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:

High Intensity User Social Prescribing Service helps reduce demand on emergency services in Dudley

Vulnerable patients are benefitting from a new High Intensity User (HIU) project in Dudley.

A one year evaluation of the project commissioned by Dudley CCG and Dudley CVS has shown a 33% reduction in A&E attendance and a 41% reduction in inpatient admissions saving the NHS over £492,995.

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.

Working together with partners, the HIU team uses a flexible and innovative non-clinical approach with the voluntary sector, to target high users of services and support the most vulnerable people within the community to flourish and find purpose in their lives.

This is in line with the Right Care Programme, which is part of the NHS Long Term Plan’s focus to better understand the needs of patients who are frequent users of emergency departments. Both will work to improve waiting times and response in emergency departments for those patients with the highest care needs is a priority.

Kelly Rea, (Urgent Care Link Worker), HIU Team said: “It all starts with a phone call, from which I am able to actively listen to understand the needs of patients accessing A&E departments. 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.

A local 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”.

Sarah Knight, Commissioning Manager, Dudley CCG, “We are really happy that the service is benefiting people in Dudley, we are always looking at new and innovative ways to meet the needs of our local population, and this is one way we are doing this”.

The programme initiated by NHS Blackpool CCG has also been rolled out in a number of other CCGs across the country.

The full impact report is available to read below:

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

 

imageDuring 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

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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