Integrated Plus Social Prescribing July - September 2019 edition

The Quarterly Newsletter

Issue 10 | July - September 2019

Aimed at GPs and health clinicians

Connecting and supporting people for wellbeing and a sense of purpose

High Intensity User Social Prescribing Service reduces demand on emergency care services Vulnerable patients are benefitting from Dudley CVS’s High Intensity User (HIU) Social Prescribing Service which is an expansion of our existing Integrated Plus service.

An end of year one evaluation report of the service has shown a 33% reduction in A&E attendances and a 41% reduction in inpatient admissions saving the NHS £492,995 over a 12 month period. This is a 3:1 ratio financial return on investment.

Delivered by the Dudley CVS’s 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, 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.

Tailored 1-2-1 support is provided to patients up to 6 months. New services are purchased from the voluntary sector to ensure community support is truly personcentred and meets the needs of the individual.

Inside this issue: Page 1 HIU Evaluation report Page 2 .

Online learning Page 3 – 7 People’s stories Page 8 About Integrated Plus

Kelly Rea, (HIU 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 to build my confidence 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”.

Published By Integrated Plus Main Office: Dudley CVS, 7 Albion Street, Brierley Hill DY5 3EE Tel: 01384 573381 For a full copy of the @intplusDudley Impact Report |visit: integratedplusblog.com Website: www.dudleycvs.org.uk | Twitter: 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)

Link Worker Learning & New Deputy at CVS Integrated Plus collaborates with NHS England on developing a new online learning programme for new link workers across the country Over the past 3 months, Integrated Plus staff have been collaborating with NHS England to help write a new online learning programme that will help induct new link workers across the country into their new roles.

New Primary Care Networks (PCNs) have been established across the country as part of the Network Contract Directed Enhanced Service (DES). PCNs are able to draw down funding from NHS England to introduce new or additional social prescribing link workers into their multi-disciplinary teams as part of the expansion to the primary care workforce.

The expansion of link workers across the country has come about as a result of successful implementation of existing social prescribing schemes, one main one being Dudley’s Integrated Plus Social Prescribing Service.

The new online learning programme will enable new link workers to understand their roles more fully and about the criteria of the roles set by NHS England. The learning programme will enable new Link Workers to learn about the following areas:    

 

Module 1: Introduction to the NHSE Social Prescribing Link Worker role Module 2: Developing Personalised Care and Support Plans with people referred Module 3: Developing Partnerships Module 4: Introducing people to Voluntary, Community and Social Enterprise Organisations Module 5: Safeguarding Vulnerable Adults Module 6: Keeping Records and Measuring Impact

New Deputy Chief Executive at Dudley CVS Kate Green, the Integrated Plus Manager has recently secured a new role as Deputy Chief Executive at Dudley CVS. Kate Green has been managing the Integrated Plus service since its inception back in 2014.

Dudley CVS is currently recruiting a new manager for the Integrated Plus service.

Quote from Kate: “I am so fortunate to have been involved in the Integrated Plus service and am sad to be leaving my role. I am so passionate about social prescribing and as a great team, Integrated Plus has achieved so much since 2014. We have made huge savings for the NHS through reducing A&E attendances, hospital admissions and GP consultations, improved quality of life for so many and secured funding from the Department of Health in 2018 to introduce a new high intensity user social prescribing service. The outcomes achieved by the service in areas of finances, mental health, physical health, learning etc have been outstanding. We have received such amazing feedback from the people we have supported and we have established fantastic relationships with partners.

Integrated Plus has not only achieved great results locally but we have delivered peer learning across the country to other social prescribing projects in early 2019, developed the new online learning programme for new link workers across the country during the summer and have been involved in regional and national work driving forward the social prescribing agenda.

I am confident that the service will continue to go from strength to strength and continue to provide valuable support to the most vulnerable people in Dudley borough”.

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Peoples’ stories Mr S feels safer and more

So, Sue made a referral to the West Midlands Fire

confident…

increasing Mr S’s feeling of safety.

Service, who promptly fitted two smoke alarms,

Sue also signposted Mr S to Creative Support, Let’s Mr S was referred to Integrated Plus by his Social

Get Healthy and football clubs in the local area, as

Worker, as she felt that Integrated Plus could identify

he wanted to get out more.

support available in the community for him. Mr S was living with a learning disability, poor mental health

Becky also identified that Mr S was quite vulnerable

and felt very isolated.

as he told her he did not feel safe going into his property in the evening because there was no

Following a home visit, Sue (Link Officer) identified

security light by the front door, making it very dark.

that Mr S might benefit from attending the Men’s

Becky made a referral to the Dudley Home

Group held on Mondays at Christ Church, Lye. She

Improvement Service and, shortly afterwards, they

asked Becky (Link Support Worker) if she could take

installed a security light outside Mr S’s property. As

Mr S to his first visit there. Mr S told Becky that he

a result, Mr S feels much safer!

really enjoyed the relaxed atmosphere and refreshments there. Whilst at the group he also participated in some ‘rock painting’ which was organised by the Connect Project in Brierley Hill.

When Sue visited Mr S, she also thought that he might be entitled to a benefit called Personal Independence Payment (PIP), which could help with his daily living and mobility needs. Becky visited Mr S at home to help him to complete the lengthy PIP application form.

After this, Mr S needed to go to a PIP Assessment in Birmingham and Becky accompanied him for moral support. Following the Assessment, Mr S was successfully awarded over £1,300 in back payments and now receives £110 each week to help him to better manage his health and wellbeing.

Quote from Becky (LSW): “It has been rewarding supporting Mr S throughout the PIP process and supporting him to attend the Men’s Group in Lye where he was able to socialise with others and develop his confidence”

Sue had also noticed that Mr S’s downstairs smoke alarm was bleeping – he was not sure why. There was also an upstairs landing smoke alarm and a disused one with wires hanging out of it.

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Peoples’ stories Anthony starts his own

Anthony was still keen to have the opportunity to

business…

employment. Anthony wasn’t sure where to start,

retrain, learn or develop skills to re-enter but mentioned he had always wanted to have his own business. The Link Officer explored Anthony’s

Anthony was referred to Integrated Plus by his GP.

strengths and assets with him and it became

Anthony had been suffering with depression since

apparent that he had a talent for woodwork.

leaving his job on medical grounds. Anthony had a

Anthony would often make items in his garage

highly skilled position in sports car manufacturing, but

during his spare time. He found this kept him

a severe heart attack meant he could no longer cope

occupied and gave him a focus as he had great

with the intensity of the role.

attention to detail.

When the Link Officer visited Anthony, it became

The Link Officer referred Anthony to Access to

apparent that he was finding it difficult to come to

Business in Wolverhampton where he took part in a

terms with what had happened to him and the impact

course learning everything he needed to know about

that it had on his life. Anthony was having counselling,

how to get started. Anthony’s daughters helped him

but wasn’t finding this particularly effective for him at

with using social media to boost his profile and to

the time and had little motivation to try anything else.

begin selling his work on Facebook and Etsy.

Anthony had not been receiving any income since his

Anthony is now successfully running Bean Toastie

Statuary Sick Pay had run out and was worried what

Designs and is busy with orders. As well as social

would happen when his savings ran out. Anthony’s

media, Anthony has been selling his work at craft

wife was working tirelessly to make ends meet but

fayres and car boots sales which has been great for

this was taking its toll on the whole family.

getting him out of the house. The transformation in Anthony has been remarkable. Anthony told us that

The Link Officer accompanied Anthony to Citizens

he is now much happier within himself and now a

Advice to get further advice regarding benefits. At the

much more motivated individual.

time, due to other incomes coming into the household Anthony wasn’t able to claim any other benefits, but it was suggested that he could apply for Personal Independence Payment. The Link Support Worker helped Anthony complete the application form and the Link Officer provided moral support at the assessment. Anthony was awarded the lower rate of the Daily Living element which helped to relieve a lot of pressure.

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Peoples’ stories Norman and Beryl improve their lives…

Norman is 87 years old and lives alone in a first floor

As a result of the interventions from Integrated Plus,

flat. Norman’s only immediate family support is his

Norman now has his Pendant Alarm which is a great

sister Beryl who is also in her early 80’s. Beryl lives

comfort to both him and Beryl, he has had his

nearby and visits Norman daily to clean, make hot

shower approved and is waiting this to be installed,

food and do washing and shopping.

he has a bed rail and trolley, which he finds so useful and gives him confidence around the flat. Norman

Norman used to go out 2/3 times a week with Beryl

was granted Attendance Allowance at the lower rate,

shopping and to Bilston Market, but no longer felt

which enables him to pay for his taxis’s to his

able to manage this due to reduced mobility. Norman

appointments, and has given him the extra money he

found himself becoming more isolated and Beryl was

needs to heat his home during the winter months.

becoming more anxious about leaving Norman at home alone and had slept on his sofa a couple of

Beryl was referred to the Carers Network for support

times when he’d been poorly. Norman was also

around her caring role for Norman.

unable to take proper care of his personal hygiene as

Norman has resumed his weekly shopping visits, and

he was unable to use the bath and was having to rely

although both Norman and Beryl still face challenges,

more and more on Beryl as he became afraid to leave

they both now feel more happy and secure.

his flat. Norman had a lot of medical appointments, which was also putting pressure on his finances as he and Beryl were having to take taxis’s. He was worried about turning his heating on due to financial restrictions and was spending most of his days sitting in the chair in his sleeping bag to keep warm.

What they said about the service: “We can’t thank you enough.

Everything you have done for

Norman was referred to Integrated Plus by his GP surgery and following this, an assessment was carried

us has made such a massive

out by the Link Officer. As a result of the assessment, a

difference to both of us, and

referral was made to Telecare Services for a Pendant Alarm, plus an occupational therapy referral for a shower assessment. An appointment was also made for the Link Support Worker to support Norman to complete an Attendance Allowance application.

it’s so comforting to know that your service is there to help people like us, who are struggling”

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Peoples stories Robert supported to volunteer and share his skills...

Robert was referred to Integrated Plus by his GP, as he was feeling lonely and isolated and struggling to find a purpose after his wife moved to a care home. Robert met Georgia Pearsall, the new Locality Link Officer for Stourbridge, Wollescote and Lye and they did an initial assessment to discuss Robert’s health, and wellbeing.

It became clear that Robert wanted to get involved in some activities to break up his long days.

Robert is an independent eighty nine year old and stressed to Georgia that he wanted to volunteer at a local group. Robert visits his wife about four days a week so he did not want to go too far from home. He

While at the group Robert met a friend who he did national service with and they chatted away about their shared experiences.

The Link Support Worker for Stourbridge, Wollescote and Lye met up with Robert to do a review a couple of months later and Robert said he had become a regular attendee at The Beacon. He said he has been helping out and has discussed with members from The Beacon doing drawing classes and hopes to be running some classes soon. Robert has enjoyed looking back at some old drawings and paintings and is looking forward to using his old skills, sharing those skills and building up his own and others confidence.

He wants to share this passion with others and inspire them to get involved.

also said he did not want to go to a support group, but would rather be a volunteer. Georgia mentioned volunteering at The Beacon in The Mary Stevens Centre in Stourbridge and Robert knew the place because it was where his daughter was born when it

Robert said: “It feels good to help

was a maternity hospital.

out other people rather

Robert also discussed his interests and hobbies and it

than being helped. I can

became clear that he was interested in film and the arts. In the past, Robert had been a member of Kidderminster Film Club and had also painted pictures and drawings for his children to colour in and trace.

lose myself when I draw and paint�

Georgia arranged for Robert to meet with the manager from The Beacon, to discuss what he wanted to do and what he could offer the group. He attended the popular Friday Coffee Morning at The Beacon to see how the group runs and meet staff, volunteers and members.

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Peoples stories Sacy was supported to thrive in a country where she is safe‌

Sacy has gone from strength to strength since then,

Sacy was originally referred to Integrated Plus in

able to financially support herself and her family.

October 2016 due to feeling isolated and depressed.

Sacy is now looking forward to the future, and feels

When the Link Officer met with Sacy, he found that

that the support she has received from Integrated

she had come to the UK as an asylum seeker, after

Plus.

and is now focusing on bringing her mom and her son to the UK to be with her. She has also been referred to Just Straight Talk, as she has qualifications in Computer Science and wants to be

facing abuse and torture in her home country of Sri Lanka. Sacy came to the UK leaving her mother and son behind. Due to the horrific treatment that Sacy had received, the Link officer and Link Support Worker worked with Sacy to support her to access Talking Therapies and the Refugee and Migrant Centre in Wolverhampton.

Sacy engaged with Talking Therapies and was also supported with her application for refugee status through a letter written by the Link Officer, outlining the work done with Sacy and confirming that she was engaged with Talking Therapies.

After a long battle, Sacy was given refugee status, which meant that she is able to stay in the country for up to five years, and apply for indefinite leave to remain after this. Sacy was overjoyed at this, as the stress caused by the prospect of having to go back to Sri Lanka, where she feared for her life, was overwhelming. Sacy has said that she feels that the letter provided by the Link Officer was key to her being awarded refugee status.

Sacy said: Terry has helped me lots. He has been really supported, has helped me to get food and provided a supporting letter for the judge when I was trying to get refugee status, which was successful. I am so happy and can now focus on bringing my sona dn mother to the UK, so I can be with them.

Follow our blog | integratedplusblog.com

About Integrated Plus Integrated Plus is a social prescribing support service delivered by Dudley Council for Voluntary Service (Dudley CVS) as part of Dudley’s integrated care model. The service:    

Provides holistic non-clinical support to patients aged 16 and over Supports patients to become less reliant on medical services (eg avoidable GP consultations, A&E attendances and hospital admissions) Encourages and supports patients to get connected into wellbeing services and activities often delivered by the voluntary sector Aims to improve quality of life and help patients find a sense of purpose in their lives

The service takes referrals from GPs in Dudley borough and at the GP led Multi-Disciplinary Team meetings/new Integrated Community Team meetings.

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 07866 020431 jason@dudleycvs.org.uk Jason.griffiths1@nhs.net

Terry Gee | Locality Link Officer Dudley & Netherton 07866 020340 terry@dudleycvs.org.uk terry.gee@nhs.net

Sue Bloomer | Locality Link Officer Halesowen & Quarry Bank 07989 478567 sue@dudleycvs.org.uk sue.bloomer@nhs.net

Georgia Pearsall | Locality Link Officer Stourbridge, Wollescote & Lye 07866 020436 georgia.pearsall@dudleycvs.org.uk Georgia.pearsall@nhs.net

Keeley Jones | Locality Link Officer Kingswinford, Amblecote & Brierley Hill 07866 020509 keeley@dudleycvs.org.uk keeley.jones3@nhs.net

Jill Aldridge | Link Support Worker Sedgely, Coseley & Gornal Tel: 07508 307498 jill@dudleycvs.org.uk jill.aldridge@nhs.net

Aiesha Turner | Link Support Worker Dudley & Netherton Tel: 07508 307528 aiesha@dudleycvs.org.uk Aiesha.turner@nhs.net

Rebecca Woodall | Link Support Worker Halesowen & Quarry Bank Tel: 07398 350844 rebecca@dudleycvs.org.uk Rebecca.woodall1@nhs.net

Rebecca.woodall1@nhs.net Gary Hastie | Link Support Worker Stourbridge, Wollescote & Lye Tel: 07398 350846 gary@dudleycvs.org.uk Gary.hastie1@nhs.net

Lorraine Hipkiss | Link Support Worker Kingswinford, Amblecote and Brierley Hill Tel: 07398 350847 lorraine@dudleycvs.org.uk Lorraine.hipkiss@nhs.net

Kelly Rea | Urgent Care Link Worker Tel: 07984 605997 kelly@dudleycvs.org.uk Kelly.rea@nhs.net

Danielle Giles | Urgent Care Link Worker Tel: 07984 606024 danielle@dudleycvs.org.uk Danielle.giles1@nhs.net