt Life Centre in Stourbridge – who could go through the debts one by one and offer to sort out a payment plan.

At the time of our referral, we had had a generous contribution of ASDA vouchers to Dudley CVS for people who were struggling to afford food or necessities at the time, especially due to the financial burdens of the pandemic. I offered one of these to Jenny and she accepted this support.   

When I called back to Jenny a month later to see how things went, she was really happy with the ASDA voucher. It meant she could buy items that they had wanted for a while, and buy foods in bulk that they needed. This helped to take the edge off the weekly shop, which can become quite pricey for a family of 5!

As a service, we had been offered 5 places for families who were struggling financially to have a Christmas dinner hamper sent to them for Christmas time. This generous offer was made by The Christmas Lunch Project who’s mission is to support families with children who cannot afford to buy all of the ingredients to cook a Christmas Lunch on Christmas Day. Jenny agreed to this, and was very grateful for the offer – “To be offered something like a Christmas Hamper by a service is truly heart-warming. Especially as my father in law who passed away not long ago, would have usually paid for this in recent years.”

Jenny explained that they had managed to find some money to pay off their debts, by the sale of her father in laws property. Although this hasn’t paid off all of the debts, they are in a better situation now where the important debts have been paid and can manage to pay monthly sums for their other debts.

We also offered the support of the voluntary sectors Operation Santa project, which take’s place every year at Christmas time in Dudley. Generous donations are gifted to the project by individuals, organisations and businesses – in order to help the children of vulnerable families or families in need at Christmas time. Jenny agreed for us to refer her into this, and presents were sorted for her 3 children ready for Christmas. Here we have been able to take the edge off another expensive time of year!

“The sale of the flat, coupled with the generosity from the voluntary sector projects like the Christmas lunch project and Operation Santa, has helped us enormously when needing support at such a difficult time financially”.

Jenny has had two face to face sessions with an Arts of Change counsellor and has found this really helpful:

I needed support because I was living in a state of panic. The counsellor here helped me with techniques and coping mechanisms to deal with panic. I am now also keeping a journal for when I have a lot of problems that I cant seem to pin down in my brain. This allows me to rationalise them and makes them clearer when I put pen to paper. The counsellor has also allowed me to talk out difficult conversations that I have had in my life, for example arguments with family members. I have then been able to see them from different perspectives. Being offered the option of seeing a counsellor face to face, especially at the time of the Covid pandemic has been really helpful. It has made the whole process more meaningful for me”. 

Jenny’s experiences on the help we offered:

“When we first ran into trouble, I thought there was no way we could get support. I was earning and so was my husband so we couldn’t claim any benefits or get any welfare grants – however in reality this money was going straight towards paying off our debts. We had relied on extra bits of income before Covid, for example my partner working longer hours and I was offering one to one schooling tuition to pay for our weekly expenses. Since covid – this extra bit of income had stopped. My husband could not find the extra work and I was unable to go into other people’s homes to teach. This really affected us, and thought we would have to sell our house in order to manage.

I was able to speak to my GP at the surgery, who then referred me onto the Mental Health nurse as well as Georgia and Gary at Integrated Plus. The support (mentioned above) that was offered to me was such a great help. It really made me feel that there was such a joined up approach within the services. I really didn’t know which way to turn and I have been helped so much by each and every service that supported us. We are now in a better position, and although there are still things to overcome, it is so nice to know that there are people out there who are willing to help”.

Georgia Pearsall & Gary Hastie

New outdoor course commissioned to improve “mental toughness” of HIU clients

Natasha, Vicky and Ami were all referred to the HIU project due to their high hospital admissions and 999 call outs. Each one of them had their own mental health issues that they were trying to work through. They always discussed how they felt they had low confidence and low self esteem and this impacted negatively on their mental health on a daily basis.

They were all approached and asked if they would like to attend our new Challenge Academy social prescribing 5 week course. The course was designed to work on developing mental health awareness, building resilience, improving mental well-being, building confidence, developing self-esteem and positive self-image. Challenge Academy CIC have an excellent understanding of social determinants of mental health and through the course focus on goal-setting and personal achievement, changing unhealthy thinking and developing a positive mind-set.

They all said they would give it a try but were very apprehensive. On their first day they met with their course instructors Chris and Gregg who would deliver the course over the 5 weeks, they got to learn all about each other and what the course would entail over the coming weeks. As the weeks went by and they continued with the course activities they were able to learn and develop through participating in outdoor art sessions, orinteering, team building activities and much more.

Over the course of the weeks it was very easy to see the positive change in all of the participants. Their confidence increased, they felt better in themselves and were wanting to push themelves out of their individual comfort zones. They could easily identify the marked inprovement in their own mental wellbeing and were noticing changes.

Vicky (HIU client) said “it’s great fun and confidence boosting, it makes me feel good I don’t even realise im doing exercise! The staff are really friendly”

Natasha (HIU client) said “staff are really encouraging and push you out of your comfort zone. The team building exercises are fun and really help to build your trust and confidence.”

The three clients have formed a close knit friendship through attending the sessions and would always give each other encouragement in all their tasks and pick each other up when they were struggling. This friendship has continued outside of the course and on weekends they now meet up and go shopping, for a coffee or visit one another.

Speaking with the clients it is clear to see the improvements, not only through their admissions and ambulance call outs drastically reducing but also through their own personal wellbeing. They all advised that they didn’t find it easy but felt with each others support and the support from the course they could do anything that was asked of them, this even included completing activites in record time by working together as a team and solving the problems they were given.

Each individual is now looking forward to taking the skills they have learnt from this course and using them in their future.

Ami (HIU client) said “There is a great atmosphere, friendly staff who really challenge you but make you realise what you’re capable of when you put your mind to it.”

Danielle Giles – HIU Link Worker

Barbara helped to stay in her own home

Barbara was referred to Integrated Plus by her GP at Lion Health.  She had some household issues she wanted to resolve and suffering with depression.  When Barbara met Georgia, the Locality Link Officer for Stourbridge, Wollescote and Lye, she went into more detail as to how she was feeling.  Barbara said she was upset and depressed because there was some uncertainty about her having to move from her property due to access and safety issues.  One of the main issues was Barbara did not have a cooker and her social worker identified that her current set up in her kitchen was a safety risk.  Georgia discussed this with Barbara and her social worker and said we could support her with applying for a Grant for a cooker which would make her property safer and more accessible.  Barbara also said she would like support with her garden which had become overgrown and unmanageable.   

Barbara has osteoporosis, brittle bones, dry macular degeneration and glaucoma.  She is also a wheelchair user and has volunteered at Beacon Centre for many years.  Barbara is a real inspiration to everybody she meets and is always willing to help others, she travels to the Beacon Centre every day on her mobility scooter come rain or shine.  She volunteers with craft groups and is always there to welcome members and volunteers.  Georgia tasked Gary, the Link Support Worker to make contact with Barbara to look at possible grants for a cooker.  Gary discussed this with Barbara and it became apparent that she would need a cable fitted as well as an electric cooker.  He applied for a grant from The Reginald Unwin Charity and this was successful but only for the amount of a cooker and not for the cable and fitting.  Barbara could not afford to pay for the rest so Gary then applied to Badley Memorial Trust who work closely with Geoff Hill in Amblecote and they agreed to fund the electric cable and fitting.

Gary met Barbara a couple of weeks later to do a review and said she was delighted with her new cooker, she said: “The cooker has made a big difference to my life, I haven’t had a cooker for nine years, I use it regularly to cook healthy food.” 

This has also enabled her to stay at her property alleviating the stress of a potential move from the home she loves.  Barbara also mentioned to Gary when they first met that she would like support with her garden which had become overgrown and difficult to manage.  Unfortunately, this was difficult to accomplish due to the lockdown, however Barbara was able to get support with this from her circle of friends and other volunteers at Beacon Centre and they have supported her to regularly tend to and maintain her garden.  The Beacon Centre opens again soon and Barbara is eagerly awaiting to be reunited with her friends and fellow volunteers.  

Barbara with her new cooker

Emma helped out of poverty in order to focus on improving mental health

Emma was referred to the Integrated Plus service by her mental health nurse who had indicated that Emma had a long-standing history of poor mental health. An appointment was arranged for the Link Officer to meet with Emma and her husband Patrick, at their home.

During the assessment Emma shared that she had suffered many traumas and losses during both childhood and adulthood. Emma has since received a diagnosis of emotionally unstable personality disorder, anxiety and low mood and was awaiting further support.

It was also identified that Emma and Patrick were really struggling financially. Emma was unable to work due to her mental health and very rarely left the house. She did not feel able to mix with other people. Patrick was her full-time carer and only source of support.

Emma revealed that their bed was broken and they dragged an old mattress into the lounge to sleep on at night. They could not afford to put the heating on, the piece of carpet they had in the living area was frayed and worn and there was no carpet in the bedroom. The fridge/freezer was broken and only worked intermittently leaving food spoiled and inedible. Emma needed support to apply for Personal Independence Payment to help support her daily living costs.

The Link Officer and Link Support Worker acted quickly and arranged for a new bed and mattress to be delivered by Loaves and Fishes with help from Leslie’s Care Packages who covered the cost of delivery. They were successful in securing grants for new carpets and a fridge freezer from The Badley Memorial Trust and Reginald Unwin Dudley Charity. Vouchers were provided for clothing and bedding from Helping Hands and for food from Black Country Foodbank. Emma was helped to complete her application for Personal Independence Payment. Ongoing support was provided to Emma via telephone.

Emma’s application for the Personal Independence Payment was successful and she was awarded high rate daily living and mobility. This has relieved Emma of so much worry and has alleviated the pressures of living in a poverty stricken environment. Emma spends the majority of her time in her home and being able to make their living environment more comfortable, and have a few nice things, has helped Emma with her mental health. Emma is now able to focus on getting the treatment she needs to improve her mental health.

Emma said: “My mental health nurse referred me to Integrated Plus. The Integrated Plus Link Officer, Jason, got in touch really quickly to offer us the support which we desperately needed. So many things were sorted out straight away eg carpets, fridge freezer, bed and food parcels also vouchers for clothes bedding etc. The support shown has been excellent very much appreciated, also throughout the coronavirus. We cannot praise enough for these workers. Without them I think our lives would still be a struggle it has been eased greatly thank you Jill & Jason x It’s nice to have someone – not just for items but for advice and to talk to. Thank you”

Emma’s living room now

Dee supported through bereavement and reconnects with old friends

Dee was referred to Integrated Plus, due to experiencing feelings of loneliness and isolation. She had also experienced the recent bereavements of her son and husband, who both passed away within 6 weeks of each other. Soon after these bereavements, the UK went into a national lockdown, further exacerbating Dee’s feelings of isolation.

When the Link Officer first made contact with Dee, it was the first opportunity Dee had to freely express how she was feeling and how difficult things had been for her. Dee stated that she had received one counselling session arranged through the GP, but these had stopped suddenly when the national lock down took place, and Dee had not spoken to anyone else since about what had happened in her life and how it was impacting her.

The Link Officer identified that some bereavement counselling could possibly support Dee to explore her emotions and hopefully, in turn, find some peace. Dee was referred to Arts of Change, who provide therapeutic counselling to support individuals to deal with a wide range of issues and life experiences. Dee was initially reluctant to engage with Arts of Change due to being let down by other services in the past, but after some encouragement from the Link Officer, Dee agreed she would give it a go. Due to Dee’s vulnerabilities at this time, the Link Officer agreed to bi-weekly calls for a short period of time to support Dee to feel less isolated, until she found her feet with the counselling.

The Link Officer then asked a Link Support Worker to call Dee to check how she was getting on. At this point, Dee had been engaging with sessions from Arts of Change. Dee reported that she felt uplifted after one of these sessions, so decided to go on the bus and into Dudley Town Centre, where she happened to meet some old friends on the journey. This small, but significant, outing seemed to breathe a breath of fresh air into Dee.

During another call to Dee, she reported that she had been struggling with the nights and feeling lonely. The Link Support Worker reassured Dee and provided her with the number for Silver Line, who she could contact any time of the day or night if she was feeling low and wanted to talk.

Dee mentioned in a later call that she had started going to Dudley Town Centre twice weekly and had been going shopping with her cousin on a weekly basis. Dee also reported that she had connected with a neighbour, with whom she was meeting for walks and general catch ups.   

At this point, the Link Officer discussed ongoing support with Dee, and Dee said that she felt things were going a lot better than they had and she was moving forward.

Dee said “I was so grateful when Integrated Plus started calling me. I looked forward to their regular calls each week, as I was in such a dark place. I am more than thankful for the support they have given to me”

Integrated Plus share excellent outcomes from year 6 of social prescribing delivery in Dudley

The Integrated Plus social prescribing service is now into its 7th year with an experienced team continuing to provide 1-2-1 social prescribing support to vulnerable patients in the Dudley Borough aged 16 and over. The team continue to provide a valuable link to the voluntary and community sector and champion the non-clinical and social needs of patients within their GP lead multidisciplinary team meetings.

Dudley CVS are delighted to have witnessed the momentum that social prescribing is gaining. We’re proud to have been part of helping to gather valuable evidence to demonstrate the effectiveness of social prescribing interventions and to have contributed towards the roll out of social prescribing roles nationally.

Our annual evaluation report for year 6 shows that support provided by the service is continuing to result in significant reductions in A&E attendances and inpatient admissions, generating strong cost avoidance figures:

  • 731 patients accepted the service
  • Inpatient admissions reduced by 45% after 12 months – cost avoidance of £450,500
  • Attendances at A&E reduced by 32% after 12 months – cost avoidance of £22,885
  • Total cost avoidance of £473,385 resulting in a net saving to the borough of £28.30 per patient

More importantly, the support continues to result in positive social outcomes for patients. After receiving support the following reductions were made in the number of patients “not managing:”

  • Finance, 87% less patients
  • Physical Health, 91% less patients
  • Mental Health, 83% less patients
  • Social Contact, 88% less patients
  • Housing, 80% less patients
  • Safety, 83% less patients
  • Learning, 88% less patients

For more information about the service, including patient stories and reflections from members of the team, you can read the full report here:

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

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: