Integrated Plus Newsletter May 2015

Issue 1 | May 2015

The Quarterly Newsletter

Aimed at GPs and Voluntary Organisations

Supporting people to become more involved, connected and active in their communities

Pat is 74 and living alone, she has some friends and family nearby but she was feeling lonely and isolated.

A referral was made to a Link Officer by the Ridgeway Surgery. Pat identified that she was feeling very low, this depression was largely due to being at home alone and not having regular engagement with others.

Pat serves a welcome hot drink to two service users.

Pat expressed a desire to help other people, she had been actively involved with community groups in the past but had not accessed any services for quite some time.

The first time Pat met the Link Officer it gave her an opportunity to openly discuss issues and give the Link Officer the chance to identify possible services that Pat may wish to access. After the initial assessment, Pat said she felt a lot better knowing that she could make some meaningful changes and that she had been listened to. During the second meeting some possible services that Pat may wish to access were discussed. Amongst the services talked about were a gentle exercise group, a knit and natter group at a local church and a volunteer opportunity with Age Concern Sedgley.

Pat was most interested in volunteering with Age Concern as it would enable her to meet new people and provide an opportunity to support others. A time was arranged to go down with the Link Officer and have an informal conversation with Denise the Manager. Soon after the meeting the relevant paperwork was completed and an induction date was agreed.

Pat has now been volunteering with Age Concern two days a week for three months. She pursued the other opportunities that were discussed but at the moment feels that her volunteering is keeping her busy enough. Volunteering has increased her motivation and she has started knitting again in her spare time.

Inside this issue: Page 1 & 2: Patient Stories Page 3: Spotlight on VCOs Page 4: About Integrated Plus

When asked about her experience 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”.

Denise commenting on their new volunteer said “No matter what you ask her to do she will do it no problem, she is a great asset to the team.

In Brief: Age Concern Sedgley & District: Age Concern Sedgley provide a Day Centre for people over 60 living in the North or Dudley who may be lonely or isolated. For a small cost service users can look forward to organised transport, breakfast on arrival followed by a three course lunch and a cup of tea and cake in the afternoon. There are plenty of things to do and lots of people to chat to in the lively and friendly environment.

For more information on this case study please contact Jason Griffiths on 07866 020431.

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)

Integration news Andrew is in his mid-50s and 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.

A referral was made by Three Villages Medical Practice to a Link Officer at a Multi-Disciplinary Team meeting because he suffered from social isolation and loneliness.

Andrew had worked at a local supermarket for 25 years, but developed a medical condition and had to take early retirement.

Andrew only left his home once a week to visit the local supermarket where he used to work.

His only companion was his cat. Andrew felt he was okay living a solitary life because this was all he had ever done.

Andrew doesn’t find it easy to make friends and became emotional, saying that this was the first time in his life he had been able to open up to someone. 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. The Link Officer was able to identify a range of support within the voluntary sector, based on Andrew’s interests including; Summit House, who hold a men’s social group twice a month, Age UK Dudley, who offer 1-1 and group IT sessions. He is now attending the group sessions, which has enabled him to meet new friends and socialise. Andrew is also going on day trips. Although he is not able to walk far, 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 mean-time, 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 reacquainted.

Andrew is now going out more; he is learning new IT skills, which is helping him to be more proficient with on-line shopping and using social media platforms, such as Facebook. He is meeting new friends and socializing.

Andrew gets out and about through the help of his Link Officer and Shop Mobility

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 have 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, she has done really well and it has made a huge difference to my life.”

For more information on this case study contact Wendy Bains on 07866 020509.

Integrated Plus has made a great start!   

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Link Officers are representing the voluntary sector at all 47 GP led multi-disciplinary team meetings (MDTs).

282 clients have been referred to the service so far.

Clients have been supported to access 201 voluntary and community sector services ranging from luncheon clubs, counselling services, sports clubs and much more.

Clients have benefitted from connecting with each other, offering mutual support with long term conditions.

Biggest presenting issues faced include isolation, loneliness, depression, long term conditions and anxiety.

Current gaps in services include transport, befriending for people who are housebound and social activities for men under 50 who are lonely, suffering from low selfesteem and depression.

Sessions will be held during 2015 with voluntary sector providers to explore innovative and creative ideas for meeting such gaps.

Carers Week | 8 – 14 June 2015

Groups supporting integration Nehemiah UCHA

Helping people to live independently and stay out of hospital Nehemiah UCHA is a progressive housing association serving the African Caribbean, Asian, Irish and European communities. The Association provides homes for single people, families, couples and elderly people in Birmingham, Coventry, Dudley, Sandwell, Walsall and Wolverhampton.

Henry Court based in Dudley provides 38 permanent one and two bed apartments. All have level access showers which are great for people who have recently been discharged from hospital or have mobility problems. Henry Court specialises in meeting the multi-cultural needs of its residents and provides a good choice of African Caribbean food. Lots of fun social activities are offered to residents and the wider community to reduce loneliness and improve wellbeing. Some of these activities include:     

A befriending service (run 2 days a week) A luncheon club (run 4 days per week) ESOL classes Prayer meetings Arts and crafts sessions

Enabling residents to manage their own wellbeing Henry Court supports residents to set up and run their own activities. Currently, residents organise bingo, dominos (a great favourite with African Caribbean men) and coffee mornings. Residents also run their own shop at Henry Court selling home cooked Asian food. Initial support was provided

by Nehemiah with insurance and food hygiene training.

“They wanted to do something for themselves and had a diverse range of retail work experience. The shop has been a huge success and is now open Monday to Friday, 9am – 3pm.

Residents cook the food themselves, go to the wholesalers, promote their shop and manage all the finances. Profits are re-invested into the shop. Enabling people to run their own activities is vital in developing self-worth and providing residents with choice and independence”.

Lucy Hales (Director of Housing and Care Services)

Easing the pressure on medical services Staff at Henry Court ensure they maintain strong relationships with a range of health clinicians to ensure residents stay out of hospital where possible, and avoid inappropriate medical call outs. Staff at Henry Court act as brokers and a vital link between residents and clinicians. 

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Staff have links with Castle Court so any changes to resident’s mental health can be reported to Community Psychiatric Nurses quickly and acted upon.

District nurses are contacted directly to request home visits when support is needed.

Staff have links with local GPs at St James Medical Practice and Stepping Stones Medical Practice to seek advice when required and request home visits. This helps prevent unnecessary GP call outs.

Staff have links with their local pharmacy to request and arrange delivery of medication on behalf of residents.

Staff often request medicines in blister packs to help residents take the right medication at the right time.

Regular chiropodist visits are held at Henry Court. This helps reduce the likelihood of falls which could lead to more complex and costly interventions.

The Virtual Ward operates at Henry Court for a resident with Chronic Obstructive Pulmonary Disease (COPD), helping him to live at home and minimise his hospital stays.

Working jointly with Bushy Fields Crisis Team has resulted in residents remaining at Henry Court by providing psychiatric team visits up to 3 times a day when needed. This avoids the need for more costly interventions such as mental health residential care, saves money and prevents A&E admissions.

For more information about Nehemiah call 0121 358 8030. Website: www.nehemiah-ucha.co.uk.

Get involved: Sign up today | www.carersweek.org

About Integrated Plus Integrated Plus is delivered by Dudley CVS as part of the integrated care model, being implemented by Dudley Clinical Commissioning Group and Adult Social Care. Integrated Plus has been established to: 

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Take client referrals (from GPs, other health clinicians and at MDTs) to support them to become more involved, connected and active in their communities.

The difference we aim to make

Represent the voluntary, community and faith sector in the integration model.

Raise awareness about what voluntary and community organisations can offer in the delivery of locality based services and activities.

Identify local service needs and broker solutions with the voluntary sector, health and social care practitioners, local commissioners and citizens.

Integrated Plus works with people aged 16 and over who frequently present at their GP practice or other medical service and people at high risk of hospital admission.

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Help people become more active and involved in their own communities

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Improve quality of life

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Support people to make a difference to their own communities e.g. through volunteering

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Enable the voluntary and community sector to play an active role in integrated care

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Reduce pressure on health services by supporting people to become less reliant on medical practices

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Ensure social inclusion of clients is taken into consideration at Multi-disciplinary team meetings

Integrated Plus is funded by Dudley Clinical Commissioning Group.

The patients in the case studies included within this publication have given permission to share their stories.

Every attempt has been made to accurately reflect their story.

Meet the team Kate Green Manager for Integrated Plus Dudley CVS, 7 Albion Street, Brierley Hill, DY5 3EE Tel: 01384 573381 buildingblocks@dudleycvs.org.uk

Wendy Bains | Locality Link Officer Kingswinford, Amblecote and Brierley Hill wendy@dudleycvs.org.uk 07866 020509 wendy.bains@nhs.net

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

Jason Griffiths | Locality Link Officer Sedgley, Coseley and Gornal jason@dudleycvs.org.uk 07866 020431 Jason.griffiths1@nhs.net

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

Nick Tromans | Locality Link Officer Stourbridge, Wollescote and Lye nick@dudleycvs.org.uk 07866 020436 nick.tromans@nhs.net