Issue 8 | April - June 2018
The Quarterly Newsletter
Aimed at GPs and health clinicians
Supporting people to become more involved, connected and active in their communities
New Urgent Care Frequent User Pilot Integrated Plus has been funded by Dudley CCG to expand its service to implement a new pilot which will offer longer term preventative non-clinical social support to high intensive users of unscheduled emergency services. There are patients who are dependent on emergency services and who are often stuck in the ‘revolving door’ of unscheduled care which puts increasing pressure on A&E and the ambulance service. These patients may be accessing other statutory/NHS services already but may benefit from trying a different approach in addition to these services. Data for 2016/17 shows that 101 people have accessed unscheduled emergency services over 12 times costing the NHS around £1.3 million. 4 of these 101 people have accessed emergency care services 411 times costing the NHS approximately £200k. The two new urgent care link workers will offer a complementary support service including:
Meeting patients in their own homes to sensitively uncover the reasons for them utilising emergency services frequently and to discuss their aspirations, goals, issues, hopes and assets such as their passions, skills and knowledge and interests. Offering support up to 6 months working with them to achieve their goals and aspirations. Chaperoning patients to services and activities when their confidence is low. Connecting patients up for peer support, encouraging/brokering new friendships. Chaperoning patients to tribunals when their benefits have been cut (if they have low
confidence or anxiety issues in attending tribunals).
Inside this issue: Page 1 Urgent Care Pilot . Page 2 New staff member Page 3 – 7 People’s stories Page 8 About Integrated Plus
Helping patient’s access grants through charitable trusts and foundations. Helping with non-means tested benefit form filling. Connecting patients into a whole range of specialist support groups in the voluntary sector e.g. learning disabilities, long term conditions, mental health charities, substance misuse charities, housing charities etc. Supporting patients with accessing volunteer opportunities.
Danielle Giles joined Integrated Plus as one of our new Urgent Care Frequent User Link Workers in April. She states she is a highly motivated individual who thrives under pressure. Danielle’s background was Care Co Ordination, Hospital Discharge Pathway and Occupational Therapy for the private Mental Health Sector. Kelly Rea joined Integrated Plus as one of our new Urgent Care Frequent User Link Workers in April. She states she is passionate about facilitating people to change and is a good motivator. Kelly’s background was working within the Alcohol and Drugs service working with hard to reach clients to motivate and achieve positive outcomes and helping clients improve their lifestyles.
Published By Integrated Plus Main Office: Dudley CVS, 7 Albion Street, Brierley Hill DY5 3EE Tel: 01384 573381 Website: www.dudleycvs.org.uk | Twitter: @intplusDudley | Blog: integratedplusblog.com Integrated Plus is delivered by Dudley CVS and funded by Dudley Clinical Commissioning Group Dudley CVS is a registered charity (number 517766) and a registered company limited by guarantee (number 1998105)
Peoples’ stories Wendy’s income has increased and her home is safer Wendy has several long term conditions which include osteoarthritis, fluid retention in her legs and reduced kidney and liver function. Following a referral from Wendy’s GP, the Link Officer visited Wendy in her home to discuss activities and extra support available to improve her health and wellbeing. Wendy explained that, prior to her health deteriorating, she had led an active lifestyle.
They provided a bath riser which means she feels safer getting in and out of the bath. She also has a chain on the front door which means Wendy feels safer in her home. The Link Support Worker made a follow up call to Dudley Home Improvement Service to enquire about Wendy having grab rails and a sensor light fitted outside her home. Wendy is now waiting for these to be fitted.
The Link Officer identified that Wendy was claiming Job Seekers Allowance (JSA). Wendy explained that, due to her health conditions, she was unable to work but was still required to attend her local job centre fortnightly, which was becoming increasingly difficult. The Link Officer suggested that Personal Independence Payment (PIP) might be a benefit she could claim in order to get help with some of the extra costs caused by her long term ill-health.
Wendy expressed relief that nuisance calls had been reduced as a result of the referral to the TPS. Wendy has also applied for a Blue Badge and is awaiting the decision. If granted, this will reduce the amount of walking she has to do to be nearer to shops and social activities.
The Link Officer supported Wendy to complete her PIP application form and provided a supporting letter. She also requested for a Department for Work and Pensions (DWP) Assessor to visit Wendy in her own home as Wendy has limited mobility and was scheduled to have surgery. This request was granted. Wendy has now been awarded PIP and her income has increased by nearly £80 per week. Wendy is very relieved that that she is no longer required to visit the Job Centre. The Link Officer provided Wendy with information regarding a number of services and activities based on her circumstances and interests including the Dudley Home Improvement Service, Telephone Preference Service (TPS), the Blue Badge Scheme and gentle exercises classes locally. The Link Support Worker visited Wendy to complete a follow up Review. Wendy had been proactive with the information provided and had rung Dudley Home Improvement Service.
Wendy is looking forward to the future and is spending more time with her daughter and grandchildren.
Welcome to a New member of The Integrated Plus Team:
Natalie joined Integrated Plus in March this year covering maternity leave as a Link Support Worker in the Dudley and Netherton locality alongside Terry Gee. Natalie applied for this role because she has an interest in working with people and is looking forward to supporting people in accessing services and activities suitable to their needs. Natalie has a background in working with children and families.
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Peoples’ stories Helping Peter to regain his confidence after the death of his father Peter was referred to Integrated Plus by his GP. Peter has had a difficult couple of years dealing with the recent loss of his father and a cousin. He is a carer for his mother who has long term health conditions and was also a carer for his father before he died. The impact of his father’s death closely followed by the death of his cousin greatly impacted on his health and wellbeing and added to his anxiety, depression and social isolation. Peter met with Nick, the Link Officer and discussed his fears, needs and aspirations. It became apparent that he was depressed, low in confidence, socially isolated and grieving. Nick focused on a holistic approach to dealing with these issues and they discussed Peter’s mental health and Dudley Talking Therapies, Peter was interested and referred himself by phone to the programme. Nick also discussed the Dudley SelfManagement programme which is a free six week course for people living with long term health conditions and Peter was also interested in that course. Dudley Mind have peer support groups focusing on depression and anxiety and Nick gave Peter some information on this group for him to consider. They spoke about bereavement and Nick gave Peter a flyer for TLC, a Stourbridge bereavement support group who offer friendship and support with bereavement. During the initial meeting Peter also spoke about his previous jobs in IT and mentioned his future aspirations of returning to work when he felt better able to cope. Nick talked about help with employment through Bridges Support Service an organisation which gives support and guidance around employment and Peter was interested in this scheme so Nick referred him onto the programme. Gary Hastie the Link Support Worker met with Peter a couple of months later to check his progress and to see if there was any further support needed and to receive any feedback from Peter. Peter has been very busy attending the groups and programmes mentioned to him and he said there has been a significant improvement in his health and wellbeing and in his confidence.
He said he is in “…a much better place now than when he first met Nick.” He has enjoyed the depression and anxiety peer support group at Food for Thought Café at Dudley Mind in Stourbridge and felt that he has been able to share his feelings with the group and help others at the same time. He has also recently finished a Dudley Talking Therapies course and a SelfManagement Course with has also helped with his depression and anxiety. Peter attended TLC for bereavement support and has benefitted from this and has recently organised a memorial service for his father for family and friends to attend, this represents a major improvement in Peter’s health and wellbeing in comparison to his father’s funeral when he did not feel able enough to organise the funeral. He sees this as another important step in the grieving process. Peter also attended Bridges for employment support and has also been applying for jobs and he is due to start a four week work placement and is looking forward to getting back to work. He has also arranged for extra support for his mother which will enable him to return to work and lessen his caring responsibilities at home.
Peter is now looking forward to the future with increased confidence and hope.
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Peoples’ stories Paul supported following a recent bereavement Paul was referred to Integrated Plus by his GP following the recent loss of his wife. Paul had been his wife’s carer for the past 20 years. The GP felt that Integrated Plus could help identify support for Paul’s isolation and depression. During an initial telephone conversation with the Link Officer, Paul said that he was grieving, felt lost, was reluctant to leave his home, was not eating well and had money concerns. His main source of comfort was his 16 year old dog, Jack. During a home visit, the Link Officer identified that Paul has several long term conditions including osteoarthritis, difficulty mobilising and a heart condition. She thought that Attendance Allowance might be a benefit that he could claim. The Link Support Worker supported Paul to apply for Attendance Allowance, applicable to those over 65 who need help at home. She also helped him to complete a Blue Badge application as Paul was not leaving his home very often (being unable to walk long distances). Paul has now been awarded Attendance Allowance and received a back payment of £278! In addition to this, Paul no longer needs to pay rent as this is fully covered by Housing Benefit. With his increased income, Paul has been paying off a debt he had incurred to pay for his wife’s funeral and he is also buying healthier food. He was surprised to be awarded a Blue Badge and this allows him to park closer to shops, social activities and for health related appointments. The Link Officer identified that Paul struggled with daily tasks at home. She made a call to Dudley Telecare as Paul’s bungalow was fitted with a pull cord alarm and he was unsure whether this was working. Following this call, it was found that the alarm was no longer in use. Dudley Telecare visited Paul within 48 hours, fixed his alarm and provided him with a wrist alarm so that he can summon help in the event of a fall. Paul now feels a lot safer in his home. He is also receiving physiotherapy which should help to decrease the number of falls and stumbles he experiences
The Link Officer also made a call to Dudley Home Improvement Service and confirmed the approximate date that Paul was due to have a wet room fitted as he was not sure. This will mean that Paul will now be able to better manage his personal safety when showering. The Link Officer also provided Paul with information about Age UK’s Fix-a-Home Scheme where trusted traders are listed that can carry out all manner of household jobs. Although Paul decided not to access a bereavement counselling service, he now knows about the service and can contact it in the future if he needs to. He feels well supported by family, friends and neighbours and always has his trusty dog Jack by his side for company too. He has been very grateful for the support provided by the Integrated Plus team and has told his friends about it!
"If it wasn't for Integrated Plus I wouldn't have known what I could claim. With your help in claiming Attendance Allowance and a Blue Badge it has enabled me to live a better life. All I can say is thank you"
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Peoples’ stories Tracy helped with feelings of isolation Tracy is 36 and used to be a Dental Nurse, who enjoyed motor biking and walking, but after losing her mum just over a year ago due to heart and lung problems, she has been unable to return to work due to low mood, depression and anxiety. Tracy felt very isolated, she has no family nearby and no friends. What family she does have, live on the other side of the Midlands. After paying bills and rent, Tracy only has £6 each week to live on. This is due to the under occupancy charge (bedroom tax), and debts she is struggling to manage. Tracy explained that she had run up rent arrears, as well as debt with her water rates, totalling thousands of pounds, and she could not see how she could ever begin to clear her debt. The link officer and Tracy discussed the possibility of her moving, to reduce her outgoings, but she felt afraid. She feels anxious about moving to an unfamiliar place and likes that her GP surgery is just down the road, plus she knows the local shops. Her anxiety is such that she only leaves the house in the very early hours, to avoid mixing with others. Tracy explained that she used to be overweight, but her issue now is in with regards to her being underweight. She had not been eating healthily for some time, and her weight problem was not noticeable, due to her wearing so many layers of her clothes in an attempt to keep warm. The property was very cold as she could not afford to have the heating on. Tracy had been referred into mental health services, to complement the medication she had originally been prescribed, and she was expecting a call from a mental health practitioner, but she had missed it, and did not have credit on her phone to call them back. This had been some months prior to our meeting. The Link Officer visited with a food bank parcel, as she would be unable to access one of their distribution centres due to having no money for bus fare; her address is a 40 minute walk from her nearest distribution centre and, although she may be able to get there, she could not get back with bags of shopping. Her anxiety and social phobia prevents her from engaging also.
The Link Officer made a referral to Dudley and Walsall Mental Health and Tracy began talking therapy sessions with them. The Link Officer made a referral to Housing Support who allocated her a support worker who helped her with a discretionary Housing Benefit to relieve her from paying the under occupancy charge, and worked with her to help Tracy to begin to manage her debts better. A referral to Winter Warmth was made, who provided her with reflective radiator foils to keep her property warm, as well as an electric blanket, and advice on the best energy tariff to best suit her needs. Tracy returned to work and cleared her debt, but unfortunately, has recently been made redundant. She made contact with the Integrated Plus service again, as she was experiencing a delay in her Universal Credit claim being paid, and so she has had a food bank parcel. Tracy is now worried of slipping back into her depression but is trying to stay positive.
The link Officer has made a referral for Tracy to engage with the Bridges Project, who are supporting Tracy with confidence and motivation through one-to-one mentoring, and looking at volunteering opportunities, as Tracy has a career change in mind.
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Peoples stories Dave helped to increase his income to help with bills and getting out and about Dave is a client who suffers with long term conditions including arthritis, trouble with both hips and COPD. Dave was referred to us due to low mood and anxiety after a recent family bereavement, loneliness and isolation and issues with benefits. When we first met Dave, his Employment Support Allowance (ESA) had been stopped and he was having to claim job seekers allowance – in order to contest this decision we helped him fill in an appeal form. Once the appeal date came through, Jason took Dave to the courts in Wolverhampton for his ESA tribunal. A short while after this tribunal, Dave found out that he had been awarded full ESA benefit from the courts. Because of his health conditions and the subsequent struggles with day to day living, we helped Dave apply for Personal Independence Payments by helping him fill in the form. Dave had an assessment for this and was awarded £315 a month. Prior to our intervention, Dave was getting around £292 every 4 weeks by claiming job seekers allowance. After our intervention, with helping to appeal the ESA decision and to claim PIP, Dave now gets £970 every 4 weeks. Dave has had help from Creative Support’s Garden Pathways service. To do this, they cleared his back garden of brambles and long grass. They were with Dave for around 2-3 days. Dave is engaging with Dudley Talking Therapies, a service that offers help and support for Dave’s low mood, bereavement and anxiety. Dave is actively looking and bidding for a bungalow in the Dudley area. For his current home, Dave has applied for discretionary housing payments due to the number of bedrooms and has been awarded this.
A few words from Dave: “Jason and Georgia have been really helpful. They are easy to talk to and east to contact – I know they are only a phone call away.” “It is nice to talk to Jason and Georgia as they are aware of the social care and benefits system, as nowadays it is so hard to figure out! Knowing that they’re there if I need them has made me feel more confident in approaching systems like this myself.” “Since the intervention of Integrated Plus, my finances have tripled! Before this increase, over 50% of my monthly finances would have gone on bills such as gas and electricity to heat my home. Leaving me very little for necessities such as food and water. Now I don’t have to worry about this and have enough to fuel my car, buy in food and pay someone to maintain my garden!”
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The power of social networks Emma helped to get out and about Integrated Plus began working with Emma when she was referred by her GP because of long term health issues, social isolation and depression. During the initial visit Emma told the Link Officer about how she had moved to Dudley from Leicester because of problems in a relationship. Her family still live in Leicester. Emma suffers with a prolapsed disc and arthritis which causes her a lot of pain and means she has limited mobility. She uses two sticks to mobilise and also has a scooter and a mobility car. These issues have impacted on her mental health, resulting in a diagnosis of depression and anxiety. Emma is having fortnightly counselling sessions and has recently had her medication changed which is already having a positive effect. The mental health issues are also impacted by not having any friends or family living nearby as they are all still in Leicester. Emma had already got herself back on the council housing register for Leicester, but as an out of borough bidder she was at the bottom of the bidding priority list. The Link Worker helped Emma attend an appointment with DMBC housing support where she was advised to write a letter and ask for her banding to be reconsidered on medical grounds.
Emma has since emailed to say that she has been offered a bungalow that meets her needs in Leicester which she has accepted. Emma said that she is over the moon with the news but that she still plans to keep in touch with her new friend.
Emma told us: ‘You have basically changed my life. I am now choosing to go out.’
Whilst this was in process, Emma was keen to try and alleviate the isolation she feels within her community so she asked Integrated Plus to research some local social and peer support groups. The Link Worker researched and suggested that Emma try attending the Friday Friends group, supported by Dudley CVS. The Link Worker attended the group with Emma for the first time to offer moral support. Whilst at Friday Friends, Emma became friendly with another lady who told her about a local Choir. They swapped phone numbers and Emma attended the next choir meeting. This was a huge step for Emma as her counsellor had been trying to get her to go out and socialise more for a some time.
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About Integrated Plus Integrated Plus is delivered by Dudley CVS as part of the Dudley Borough’s new care model. Integrated Plus works with people aged 16 and over who frequently visit their GP and people who at high risk of hospital admission. The difference we aim to make
Help people become more active and involved in their own communities Ensure people are accessing services appropriate to their needs and that they are entitled to Improve people’s mental health and wellbeing Support people to make a difference to their own communities e.g. through volunteering and peer support Enable the voluntary and community sector to play an active role in integrated care Reduce pressure on health services by supporting people to become less reliant on medical practices thus saving money Ensure social inclusion of clients is taken into consideration at 46 multi-disciplinary team meetings (held at each GP surgery)
Integrated Plus is funded by Dudley Clinical Commissioning Group. The clients in the stories included in this publication have given permission to share their stories. Every attempt has been made to accurately reflect their story.
Meet the team Kate Green Integrated Plus Manager Dudley CVS, 7 Albion Street, Brierley Hill, DY5 3EE Tel: 01384 573381 buildingblocks@dudleycvs.org.uk
Jason Griffiths | Locality Link Officer Sedgley, Coseley & Gornal jason@dudleycvs.org.uk 07866 020431 Jason.griffiths1@nhs.net
Terry Gee | Locality Link Officer Dudley & Netherton terry@dudleycvs.org.uk 07866 020340 terry.gee@nhs.net
Sue Bloomer | Locality Link Officer Halesowen & Quarry Bank sue@dudleycvs.org.uk 07989 478567 sue.bloomer@nhs.net
Nick Tromans | Locality Link Officer Stourbridge, Wollescote & Lye nick@dudleycvs.org.uk 07866 020436 nick.tromans@nhs.net
Keeley Waldron | Locality Link Officer Kingswinford, Amblecote & Brierley Hill keeley@dudleycvs.org.uk 07866 020509 wendy.bains@nhs.net (Covering long term sickness for Wendy Bains)
Georgia Davis | Link Support Worker Sedgely, Coseley & Gornal georgia.davis@dudleycvs.org.uk Tel: 07508 307498
Gary Hastie | Link Support Worker Stourbridge, Wollescote & Lye gary@dudleycvs.org.uk Tel: 07398 350846
Natalie Polito | Link Support Worker Dudley & Netherton natalie@dudleycvs.org.uk Tel: 07508 307528 (Covering maternity leave for Aiesha) Parker
Rebecca Woodhall | Link Support Worker Halesowen & Quarry Bank rebecca@dudleycvs.org.uk Tel: 07398 350844
Lorraine Hipkiss | Link Support Worker Kingswinford, Amblecote and Brierley Hill lorraine@dudleycvs.org.uk Tel: 07398 350847
Kelly Rea | Urgent Care Frequent User Link Worker kelly@dudleycvs.org.uk Tel: 07984 605997
Danielle Giles | Urgent Care Frequent User Link Worker danielle@dudleycvs.org.uk Tel: 07984 606024