“Excellent service of which a number of patients have benefited from. Keep up the good work!” (Penny Massey, Health Care Assistant)
“Integrated Plus offers a real solution to the people who would perhaps not be assisted via other routes. Enhancing wellbeing of the person which assists in them requiring less need for medical intervention” (Kim Wilkes, Social Worker)
The journey so far... a report on progress, learning and impact
“A fantastic service. A real game changer” (Dr Rebecca Willetts)
September 2014 to May 2016 Supporting people to become more active and involved in their communites (Integrated Plus is delivered as part of Dudley borough’s New Models of Care)
Dudley Clinical Commissioning Group
The intention of this report is to: • Share learning about what we have found from implementing Integrated Plus • Demonstrate the value of the approach undertaken by the Locality Link Officers • Share information about outcomes being achieved for local people through Dudley’s integrated care model • Demonstrate the importance and value of local diverse services that make a huge difference to people’s lives • Highlight areas for debate and discussion with organisations and partners about people’s needs and new ways of working that would help improve the health and wellbeing of local people
Sections covered in this report include: Key findings so far Dudley’s New Models of Care About Integrated Plus Locality Link Officer - ways of working Referral information and findings from our data Importance of local services and activities Feedback on Integrated Plus Outcomes being achieved by Integrated Plus Stories about people who have benefited from Integrated Plus and local services Encouraging peer support and volunteering Stimulating new activities to meet need Views from the Locality Link Officers Final reflection of what we have learnt and what next? Organisations and projects we have referred people to
2
Page Page Page Page Page Page Page Page Page Page Page Page Page Page
3 4 5 6 7-10 11 12 13 14-16 17 18 19 20 21-24
Making a difference to the NHS
Referrals
GPs and health clinicians are more aware of the diverse range of
Locality Link Officer approach why it’s working It combines a flexible, non-clinical, holistic package of support
1304
Integrated Plus
We focus on the whole person’s needs whatever they might be to jointly find solutions to problems faced
2547
246 77 Local Authorities
48 5
National Government
43 projects and activities run by voluntary and statutory sector organisations private sector organisations
inappropriate home telephone GP visits visits consultations by 30% by 21% by 35% voluntary sector
services available 92% of GPs and other health clinicians stated that Link Officers are pivotal to MDTs in the future to represent the voluntary sector
44 people supported at
an average of
on a sample size of
£8,547
Dudley CVS is working with Birmingham City University and the PSIAMS team on developing a detailed methodology for cost savings and cost avoidance
We have a ‘can do’ approach and attitude as we are not tied by organisational cultures and boundaries
The voluntary sector needs to be viewed as a core part of the health and social care integrated system
people 41 supported
saving the NHS
The diverse range of services provided by the
un
We do what we can to help whatever the support needs are We spend time with people, actively listening to their needs and aspirations
and not merely as an optional extra
m m u ni
£5,170
The voluntary sector plays an important role in ... supporting people to live independently enabling people to manage their health conditions better reducing isolation promoting self-help and much more
fai
sector are vital to Dudley’s New Models of Care
Integrated services “Teams without walls” The multidisciplinary team approach
We ensure people are accessing services appropriate to their needs
tary
co
organisations
based on
v ol
486 statutory
£375,000
The voluntary sector adding value Support is independent and impartial
voluntary and community sector organisations
We have reduced
th
(The below figures are based on people being referred to more than one organisation and service)
Estimated NHS cost saving/avoidance of up to
ty
A
Key Findings So Far (Sept 2014 – May 2016)
There has been less silo working
is proving to be a positive and productive shared way of improving joined responsibility up care and support for for people’s vulnerable people in care Dudley borough
a significant There are shift in now organisational cultures
genuine ‘teams without walls’
clinical focusing on both
a pulling together of different skills and expertise
nonclinical
support to help improve people’s quality of life
3
B1
Under the new model, people who are registered with a Dudley GP and who are at high risk of hospital admission, for example, with frailty and long-term conditions, will have their care overseen by a multi-disciplinary team in the community. This team includes the Dudley CVS locality link officers who are connecting the most vulnerable people to the 1000+ community and voluntary sector organisations in Dudley. This ensures a more rounded approach towards care that better meets the person’s medical and social needs – at one time, in one place. These links also help to ensure that people have access to support and care from their local community.
B2
As a result of the health and care system working together in this way, people are not only receiving the coordinated support necessary for their health needs, but they are also linking to the wider network of care and social interaction in their community to help them live more independently for longer. New ways of working will also mean that health and care staff will have more time to care for the people that need their expertise the most. A short film has been produced to describe the Multi-Disciplinary Team (MDT) approach, please go to www.dudleyccg.nhs.uk/integration
4
Planned Care
Triage
Urgent Care
UCC
MCP (Multispeciality Community Provider): Commissioning Shared Outcomes
part of a wide as s e lti-disciplina r u r GP M
twork al ne utu m team) y
Dudley is one of the areas selected to test a new model of care following the publication of the NHS England Five Year Forward View. People are living longer, with more complex health issues, and across the NHS it is now recognised that to really meet these challenges a longer term view needs to be taken. Dudley Clinical Commissioning Group is working with partners in Health (the Dudley Group NHS Foundation Trust, Dudley and Walsall Mental Health Partnership Trust, Black Country Partnerships NHS Trust), Social Care (Dudley Council) and the voluntary sector (Dudley Council for Voluntary Services) to develop a new care model. All Together Better describes this partnership. Partners are now working together to develop a new care model called a Multispecialty Community Provider (MCP) to improve the way the most vulnerable people are looked after.
Value added treatments: Commissioning best practice pathways
Other s er MDT vic (
Dudley’s New Models of Care
Our model
Person
GP-Led Care Our model is based on the following principles: Shared:
ownership Maximising responsibility the potential benefits of:
The individual (in their community) Our staff in supporting the individual Our staff working effectively with each other
Dudley’s Integrated Care Model Community Nurse Other Support Services
Virtual Ward Representative
Mental Health Nurse
Practice Based Pharmacist
Person
DCVS Locality Link Officer
Social Care Link Worker GPs
About Integrated Plus Integrated Plus supports people aged 16 and over who frequently visit their GP and who are at high risk of hospital admission. The aim of the 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. The Locality Link Officer roles are new and were created specifically to complement Dudley’s New Models of Care. Locality Link Officer’s attend the 47 multi-disciplinary team meetings in their locality (held at GP practices) to ensure non-medical needs of people are being met. Integrated Plus is delivered through five Locality Link Officers, one manager, administration support and volunteers. One Locality Link Officer is located in each of the five localities.
The difference we aim to make Integrated Plus aims to help people: • • • •
Improve their mental health and wellbeing Become more active and involved in their own communities thus reducing isolation and increasing self-esteem and confidence Access support that they need to help improve their quality of life Make a difference to their community eg through volunteering and becoming active citizens
Integrated Plus aims to help the voluntary, community and faith sector to: • Keep informed of the integration agenda and enable voluntary organisations to play an active role in Dudley’s New Models of Care • Raise their profile to a range of health clinicians and funders so that the voluntary sector is viewed as a credible partner delivering effective, high quality services that meet local needs Integrated Plus aims to help GPs and other health clinicians to: • Reduce pressure on medical practices by supporting people to become less reliant on medical services • Ensure social inclusion of people at high risk of hospital admission and frequent presenters are taken into consideration at MDTs
5
Locality Link Officers not only broker people into services and activities, the support is much more tailored and in-depth when people are in crisis, are waiting to access services and who have an urgent need.
We support people with navigating the health and social care system
Ge
We help people access disabled bus passes and connect people to transport services such as Ring and Ride
We support people with family issues We issue emergency one-day travel passes when people are in crisis and who have no money to attend benefit appeals appointments
d suppo an
We connect people with each other to offer peer support
cti nne ng
cessing Ac
Bu i
We connect people into a wide range of social activities
We ensure people are getting the right care and support they need and are entitled to
gp rtin eo
6
d
ng aroun tti
ng a ho ldi
me
We help people access work programmes, adult education and ESOL classes
We help people access white goods vouchers
Co
We ensure people are getting the benefits they are entitled to
We connect people into services that can help with all kinds of issues eg mental health issues, drug and alcohol addiction etc
on offer es
e servic h t
We ensure people have adequate heating and food by issuing food bank vouchers and signposting people to Public Health’s Winter Warmth scheme
We help to resolve household issues
ple
C
Locality Link Officers - ways of working
We support people into volunteering opportunities
We help people reconnect with family or friends
D
Referral information and ďŹ ndings from our data Sedgley, Coseley & Gornal Coseley Medical Practice (32) Woodsetton Medical Practice (29) The Ridgeway Surgery (26) Northway Surgery (24) Castle Meadows Surgery (22) Bath Street Medical Centre (15) Lower Gornal Health Centre (14) The Greens Health Centre (13) Bilston Street Surgery (3) MaseďŹ eld Road Surgery - Lower Gornal Branch (0)
249
Other referral sources (71)
total
279
Kingswinford, Amblecote & Brierley Hill Rangeways Road Surgery (45) Three Villages Medical Practice (31) Moss Grove Surgery (17) Wordsley Green Health Centre(15) A W Surgeries(14) Kingswinford Medical Practice (9) High Oak Surgery (3) Waterfront Surgery (2) Quincy Rise Surgery (2) Wollaston Surgery - Three Villages Branch (0) Summerhill Surgery (0) Withymoor Surgery - AW Branch (0)
Stourbridge, Wollescote and Lye Lion Health (79) Wychbury Medical Group (65) Pedmore Medical Practice (59) Norton Medical Practice (13) The Limes Surgery (10) Chapel Street Surgery (4) Other referral sources (48)
Dudley and Netherton
total
Eve Hill Medical Practice (57) Keelinge House Surgery (54) Central Clinic (26) Links Medical Practice (18) Netherton Health Centre (18) Steppingstones Medical Practice (16) Cross Street Health Centre (11) Bean Road Surgery (9) Dudley Partnerships for Health (9) St James Medical Practice - Dr White (4) St James Medical Practice - Dr Porter (3) Hazel Road Surgery - Links Medical Practice Branch (0) Other referral sources (54)
total
241
Halesowen and Quarry Bank total
257 total
278
Feldon Lane Surgery (40) Halesowen Medical Practice (32) Crestfield Surgery (19) Stourside Medical Practice (15) Lapal Medical Centre (14) total Meadowbrook Surgery (14) Thorns Road Surgery (12) Wychbury Medical Group (10) Clement Road Medical Centre (4) Hawne Lane Surgery - Feldon Lane Branch (4) Alexandra Medical Practice (4) Chapel House Lane - Wychbury Branch (0) Quarry Bank Medical Centre (0) Tenlands Road Surgery - Stourside Branch (0) Coombs Road Surgery - Stourside Branch (0) Other referral sources (89)
7
Presenting issues by demographics
Isolation (535) Long Term Conditions (535)
16 - 17 (4)
Depression (379)
18 - 23 (47) 24 - 48 (228)
Age ranges
Household issues (227)
49 - 63 (241)
?
64 - 78 (316) 80 + (440)
Other eg unable to cope at home, other health issues (182) Stress (156)
Unknown (18)
Family relationships (138)
Presenting Issues
Frequent presenter (91) Bereavement (80)
Gender
female (60) male (40%)
Carers
Have carers (57%) Are carers (39%) Have carers and are carers (4%)
Other mental health (73) Drugs or alcohol (62) Learning disability support (42) Dementia (31) abc 123
Lack of basic numeracy and literacy (16)
White british (873)
Ethnicity
8
Not known/speciďŹ ed (339) Pakistani (16) Caribbean (16) Other mixed/multiple ethnic background (15) African (14) Indian (7) Other white background (7) White & Black Caribbean (7) Irish (4) Chinese (1) Prefer not to say (1)
Ethnicity
White British (67%) Other ethnic background (26%) unknown (7%)
Presenting issues by locality
A higher number of people have multiple issues of:
A higher number of people have multiple issues of:
152
92
88 94 64
79
34
38
37 21
Sedgley, Coseley and Gornal
Dudley and Netherton
17 78
66 21
Key:
91
Isolation Long Term Conditions Depression Household issues
A higher number of people have multiple issues of:
69
Kingswinford, Amblecote and Brierley Hill
Highest presenting issues are:
Halesowen and Quarry Bank
Frequent presenter Drugs or alcohol
21 95 29 121
58 87
A higher number of people have multiple issues of: 30
35
53 63
72
Stress Family relationships
Stourbridge, Wollescote and Lye
99
A higher number of people have multiple issues of:
9
24-63
usehold iss ho u
year olds
health iss erm gt
s ue
year olds
s
10 nt prese que nt fre
depress io
year olds
s drug & alco
64-80+
n
<24
ss & anxiety tre lon
eliness & lon i
G Presenting issues by age groups across Dudley borough n latio so
l ho
s er
es
Importance of local services in Dudley borough in Dudley’s New Models of Care The diverse range of local services and activities provided by voluntary, community and faith based organisations and groups are vital to Dudley’s New Models of Care.
Integrated Plus 184 21
2547
The sector plays an important role in supporting people to live independently, enabling people to manage their health conditions better, in reducing isolation, promoting self-help and much more.
referrals to
referrals to voluntary and community sector organisations
Statutory services
specific projects run by the voluntary sector.
Most utilised voluntary and community sector organisations and services include:
Voluntary organisations and enterprises
Library Services DMBC
Dudley Self Management Programme Public Health 55
Winter Warmth Public Health
39
50
Access team DMBC
36
Community Engagement Service Occupational Thearapy/DMBC
Social prescribing AgeUK Dudley
114
Springboard AgeUK Dudley
50 39
44
23
44 53 37
37 37
11
Good Neighbour Scheme AgeUK Dudley
Luncheon Club Zion Christian Centre
15
90
For Men Monday Club Lye Church
32 31
Adult Social Care telecare/DMBC
Specific projects
250
347
Adult Learning DMBC
61
Luncheon Club St Michael's Church
Ring and Ride West Midlands Special Needs Transport 92
West Midlands Fire Service
Statutory organisations
Dudley MBC 47
24
14
Dudley & Walsall Mental Health Trust
11
People’s views on Integrated Plus
92
L pi ink vo O in tal ffice th to rs ef M a ut DT re ur s e
10
100%
rate the service as a 5 star excellent or 4 star good service.
0%
rs ce ffi ingeal k O dd t d to a Lin re rea lue a a a g f v DTs o M
What people we supported have told us
100%
rated Integrated Plus as a 5 star excellent service and 4 star good service
%
What GPs and other health clinicians have told us
People who have accessed the service told us that the service is unique in that it combines a flexible, non-medical, holistic package of independent support that focuses on people’s goals and strengths. The service does not hand off people to other services but works with them holistically, helping them to resolve issues and plan personal goals. The service genuinely goes that extra mile with help and support.
I valued the quality time spent with me
67% it is independent,
the service helped me find solutions to problems
%
67
% 58
%
8%
20%
30
67%
the service is valuable as Link Officers spend quality time with people
now seeing patients less in my surgery
20
es go ile le ice a m p rv tr eo se ex p e t for th tha
12
flexible and a non-clinical service
t ph we eo e se llb ple rvi ei ’s h ce ng e im alt p h rov an e d s
I value the service because it is independent, flexible and holistic in its approach
%
I L re ex ink ally as pl O v pi or ffi al ra in ce ue tio g rs d ns per w so ith na m l e
50%
I li as ke t so a it t he c c a se neial i coukes rvi ed ncl nt int ce pa s ofusiothe o tie m n nt y s
10
Ih fro ave m be Pl Inte ne fi u de s a gra tted g al/ re ted a l at ot
0%
%
s rk n woin a ice le nd rv p a se eo ed y e p at wa th ith gr c w nte listi i o h
75
0%
g in be to ed d lu ne va iste l
10
80%
pe th op e an le inserv d to ice sta v b tu ol ro ac torunt ker tiv y l ary s iti ed es
58
%
Better ab cope withle to life
Feel isolatseless d
Reduced stress and anxiety
66%
3%
3%
63%
56%
38%
38%
alco
lth hea
m en
ta
on cati
l h e alt h
li fe s k ill
t status en
em or
lm
e Fe
d se ips a e r sh Inc iend r ity 63% f ual q er Bettlife f 50% o n in s ctiouation u d Re is sit 38% cris in re rted uppo social ca s w No and 25% health ss to Improved acce 22% statutory services 16% Family members / carers
financ
feel better able to cope Fa mily issues 9% now resolved
healt cal
phys i
hous
commu
feeling
sta ing tu
s
e in my saf
16%
28%
ate Now up to ndt with my re
28%
6%
Feel safer where I live
16%
13% 16%
28%
e ag
dis Do cri no m tf No ag inate eel av w a d d icti o Do m no inst of t fe not cri el fee me l exp at ri s loit k o Now atio f kno w con who n t emeact in ato rgen n c Feel s afe in y my relati onshi p comfortaFbeel in my peeler groups 9%
d an an n m n ure tio to tio sec oda le ica ve m Ab ed ha m w cco m No fe a on sa dati eds mo ne om eets Acc m d now orte supp Feelsocial by orks netw ot Now enless hom
6%
Now out anable to ge d abo t ut 44% Imp lifes roved tyle he alth 41% Inc y and reas sel ed c 25% A f-e on ne ble ste fid em enc ed to 16% A c s e ble om p er t 9% mu so o nic na ma ate l c na a 38% re ge 47%
h
/ debt es
ly Now activeent 16% m y lo p m e g seekin ng 6% anagibts e d Now m t curren g ssin 19% acceenefit w No rant/b led to g entit e 22% nag es a o m anc 25% le t n fin b a ingrt r ow s s e ce o Bett 25% ac supp w h l 6% o a g i N nc ou e on a n n e fi iv ve o l ha ey t w n No mo
s
y nit
Now looking to 16% improve skills
ed at v oti
63%
l/drug ho
sexual
66%
Inc frienreased dshi ps Fee l ha ppi er Im pro ve F dw in eel ell m co o be m re in g m i un nv ity olv ed
ti en flu
No 3% w an ha 3% No d m ve w ha 3% on bas ve i e b c y s li an asi 3% kil fe dl cn ls ite um rac er 3% y s acy for N ma ow kil ls l qu acc 3% alifi ess cati ing deve Fee o ns edu lopm ls per 9% ent sona is go l od Now a 13% ctively career seeking s guid ance 6% Now reduce d b iers ploym to gettingarr a job 6% em
69%
use
w No
From a sample size of people supported through Integrated Plus the following outcomes have been achieved so far.
isusing Now notmalcohol talk ent tocerns onfid n Feel c out co b a ife sic l s e ba skill hav ney t Nowand mo pac r m i iou the av y of beh are al d m ip Aw sexu sse sh n a e of h e p tiz lis av ci ng I h UK nE
Outcomes being achieved by Integrated Plus
13
Stories about people supported through Integrated Plus and local services
Andrew’s story Andrew in his fifties, suffers from a medical condition which affects his mobility. He had lived all his life with his mother, in the family home, until she passed away in 2002 and since then has lived alone. He has no other family members and no close friends. Previously he had worked at a local supermarket for 25 years, when he developed his current medical condition and had to take early retirement. Andrew was referred to Integrated Plus, by his GP, through a MultiDisciplinary Team meeting because he suffered from social isolation and loneliness. Andrew only left his home once a week to visit the local supermarket where he used to work, to get his shopping and to meet with his old colleagues, whom he considers his friends. He was only able to do this by using taxis as a way of transport. His only companion was his cat, however despite all this he maintained a positive attitude towards life, believing that everything would be fine once his medical condition improved. Andrew felt that he was okay living a solitary life because this was all he had ever done, he said that he did not make friends easily as he had always felt that he did not fit in. Andrew became emotional, saying that this was the first time in his life that he had felt able to open up to anyone like this. He also felt disappointed that he had lost contact with a friend when he became ill and would love to be in touch with him again. Through face to face intervention with Andrew, the Link Officer was able to identify a range of support within the voluntary sector. The Link officer provided Andrew with information regarding a number if services and activities, based on Andrew’s interests including; Summit House, who hold a men’s social group twice a month, which allowed Andrew to meet new friends with similar interests, Age UK Dudley, who offer 1-1 and group IT support sessions. He is now attending the group sessions, which has enabled him to meet new friends and socialize. Andrew is also considering
14
their day trips. Although he is not able to walk far on any of these trips, he enjoys the social aspect of the coach journey and is considering purchasing a mobility scooter, which he can then take with him. In the meantime, with the Link Officers help, Andrew is now registered with Shop Mobility and is now able to hire a mobility scooter. The Link Officer was able to locate his lost friend and they are now reconnected. Andrew is now going out more often; he is learning new IT skills, which is helping him to be more proficient with online shopping and using social media platforms, such as Facebook. He is meeting new friends and socializing. Andrew now feels he has more of a social life, his life is enriched and his confidence is growing.
Andrew stated “due to this disability I had to give up work and I am now virtually housebound. The link officer has opened up a lot of possibilities for me by encouraging me to become involved with a number of activities which has been a massive help to me, she has done really well and it has made a huge difference to my life.”
Jayne’s story Jayne is a mum in her early 40’s with three children aged between 8 and 13 years. The eldest child is 21 and lives away from home. Although Jayne’s father lives fairly local and is very supportive, he has his own medical needs and increasingly relies on Jayne for support. Jayne felt that her children were not listening to her. The youngest child, she felt, showed little respect towards her. The children regularly fought with each other, this was causing Jayne stress and Jayne was unsure about how to deal with the situation. Jayne said the children did not enjoy her food and would often refuse to eat it. Furthermore she felt lonely, money was tight and she felt overweight.
Programme and feels like she is benefiting from it. Furthermore the school is continuing to support Jayne and her children when she needs. Jayne has also started volunteering at a local Community Centre on a weekly basis and is enjoying meeting new people and socialising. Jayne is now looking forward to beginning the Get Cooking programme, which is due to start soon and she is really happy that she is able to attend all these new activities using her free bus pass.
Initially the Link Officer spoke with Social Services and to the Early Help Common Assessment Team (previously known as the CAF team) in order to identify if there was support in place. The Link Officer spoke with the Head Teacher and attended a CAF meeting at the child’s school. Next the Link Officer arranged for Jayne to attend a Triple PPP programme (Positive Parenting Programme) and referred Jayne to Health Exchange “I am really pleased with all for one of the Health Trainers to provide 1-2-1 support with weight loss the Link Officer has done for me. and for Jayne to attend a Get Cooking programme, designed to teach I have now lost weight and feeling happy about people how to cook more nutritious meals in a fun relaxed way. The Link Officer further referred Jayne to Dudley CVS Volunteer Centre, as Jayne was interested in doing some voluntary work. Finally the Link Officer then helped Jayne to apply for a free disabled bus pass in order for her to be able to access all of these services. Jayne has built up a good relationship with the Health Trainer and meets with him on a weekly basis and she is enjoying the sessions. Jayne has lost weight and both she and her trainer are really happy with her progress to date. Jayne is enjoying the Triple PPP Positive Parenting
that. Having this bus pass means I can get out and about more and I do not have to worry about the cost of bus fares. I can now visit my Dad more often and he says the Link Officer has been a big help to me. I really enjoy volunteering at the community centre, sometimes we play quizzes and I really enjoy that. (Jayne)
15
Mr. P’s story Mr. P has a learning disability and was having little contact with others, only seeing his brother occasionally. Mr. P lost his job a few years ago which significantly knocked his confidence and he struggled to build routine into everyday life, feeling frustrated and isolated as a result. Mr. P was referred to Integrated Plus via a Care Co-ordinator in the north of Dudley. He was referred to the service as he frequently attended the practice and the Care Co-ordinator and GP felt he would benefit from accessing social opportunities and support. Jason Griffiths, the Link Officer for Sedgely, Coseley and Gornal met with Mr. P at the practice and discussed his circumstances at length. It was clear that he was frustrated with his current situation. Mr. P wanted to meet new people who he felt would understand him and offer him an opportunity to get out of the house more. Several services were identified which were of interest and Jason accompanied Mr. P to Dudley Voices for Choice (DVfC). DVfC are a user led charitable organisation that supports people with learning disabilities and autism to speak up for themselves. They have been supporting people across the borough for over ten years. They offered him an opportunity to volunteer and access their social day on a Friday where he could meet people, gain new skills and hone his existing pool playing talents. To enable Mr. P to access the social events we applied for a Network West Midlands concessionary travel pass, accompanied with a supporting letter from his GP, this came through successfully in under two weeks. Further conversations with Mr. P identified that his long term goal was to gain employment but he did not feel ready due to low confidence and because of a previous poor employment experience. We discussed Employment Plus, a Local authority service who support people with a learning disability and/or autism into paid employment. They work in a person centered way at a pace that suits the individual and ensure employers offer suitable support for people with learning disabilities. They were able to help Mr. P settle into a mandatory DWP Work Programme delivered by the Salvation Army. There he has been able to gain employability skills and has been accessing numeracy, literacy and IT courses. Since initially engaging with Integrated Plus and DVfC, Mr. P has also accessed further support through Dudley Advocacy and has volunteered at a local Gap Club. These are social clubs for adults with a learning disability and learning difficulties delivered by Langstone Society at community venues across the borough.
16
This has given him the confidence to take on other volunteering roles including one at a bike shop where he enjoyed meeting new people and gaining customer service skills. Having had conversations with Mr. P, his Care Co-ordinator and the voluntary sector supporting organisations, we felt that it was important to have a number of services for Mr. P to draw upon. This meant that he was clear of when and where he could access specific support. DVfC are continuing to work with Mr. P and to help him get the right balance when managing his busy schedule. He is keen to move into employment and is currently gaining new skills and enjoying socialising in environments he feels comfortable in.
“Jason (Link Officer) has helped me a lot, he has given me my confidence back. He is a very kind person. I am getting on well with people and beating everyone at pool. My life is getting better and I feel I will get back into work.” Mr. P “Mr. P’s coming in to the practice a lot a less, I’m here but I haven’t seen him. He used to come in a lot. Mr. P is a social person, it’s great that suitable services have been identified.” Care Coordinator “Since we first met Mr. P we have witnessed his confidence grow and willingness to engage in new activities increase. He is now an integral part of our team and makes invaluable contributions to our service. We look forward to continuing to be a part of his journey.’ Sarah DVfC
Encouraging and supporting peer support and volunteering
Volunteering
Peer to peer support
Integrated Plus helps people to get more involved and active in their communities through volunteering and active citizenship. Integrated Plus works with Dudley CVS’s Volunteer Centre to help identify suitable volunteering opportunities. One example of success is: Pat expressed to a Link Officer that she was interested in volunteering with Age Concern as it would enable her to meet new people and provide an opportunity to support others. Through support from the link officer, Pat is now volunteering with Age Concern Sedgley regularly. Volunteering has increased Pat’s motivation and she has started knitting again in her spare time. Denise commenting on their new volunteer said “No matter what you ask Pat to do she will do it no problem, she is a great asset to the team”. Pat said “I could have just stayed at home and given up. I wished I would have known about this five years ago. I’ve got what I really want, it’s lifted me and I have a laugh. I can feel a change in myself – I feel more alive to be honest. If I hadn’t have gone to the doctors and been referred to Integrated Plus none of this would have happened, it’s the Link Officer’s help that’s got me here and I thank him very much”.
Integrated Plus helps to connect people, who have been referred to the service, to encourage peer to peer support and friendships to flourish. Integrated Plus also refers people into existing peer to peer support groups. Some examples of success include:
• Two people with similar long term conditions were introduced to each other through a Link Officer. They didn’t know each other and were from different GP practices but lived in the same locality. They spent two hours together at the Net Café in Lye talking, playing Jenga and using adult colouring books. They exchanged telephone numbers and became friends on Face Book. Both have plans of joining a new arts group in June together.
To date, 22 people have been supported into volunteering.
To date, over 100 people have been connected to peers for support and to peer to peer support activities.
• Two patients independently supported by a link officer both had an interest in fishing but did not want go fishing alone. A link officer introduced these people to each other. They are now friends and go fishing regularly together. • Two patients have been supported by a link officer to attend a self-management course. They and are now friends and support each other with their long term conditions.
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Encouraging and supporting peer support and volunteering For Men Monday Club The For Men Monday Club started in July 2015, following a discussion led by a Locality Link Officer and involving Lye Church and Dudley and Walsall Mental Health Trust. The context for this discussion was a concern for the wellbeing of local men with mental health conditions and the fact that nationally: • Suicide remains the most common cause of death in men under the age of 35. • Men are three times more likely to commit suicide than women (and it is thought that men are less likely to seek help such as talking to someone or visiting their GP for advice). The Link Officer had noticed that many of the men with mental health problems referred to Integrated Plus in the Stourbridge, Wollescote and Lye locality, particularly single men, were isolated and found it difficult to engage socially. Many had been recently divorced, had experienced bereavement or were unemployed. It was not uncommon for these men to feel low self-esteem and that they had limited economic and social usefulness. The Club would make good use of existing connections with voluntary organisations, Christian faith groups and local mosques, and health professionals. It would create a place where men could meet socially, have a hot drink and a light breakfast, read newspapers or play games such as chess, pool, etc. A grant was obtained to initially help set up the club. So far the club has, so far, met 43 times attended by over forty men. The Club is a good opportunity to pick up information or find out what support might be available. It is also a place where other voluntary organisations can attend with clients or just be on hand to give advice. The Club is good at providing peer support: attendees often feel more comfortable talking about their problems here than in another setting. Simon, a recent starter, said: “It’s really worth coming to the group; I enjoy taking part, sharing banter about football and trying out those delicious meals we’re cooking! Everyone gets involved in setting up and there is always someone prepared to listen”. An activity takes place at most sessions and there is usually something for everyone. This has included, for example, a six week Get Cooking course, indoor sports such as bowls and relaxation sessions on mindfulness. Alternatively, attendees can sit quietly, if they wish. The cooking course has proved particularly popular and has provided an opportunity to learn how to cook nutritious and affordable meals.
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Mental Health Peer Support Dudley – encouraging and stimulating support networks Over the last few months, partner organisations including Dudley and Walsall Mental Health Trust, exboozehound, Dudley Mind, Rethink, Creative Support, Healthwatch Dudley and more recently Integrated Plus have been meeting to explore and develop opportunities for encouraging peer support and social networks for people with mental health issues. Three sessions have been held to date involving people who have mental health issues to explore with them how they would like the sessions to function. Work has also taken place on mapping what peer support groups and projects already exist in Dudley borough in order to make information accessible for local people. The sessions are now held every two weeks in Brierley Hill. The peer support sessions are designed to help facilitate exchange between people who share something in common based on lived experiences. Peer support offers many health and wellbeing benefits, often helping people to feel empowered in their own recovery, increasing confidence and self-esteem. Mutuality and reciprocity that occurs through peer support enables individuals to feel valued, provides the opportunity to help others and be better connected in their communities. “Without Peer support being taken seriously the same old patterns and vicious circles of mental health will continue. I bet every person reading this has at some point felt lifted, less alone from a simple 5/10 minute conversation with someone with similar issues. Peer support offers strength in numbers, as a group we can make things happen. Peer support hands the power back to the people who are fighting the fight. Recovery won’t happen if we sit back expecting the meds and a 25 minute appointment with a psychiatrist every 4 months, we MUST own our illness and more importantly own our recovery”. (Jon, exboozehound)
Views from the Locality Link Officers Working as part of a multidisciplinary approach across the locality is proving to be an extremely productive way of offering an holistic package of support to individuals. We are able to discuss and better understand the various issues a person is facing and act accordingly within their best interests. The Multidisciplinary Team Meetings act as a platform in which to share best practice and we are able to draw upon the vast knowledge and varying skills from around the table. We are able to share our knowledge of an individual’s situation and environment before engaging the additional relevant services and agreeing actions. A number of individuals I have spoken to have been impressed by the speed in which we have worked and of the breadth of support and services available across the borough. (Wendy Bains, Locality Link Officer, Kingswinford, Amblecote & Brierley Hill)
Our roles give us the freedom to work without an agenda on the issues that really matter to people. I love being part of forging a new way of working for the health, social and voluntary sector. (Terry Gee, Locality Link Officer, Dudley & Netherton)
Working as a Locality Link Officer, I have learnt so much about Halesowen and Quarry Bank. There is a wealth of support and activities available for people. The role has brought a new awareness for me of the difficulties that old age and poor physical health can bring. I am privileged to share poignant moments with people when they share their life stories. Meeting volunteers and leaders who are passionate and caring about what they do is so inspiring. What I love about my role is being able to cheer someone up and motivate them to consider trying something new. Getting a ‘thank you’ from people we work with is so rewarding. (Sue Bloomer, Locality Link Officer, Halesowen & Quarry Bank) Integrated Plus offers a real opportunity to impact on people’s health and wellbeing by providing information tailored to individual need and by encouraging participation in activities. As a Locality Link Officer, I have been able to play an active part in working with clients, helping them see the possibilities in terms of, for example, reducing social isolation, which has been very rewarding. It has also enabled me to collaborate with health and social care professionals, at a local level, to develop people centred solutions. The future offers some exciting opportunities to meet gaps in need, working creatively, and as team we are starting to look at peer groups, improving social networks, etc.
I see the role of Link Officer as a strange privilege, and one that I’m only beginning to properly understand. Sitting in the living room of an (Nick Tromans, Locality Link Officer, Stourbridge, Wollescote and Lye) individual’s house you are invited into their world. Avoiding the temptation to hastily fix problems as they are disclosed and giving time for the person to talk you can begin to understand. The picture is painted before you and you realise that the passing of a child in 1987 led to the depression which caused the marriage breakdown which brought about the ’isolation’ on the ticked box of the referral form. Of course it’s not always as melancholy as that but what you begin to learn when you genuinely give someone your time is that there are many layers and complexities behind every door you pass through. The stories range from absurd to hilarious, sad to devastating, but they are rarely dull. There are common themes that can be learned and all reflect the human condition. Sometimes there is little we can do but listen, and try to show that we genuinely care. Other times we have an abundance of potential solutions and it is wonderful to see a glimmer of hope on a face that seemingly had given up expressing feelings of happiness. To sit with someone, to be empathetic, to see how lives are so different and yet so similar is, I think, a privilege. A privilege with an opportunity and that opportunity depends on how quickly we can forge a relationship and build trust. Not to push outcomes or to shoehorn people into services but to listen and attempt to understand. The thing I most like about this job is the thing I find most difficult; the people themselves. It’s challenging because, as so many of the people I work with put it; ‘that’s life isn’t it?’ But it’s also hopeful, as we witness resilience and the desire to improve the cards these people have been dealt. (Jason Griffiths, Locality Link Officer, Sedgely, Coseley and Gornal)
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Encouraging and supporting peer support and volunteering Issues and challenges • Increasing demand for services with diminishing resources is bringing about many challenges to the health, social care and voluntary sector. Waiting times for services are increasing which is having a negative impact on people in need of support. • We have relied on the good will of the voluntary sector so far in relation to Dudley’s New Models of Care. Significant funding cuts to the voluntary sector will greatly impact on vulnerable people’s lives and on health and social care services. There is a need to explore funding models across the system to help sustain the valuable services provided and how new funds can be generated to help meet new needs being identified through Integrated Plus. • The voluntary sector can offer new and creative ideas to help reduce hospital readmissions but it has been difficult to get ideas off the ground with a lack of joined up commissioning processes across the system. • Some voluntary and statutory services are already at full capacity, in particular, services providing support for people in areas of mental health, housing and befriending. • Some people in need of support do not meet thresholds or criteria for services which means that their support needs are not being met.
Gaps and needs • There is an increasing need for befriending services for people who are housebound and people who do not qualify for support services. Many services that provide such support are at full capacity and are struggling to recruit enough volunteers to help. • There is increasing demand for transport services so people can become more active in their communities. Locally there has been funding cuts for transport services. We have found that some vulnerable people struggle to travel alone to services outside of their own locality. • There is a lack of one to one support services for people with issues of alcohol dependency. Some people referred to us are not ready for group support and struggle to travel to services outside of their locality. • There is a need for organisations to conduct home visits where possible for people who are housebound and particularly for people with mental health issues, those with financial issues and those who are isolated and lonely. Many services currently require people to attend appointments at their offices or in clinics. • There is a need for short 30 minutes to 1 hour respite for carers so they can do shopping or other health and wellbeing activities. Respite, in particular for people with dementia is costly.
What next? • We would welcome discussions about our findings and experiences across partner organisations and the voluntary and community sector to jointly explore solutions and new opportunities to meet need. • We will explore ways that the voluntary sector can work more collaboratively to develop services that meet new needs identified. • We will share our findings with the voluntary sector on the cost savings methodology developed with Birmingham City University and the PSIAMS team. • We will work with the PSIAMS team to further explore ways of mapping trends from our data. • We will build on our progress in raising the profile of the voluntary and community sector to GPs and other health clinicians. • We will explore and discuss ideas with partners and the voluntary sector on a potential funding model that could help to meet local needs.
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Organisations we have referred and signposted people to Action on Hearing Loss Age Concern Sedgley & District Age Concern Stourbridge Age UK Dudley Agewell Community Hub Alcoholics Anonymous Alzheimer’s Society Amblecote Christian Centre Amblecote Phoenix - National Council for Divorced, Separated and Widowed Art Space Arthritis Research UK Autism West Midlands Beacon Centre for the Blind Beacon Extra Care Berith & Camphill Partnership Bethel Chapel Lunch Club Black Country Artists Black Country Fibromyalgia Support Group Black Country Foodbank Ltd Black Country Housing Black Country Neurological Alliance Blackheath Central Methodist Church Blackheath Library Blackheath Live At Home British Red Cross British Trust for Conservation Volunteers Bromsgrove Council Buddhist Centre, Cradley Heath BURT Community Transport Care Home Select Carters Lane Church Centro
Chawn Hill Church Churches Housing Association of Dudley & District CHADD Citizens Advice Bureau (Dudley) Citizens Advice Bureau (Halesowen) Citizens Advice Bureau (Sandwell) Citizens Advice Bureau (Wolverhampton) Colley Gate Gardening Club Community Association of Norton Cornbow Quilters Cradley Community Centre Cradley Heath Creative Creative Support CRI Atlantic House Crossroads Care Dudley Cruse Bereavement Care Cystitis and Overactive Bladder Foundation DeafPlus - debt advice Department for Work and Pensions Diabetes UK Disability in Action Dudley MBC Dudley & District Amateur Radio Society Dudley Advocacy Dudley African Befriending Scheme Dudley and Walsall Mental Health Partnership NHS Trust Dudley Asian Women’s Network Dudley Autistic Support Group Dudley Canal Trust Dudley Carers Forum Dudley Counselling Centre Dudley Hearts Undergoing Support (H.U.G.S.) Dudley Methodist Church
Dudley Mind Dudley Parents Carers Forum Dudley Rheumatoid Arthritis Support Group Dudley Stroke Association Dudley Voices for choice Ehsas Carers Enhanced Primary Mental Health Service Enville Street Dramatic Society Epilepsy Association Flame Church, Blackheath For Men Monday Club (Lye Church) Future Proof by Agewell CIC Gigmill Church Groundwork West Midlands Haden Hill Leisure Centre Halas Homes Halesowen Asian Elders Association Halesowen College Over 50s Club Halesowen in Bloom Halesowen Leisure Centre Halesowen Neighbourhood Watch Halesowen United Church Hasbury Christian Fellowship Hasbury Methodist Church Headway Black Country Health Exchange Healthwatch Dudley Home Instead Heantun Housing Association Hearing Dogs for the Deaf Hope Centre Huntingtree Healthy Hub Iris Sandwell
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Organisations we have referred and signposted people to (Continued) Just Straight Talk Kidderminster College Langstone Society Leasowes Adult Education Leasowes Park Activities Life Line Options Lower Gornal Darby and Joan Lunch on the Run Lutley Community Association MacMillan Cancer Support Macular Society Dudley Support Group Making Smiles Man Made Dudley Mental Health Peer to Peer Support Group Midland Heart Miles and Smiles Club Mindful Gifts Multiple Sclerosis Society (Dudley & District Branch) National Association of People Abused in Childhood (NAPAC) National Osteoporosis Group Net Cafe, Lye Netherton Photographic Society Norton Community Centre Omega Care for Life (Bereavement) On Call Opticians Oxfam Parkinson Disease Society Physically Handicapped and Able Bodied Club Portway Leisure Centre Providence Methodist Church, Lye Queensway Centre for Retired Citizens Quinbourne Centre
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Quality Meals KFC Quarry Bank Community Association Queens Cross Network Quinton Methodist Church Recovery Near You Refugee and Migrant Centre Relate (Sandwell and Dudley) Rethink Mental Illness Revival Fires Ring and Ride West Midlands Special Needs Transport Romsley and Hunnington History Society Romsley Methodist Church Royal British Legion (Halesowen) Royal National Institute for the Blind Royal Signals Association Royal Voluntary Service Salvation Army Samaritans Sandwell Adult Social Care Sandwell Deaf Community Association Saneline Scope (Stourbridge) Self Help Painting Group - Sedgley Senior Citizens Enterprise Woodwork Group Shelter Short Cross Methodist Church Side by Side Theatre Company Stourbridge Silverline (Befriending Service) Slimming World Smile Specsavers Spurgeons - Young Carers SSAFA Forces Help Dudley Division
St Michael and All Angels Church St Peters Church, Cradley St. James’ Church - Wollaston St. Paul’s Church Blackheath St. Thomas’s Community Network Step Change Sunday Friends Tandrusti Health Education Project Telephone Preference Service Time Out Top Church Training Towns Women’s Guild (Halesowen) Triple PPP (Positive Parenting Programme) Triumph Over Autism Dudley Support United Church Lye Universal Support Project University of the Third Age (U3A) Up and Downs Support Group Victim Support Volunteer Centre DCVS Wall Heath Community Association Warley Baptist Church West Midlands Fire Service West Midlands Guild of Woodworkers What? Centre Ltd White House Cancer Support Wiltshire Foods Woodside Community Association Writing West Midlands Youth Hub Zion Christian Centre
Projects and activities we have referred and signposted people to 50+ Exercise Class (Age Concern Sedgley) Access Team (Adult Social Care, Dudley MBC) Adult Social Care (falls prevention service, Dudley MBC) Adult Social Care (low vision support service, Dudley MBC) Adult Social Care (occupational therapy, Dudley MBC) Adult Social Care (telecare service, Dudley MBC) Adults Social Care (carers assessment, Dudley MBC) Blue Badge Scheme (Dudley MBC) Blue Light Programme (Dudley Mind) Care and Disability Advice Line (Dudley and District CAB) Carers Co-ordinator (Dudley CVS) Community Offer Service (Sandwell Council) Connexions (Dudley MBC) Daybreak companionship (AgeUK Dudley) Deaf Support Service (Dudley MBC) Dementia Gateway Dudley Health Visiting Service (Black Country Partnership NHS Foundation Trust) Dudley Home Improvement Service (Dudley MBC) Dudley Mediation Service (Dudley MBC) Dudley Self-Management Programme (Public Health, Dudley MBC) Early Help Common Assessment Team (previously CAF, Dudley MBC) Enabling Community Support (ACET Team, Dudley MBC) Get Cooking Public Health (Dudley MBC) Good Neighbour Scheme (AgeUK Dudley) Home library service (Dudley MBC) Homelessness Prevention Team (Dudley MBC) Housing (Dudley MBC) Leap Service Stay Active (AgeUK Dudley) Library services (Dudley MBC) Living Well, Feeling Safe (Dudley MBC) Lunch Club (Zion Christian Centre)
Luncheon Club (St Michaelâ&#x20AC;&#x2122;s Church) Mental Health Floating Support (Creative Support) New Beginnings Domestic Abuse Support Service (CHADD) Shop Mobility (AgeUK Dudley) Springboard (AgeUK Dudley) Stay Safe Small Tasks practical help (AgeUK Dudley) Social Prescribing (AgeUK Dudley) Volunteer Centre (Dudley CVS) Winter Warmth Service (Public Health, Dudley MBC)
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How to get in touch Contact 01384 573381 Blog: integratedplusblog.com Follow us on twitter: @intplusDudley Our main registered office: Dudley CVS 7 Albion Street Brierley Hill DY5 3EE
Integrated Plus is funded by Dudley Clinical Commissioning Group Dudley CVS is a registered charity and company limited by guarantee. Place of registration: England Charity Number: 517766 Company Number: 1998105
Dudley Clinical Commissioning Group