Dudley CVS Integrated Plus High Intensity User Social Prescribing Project - Year 3 evaluation report

HIGH INTENSITY USER SERVICE EVALUATION REPORT

2020 - 2021 YEAR 3

02 | Evaluation Report 2020 - 2021

CONTENTS PAGE 3

INTRODUCTION

4

HIGHLIGHTS

5

TEAM AND DELIVERY

6

COVID-19 SUPPORT

7-8

SERVICE USERS

9

ONWARD REFERRALS

10

VOLUNTRY SECTOR SOCIAL PRESCRIBING FUND

11-12

OUTCOMES

13-14

COST AVOIDANCE

15-18

CLIENT STORIES

19-21

LEARNING

22

APPENDICES

03 | Evaluation Report 2020 - 2021

INTRODUCTION Dudley CVS delivers Integrated Plus, and is an independent, second tier (umbrella) local infrastructure organisation supporting voluntary and community organisations, faith based organisations and social enterprises in Dudley borough. Dudley CVS's vision is for a borough that has caring, vibrant and strong communities where everyone can fulfil their potential.

Dudley CVS has delivered its High Intensity User Social Prescribing project since 2018, as a result of the success of its Integrated Plus Social Prescribing service.

Through Dudley CVS’s experience of delivering Integrated Plus, it was recognised that there was a gap in high end intensive support for people who are very dependent on emergency services. Expanding the existing Integrated Plus service would: Widen the current social prescribing offer to secondary care services Meet the NHS RightCare model threshold which is people who have a very high dependency on A&E, the Urgent Care Centre (UCC) and West Midlands Ambulance Service (WMAS). This patient cohort will be patients who live in Dudley borough.

Offer a voluntary sector collaborative model of high intensity social prescribing support to those who are most vulnerable in society.

At the time, Dudley CVS was aware that the Department of Health was promoting a new Social Prescribing Health and Wellbeing Fund open to voluntary sector organisations. Matchfunding was required for applications so Dudley CCG and Dudley CVS took advantage of this opportunity and applied for the funding to enable; the HIU project to be funded for 3 years rather than 2 to enable more time to be allocated to really testing out the model, and also meant that Dudley CVS would be able to apply for direct funding which could be spent in the voluntary sector to help establish new activities based on new needs.

In early 2018, Dudley CVS and Dudley CCG were successful in securing the grant award and hence the HIU Social Prescribing project was launched.

04 | Evaluation Report 2020 - 2021

HIGHLIGHTS Urgent Care Link Workers supported 262 individuals throughout the year.

227 were referred for Covid-19 crisis support

High service acceptance rate of 70 % Top 3 reasons for referral were: Depression Other mental health conditions Drugs and alcohol

77% of onward referrals made by Link Workers were to the Voluntary, Community and Social Enterprise sector

5 organisations were commissioned through our voluntary sector social prescribing fund to deliver tailor made services for clients

77% increase in feelings of happiness post support 63% reduction in A&E attendances and 69% reduction in inpatient admissions 12 months after support

Total cost avoidance figure of £275,470 twelve months post support

05 | Evaluation Report 2020 - 2021

TEAM AND DELIVERY

The team consists of 2 full time Urgent Care Link Workers and the service targets the most vulnerable socio-economic groups in Dudley borough who face multiple challenges from poverty, co-morbidities, substance misuse, unhealthy lifestyles, potentially risky behaviours, homelessness, mental health issues, relationship breakdowns, physical disabilities etc. They must be registered with a Dudley GP, aged 18 and over and having unscheduled care activity more than 12 times in any 12 month period.

The Integrated Plus approach involves:

Combines a flexible, non-clinical, holistic package of support.

Focuses on the whole person’s needs to jointly find solutions to problems faced and uncover the real reasons why people are calling 999 or attended the hospital Support is independent and impartial.

Support is provided in peoples own homes, where possible, so that the service can build a true picture of the person, their living conditions and family support networks.

Staff have a ‘can do’ approach and attitude as the service is not tied by organisational boundaries and cultures.

Staff do what they can to help whatever the support needs are.

Quality time is spent with people, actively listening to their needs and aspirations.

Staff ensure people are accessing services appropriate to their needs.

Staff help people to navigate the health and social care system.

The role of frontline staff involves:

URGENT CARE LINK WORKERS X 2

Conducting the initial appointments to get to know the person, what matters to them, undertake our bespoke holistic assessment and identify and agree goals with the person using assetbased approaches Being responsible for follow up 12-1 patient support , including out of hours where required Chairing core group meetings to identify appropriate referrals from WMAS and A&E frequent attender lists Identifying gaps when voluntary sector is unable to meet support needs of people and utilising Social Prescribing Fund to develop new tailored solutions

EXAMPLES OF INTERVENTIONS Helping people to access services on offer, e.g. mental health support Help people to get around e.g. accompany to a service if their confidence is low Connect people to a wide range of social, leisure and faith based activities Help people apply for non-means tested benefits, ensuring people have adequate housing and food Connect people with each other to offer peer support Ensure people are getting the care and support they're entitled to

06 | Evaluation Report 2020 - 2021

COVID-19 SUPPORT The Integrated Plus team played an important role in supporting the Dudley CVS community support response to the Covid-19 pandemic. Volunteers were mobilised and along with partners, Dudley CVS quickly set up six Community Support Networks to ensure that the most vulnerable residents of Dudley received food, medication and befriending support.

Between 1st April 2020 and 31st July 2020, the two Urgent Care Link Workers acted as a lead for one of six Covid-19 Community Support Networks. This work involved: Receiving referrals from GP surgeries and other key partners for vulnerable individuals who required support during the pandemic Triaging each referral in order to allocate a volunteer to assist with shopping, collecting medication or to provide befriending Chairing weekly virtual meetings with partners to arrange support efficiently for individuals with more complex support needs The weekly meetings were productive and when discussing referrals Link Workers reported how exceptionally responsive all partners were in arranging immediate support for people in need. Strong, positive working relationships were developed through all six networks and all partners agreed to continue meeting on a monthly basis to maintain links. Partners included West Midlands Police, Public Health, Dudley MBC, NHS and voluntary and community sector organisations.

COVID-19 REFERRALS During this period Integrated Plus team received 907 referrals for Covid-19 specific support.

The two Urgent Care Link Workers arranged support for 227 of the 907 referrals.

Referrals were received from the following partners:

GP surgeries Dudley MBC VCS organisations Mental health services Public Health Social Services Other 0

250

500

750

07 | Evaluation Report 2020 - 2021

SERVICE USERS Responses to the service from referrals are illustrated below for the twelve months April 2020 to March 2021. These referrals were additional to the 227 people that received Covid-19 crisis support from the two Urgent Care Link Workers.

SERVICE ACCEPTANCE Yes - Service accepted

35

No - Service declined

8

No - Unable to make contact

6

No - Inappropriate referral

1

Total number of service users offered service

50

70% acceptance rate

REASON FOR REFERRAL Frequent presenter

50

Family relationships

7

Other mental health condition

18

Household issues

3

Drugs and alcohol

14

Isolation

2

Depression

13

Learning disability

1

Bereavement

1

Stress

1

Long term health conditions 9

DELIVERY HELD TWO KEY PERFORMANCE INDICATORS People contacted to offer service

90

Service Users supported

50

Due to Covid-19 Community Support work taking precedent, less people were contacted to offer the service however a higher number of individuals received support:

People contacted to offer service

50

Service Users supported

262

08 | Evaluation Report 2020 - 2021 DEMOGRAPHICS GENDER Male

24

Female

26

Male 48%

Female 52%

AGE 18- 19 years

5

60 - 69 years

1

20 - 29 years

15

70 - 79 years

3

30 - 39 years

8

40 - 49 years

8

50 - 59 years

10

18-19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60-69 yrs 70-79 yrs 0

5

10

15

ETHNICITY White English/Welsh/Scottish/Northern Irish/British Any Other Black/African/Caribbean Background

29

Black & White Caribbean

1

1

Unknown

19

SERVICE USER SATISFACTION Service users were asked to rate how satisfied they were with the service. Options included Very Satisfied, Satisfied, Neutral, Dissatisfied and Very Dissatisfied. Service Users were also asked to rate the service overall. Options included Excellent, Good, Average, Poor and Very Poor.

Additional review data including benefits received and wider assistance is included in Appendix A.

VERY SATISFIED 11 PEOPLE 73%

SATISFIED 4 PEOPLE 27%

EXCELLENT 12 PEOPLE 80%

GOOD 3 PEOPLE 20%

09 | Evaluation Report 2020 - 2021

ONWARD REFERRALS The service referred to a number of organisations and services during year 3 of delivery. A total of 36 individual referrals were made to 13 organisations.

NHS 7.7%

Organisations referred to by Link Workers included:

Black Country Foodbank Citizens Advice Dudley and Wolverhampton Creative Support Riverside House CIC The Arts of Change Kaleidoscope Challenge Academy CIC Dudley MBC (Adult Social Care and Carers Hub) CLG Atlantic Recovery Centre Dudley Young Carers Leslies Care Packages for the homeless Creative Health CIC Black Country Healthcare NHS Foundation Trust

Statutory 15.4%

VCSE 76.9%

The largest proportion of organisations referred to were from the Voluntary, Community and Social Enterprise (VCSE) sector, a total of 77%.

VOLUNTARY SECTOR SOCIAL PRESCRIBING FUND 5 of the 13 organisations referred to were VCSE organisations who received funding from the projects Voluntary Sector Social Prescribing Fund.

This was an important element of the project as the fund enabled the development of, new activities and services that would be tailor made and meet unmet needs. Over 3 years, Dudley CVS secured £150,000 (£50,000 each year) to purchase services in the voluntary sector either through block grant funding or on a spot-purchase arrangement.

In year 1 several services were commissioned for delivery scheduled throughout year 2, based on identified gas in local services. During the summer of year 2, Dudley CVS promoted the fund to the wider voluntary sector to encourage the submission of new ideas for services and activities that would help support the service and meet the needs of HIU patients. This has continued throughout year 3.

A summary of each commissioned service or activity is on Page 10.

10 | Evaluation Report 2020 - 2021

VOLUNTARY SECTOR SOCIAL PRESCRIBING FUND ACTIVITES AND SERVICES DUDLEY AND WOLVERHAMPTON CITIZENS ADVICE BUREAU Dudley CVS commissioned Dudley and Wolverhampton Citizens Advice Service to provide clients with a bespoke one to one support offer that would better meet their needs. Clients are able to have support from the same case worker who will work at their pace and at a time convenient for them. Clients have received support with benefits, debt, housing, travel and transport, utilities and employment law advice.

CHALLENGE ACADEMY CIC Dudley CVS commissioned Challenge Academy CIC who have delivered multiple courses for clients which focused on improving their self-confidence, emotional resilience and physical health education. Challenge Academy specialise in outdoor learning and the courses have included team challenges, orienteering, foraging, outdoor art and outdoor cookery. Several clients have expressed a desire to volunteer with Challenge Academy in the near future.

RIVERSIDE STOURBRIDGE CIC Dudley CVS commissioned Riverside Stourbridge CIC to offer clients the opportunity to try something brand new, whilst benefitting from being outdoors in nature. Clients have been participating in green woodwork, blacksmithing, copper work and weaving throughout the past year. The sessions have been popular and some clients have progressed to becoming permanent volunteers.

ARTS OF CHANGE Dudley CVS commissioned Arts of Change in Dudley to deliver one to one counselling and therapy to clients. In addition to this they also delivered a series of creative arts therapy courses on a wide range of topics including anxiety, body image, anger management, addictions etc. Arts of Change offer a flexible, person cantered service tailored towards engaging clients who have previously struggled to engage in support.

CREATIVE HEALTH CIC Dudley CVS commissioned Creative Health CIC to deliver weekly Take 5, creative arts sessions focusing on five ways to wellbeing. Some sessions have been delivered in person and others via Zoom due to Covid-19 restrictions. The group have practiced relaxation techniques and creative journalling, whilst producing some beautiful artwork, all of which centred around wellbeing.

11 | Evaluation Report 2020 - 2021

OUTCOMES Throughout the majority of 2020 Link Workers were unable to complete both initial and follow up assessments with clients due to leading the Covid-19 Community Support efforts.

This work had to take precedence and was supported by commissioners.

Towards the latter end of 2020 Link Workers were able to resume use of assessments to measure the impact of social prescribing interventions on personal well-being, loneliness and isolation.

ONS4 PERSONAL WELL-BEING MEASURES The initial and final assessment gathers clients responses to the following questions, utilising the Office for National Statistics ONS4 wellbeing scale, advocated by NHS England: Next I would like to ask you four questions about your feelings on aspects of your life.

There are no right or wrong answers. For each of these questions I’d like you to give an answer on a scale of 0 to 10, where 0 is “not at all” and 10 is “completely”.

Measure

Question

Life satisfaction

Overall, how satisifed are you with your life nowadays?

Worthwhile

Overall, to what extent do you feel that things you do in your life are worthwhile?

Happiness

Overall, how happy did you feel yesterday?

Anxiety

On a scale where 0 is "not at all anxious" and 10 is "completely anxious", overall, how anxious did you feel yesterday?

The overall combined score at initial assessment and final assessment, and hence the change achieved during service is summarised below:

LIFE SATISFACTION

WORTHWHILE

1st assessment total combined scores

53

1st assessment total combined scores

52

Final assessment total combined scores

93

Final assessment total combined scores

92

Change (%)

75%

Change (%)

77%

12 | Evaluation Report 2020 - 2021 ANXIETY (REVERSE SCALING)

HAPPINESS 1st assessment total combined scores

53

1st assessment total combined scores

54

Final assessment total combined scores

94

Final assessment total combined scores

39

Change (%)

77%

Change (%)

38%

Overall, there was a positive change with all four personal well-being measures following support from the service, the largest being both worthwhile and happiness.

UCLA (UNIVERSITY OF CALIFORNIA, LOS ANGELES) LONELINESS SCALE The initial and final assessment gathers clients responses to the following two questions, utilising the UCLA loneliness scale: On a scale of 1 - 10 where 1 is never and 10 is often...

How often do you feel isolated from others?

To what extent do you feel loneliness is an issue for you?

The overall combined score at initial assessment and final assessment, and hence the change achieved during service is summarised below:

ISOLATED FROM OTHERS

LONELINESS IS AN ISSUE

1st assessment total combined scores

46

1st assessment total combined scores

52

Final assessment total combined scores

45

Final assessment total combined scores

43

Change (%)

2%

Change (%)

17%

Overall, there was a positive change with both loneliness and isolation measures following support from the service. The change was not as significant as previous years due to many clients feeling isolated as a result of the Covid-19 lockdown restrictions. The pandemic has caused more clients to feel anxious about getting out and about but many are now accessing support from befriending services.

Although outcome data for year 3 is based on much smaller sample than previous years, due to the Covid-19 Community Support efforts taking precedence, additional qualitative data has been provided on page 16 in the format of client stories.

Appendix A includes a breakdown of additional outcomes achieved through conducting client reviews of the service.

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COST AVOIDANCE

Information has been gained for key areas of emergency services: Inpatient Admissions A&E Attendances For each of these, comparative data has been gained for two timeframes: 6 Months; attendance data at 6 months before, and also at 6 months after, support 12 Months; attendance data at 12 months before, and also at 12 months after, support These datasets are both gained from analysis of Data Services for Commissioners Regional Offices (DSCRO) data. As the law states commissioners are not allowed to access Personal Confidential Data (PCD) because they are not providing direct patient care, DSCRO provides an intermediary service that specialises in processing, analysing and packaging patient information within a secure environment into a format commissioners can legally use; anonymised patient level data.

In the original proposal for this project, Dudley CCG estimated that a 30% reduction in annual unplanned emergency care usage for high intensity users may be achievable with support from Link Workers. This was exceeded in years 1, 2 and again in year 3:

INPATIENT ADMISSIONS Data shows a significant reduction in inpatient admissions for both 6 and 12 months post referral:

Inpatient admissions 6 months before referral

103

Inpatient admissions 12 months before referral

181

Inpatient admissions 6 months post referral

51

Inpatient admissions 12 months post referral

56

Total reduction in inpatient admissions

52

Total reduction in inpatient admissions

125

Change (%)

50%

Change (%)

69%

Current data indicates that a single inpatient visit costs £1,700 per person, producing cost avoidance figures for: 6 months: £88,400 overall 12 months: £212,500 overall If focus is solely on patients who had fewer inpatient admissions after support the cost avoidance figures are as follows: 6 months: 66 fewer inpatient admissions (17 patients) = £112,200 12 months: 127 fewer inpatient admissions (23 patients) = £215,900

14 | Evaluation Report 2020 - 2021 A&E ATTENDANCES Data shows a significant reduction in A&E attendances for both 6 and 12 months post referral:

A&E attendances 6 months before referral

462

A&E attendances 12 months before referral

774

A&E attendances 6 months post referral

243

A&E attendances 12 months post referral

289

Total reduction in A&E attendances

219

Total reduction in inpatient admissions

485

Change (%)

47%

Change (%)

63%

Current data indicates that a single A&E attendance costs costs £115 per person, producing cost avoidance figures for: 6 months: £25,185 overall 12 months: £55,775 overall If focus is solely on patients who had fewer inpatient admissions after support the cost avoidance figures are as follows: 6 months: 260 fewer inpatient admissions (26 patients) = £29,900 12 months: 518 fewer inpatient admissions (31 patients) = £59,570

15 | Evaluation Report 2020 - 2021

CLIENT STORIES AMI LEARNS THE ART OF BLACKSMITHING Riverside House is a beautiful and ecologically diverse site in Stourbridge which runs alongside Stourbridge canal. Riverside House is in the process of transforming the 19th century ironworks area into a heritage centre with gardens, a restaurant, crafts shop, woodland and workshops but also a place where people feel included and bespoke opportunities are provided.

Much of this work is now well underway. Our capacity building team at Dudley CVS initially helped Riverside Stourbridge to get set up as a CIC, supported them with planning, building their vision and securing funding and it is fantastic to see the progress being made. The project works with a wide range of individuals from diverse backgrounds and supports them to learn new practical skills through the conservation and preservation of the estate.

In the winter of 2020, Clare and Lloyd at Riverside Stourbridge CIC applied for funding from our voluntary sector social prescribing fund. The fund makes it possible for new activities and services to be set up and delivered to meet the needs of our Integrated Plus High Intensity User social prescribing clients, who frequently attend A&E or call 999. Their application was successful and they’re now delivering three different workshops including copper & willow weaving, blacksmithing and green woodwork.

Ami is a client accessing the High Intensity User social prescribing service, after hearing about the workshops she was keen to try blacksmithing as she enjoys being outdoors and learning new skills.

Ami attended the six week course and thoroughly enjoyed every session, she showed her Link Worker how she had made a plaque for her home to hang her keys on and how she has personalised it. Ami was able to recognise within herself how the workshop had built her confidence and helped her overcome her fear of new places.

Ami loves it at Riverside House that much that she is now part of the volunteering team and attends on a weekly basis.

Ami said: “I attended the Blacksmithing course at the Riverside House Project and I loved it! Not only did I get expert and friendly tuition in a totally new skill I had never tried before, but the guys shared their vision and dreams for the Riverside House site during the sessions and got me excited for the future of the project. All the volunteers and leaders were friendly and welcoming, always encouraging and helped me feel confident in something I had never done before! Looking forward to joining with more projects and seeing the way the RHP develops and expands in the coming years.”

16 | Evaluation Report 2020 - 2021 SIMON SUPPORTED TO START PAINTING TO IMPROVE WELLBEING AND REDUCE SOCIAL ISOLATION Simon was identified by the High Intensity User core group as a potential individual who might benefit from social prescribing interventions. Throughout the previous 12 months Simon had been admitted to hospital on 19 separate occasions. During the Covid-19 pandemic Kelly, HIU Link Worker contacted Simon over the telephone, built up a rapport with him and carried out a holistic assessment of his needs.

Simon is an older male and he had become extremely lonely since his wife had been taken into a care home. He lives in supported housing but due to Covid-19 all the activities had stopped. Kelly identified that Simon was really struggling with feelings of loneliness, and this was not helping his long-term health issues which resulted in his admissions to hospital increasing.

Kelly needed to investigate how social prescribing could help alleviate the pressure on the hospital, especially during the pandemic but most importantly help and improve the health and wellbeing of Simon.

During their many telephone conversations, Simon told Kelly that he was artistic and loved painting but could not afford to buy supplies. Kelly was able to allocate Simon a personal health budget so that he could purchase some art materials such as paints, canvas’s etc.

Kelly was delighted to see that over the months to follow, being able to paint had given Simon a sense of purpose, he now paints pictures and gives them away to his carers and to other residents, improving his social life and mental wellbeing. Simon’s hospital admissions have dramatically reduced as he no longer feels isolated, and his work is able to positively benefit other residents where he lives.

Kelly (HIU Link Worker) said: “I feel that something as simple as being able to allocate Simon a personal health budget has made a huge different to his mental and physical wellbeing and he no longer has a need to go to hospital. His paintings are wonderful. The below is painting that Simon sent to me...”

17 | Evaluation Report 2020 - 2021 CLIENTS BENEFIT FROM OUTDOOR MENTAL TOUGHNESS COURSES Sally, Charlotte and Kerry were all referred to the HIU project due to their high hospital admissions and 999 call outs. Each one of them had their own mental health issues that they were trying to work through. They always discussed how they felt they had low confidence and low self esteem and this impacted negatively on their mental health on a daily basis.

They were all approached and asked if they would like to attend the new Challenge Academy 5-week course, commissioned through Dudley CVS voluntary sector social prescribing fund. The course was designed to work on developing mental health awareness, building resilience, improving mental wellbeing, building confidence, developing self-esteem and positive self-image. Challenge Academy CIC have an excellent understanding of social determinants of mental health and through the course focus on goal-setting and personal achievement, changing unhealthy thinking and developing a positive mind-set.

They all said they would give it a try but were very apprehensive. On their first day they met with their course instructors Chris and Gregg who would deliver the course over the 5 weeks, they got to learn all about each other and what the course would entail over the coming weeks. As the weeks went by and they continued with the course activities they were able to learn and develop through participating in outdoor art sessions, orienteering, team building activities and much more.

Over the course of the weeks it was very easy to see the positive change in all of the participants.

Their confidence increased, they felt better in themselves and were wanting to push themselves out of their individual comfort zones. They could easily identify the marked improvement in their own mental wellbeing and were noticing changes.

The three clients have formed a close knit friendship through attending the sessions and would always give each other encouragement in all their tasks and pick each other up when they were struggling. This friendship has continued outside of the course and on weekends they now meet up and go shopping, for a coffee or visit one another.

Speaking with them, it is clear to see the improvements, not only through their admissions and ambulance call outs drastically reducing but also through their own personal wellbeing. They all advised that they didn’t find it easy but felt with each others support and the support from the course they could do anything that was asked of them, this even included completing activities in record time by working together as a team and solving the problems they were given.

Each individual is now looking forward to taking the skills they have learnt from this course and using them in their future.

Clients said: “It’s great fun and confidence boosting, it makes me feel good I don’t even realise I'm doing exercise!

The staff are really friendly” “Staff are really encouraging and push you out of your comfort zone.

The team building exercises are fun and really help to build your trust and confidence.”

18 | Evaluation Report 2020 - 2021 SARAH SUPPORTED TO MOVE FROM HOMELESS SHELTER INTO HER OWN HOME Sarah was referred to the HIU project due to multiple ambulance call outs where she would attempt to overdose on medication. Sarah was living at a centre, which supports people who are homeless. She was very unhappy there and wanted her own home in the Dudley area. She was struggling to complete the housing application but with support from her HIU Link Worker was able to complete and submit the application.

Within weeks, she was offered a flat in the area she had requested and was able to move in. From living at the homeless centre, she had been able to save a little bit of money and purchase items she needed but the main item she was unable to afford was a cooker. I was able to source a user-friendly electric cooker and through emergency relief funding, we were able to purchase gift vouchers for the client to purchase the cooker. Sarah was extremely grateful and felt she was finally able to get back on track. We continued to work together getting her involved in a variety of activities and from this her ambulance call outs reduced dramatically over the next few months.

Sarah has now developed her own independence through the HIU support and groups she is now involved in. She has formed friendships and continues to attend and support new clients who are referred into the service.

Sarah said: “I now have a place I can call my own, Danielle helped me get on the map and helped me get the stuff I needed, I would never have managed this and would probably still be in the homeless shelter which got me down and made me not want to live anymore as I didn’t feel I had anything to live for but now I have a home of my own”

CREATIVE ARTS THERAPY SESSIONS HELP MARIA TO MANAGE MENTAL HEALTH Maria was identified due to being a frequent user of West Midlands Ambulance, West Midlands Police and A&E department. She was very dependent on emergency services and was being admitted to hospital via ambulance every week due to poor mental health.

Maria has a mental health diagnoses and struggles with her day-to-day activities. This puts a strain on her relationship with her family and friends. The HIU Link Worker befriended Maria and formed a strong therapeutic relationship, she explained how she was struggling, and I was able to offer her a range of groups to attend at Arts of Change (AOC) in Dudley. The Creative Orchid Project (AOC) consists of a series of creative arts therapy sessions which cover topics as body image, anxiety, self-esteem, depression and anger.

Maria began to attend the groups, at first, she struggled in a group setting and at one point felt she may not be able to carry on. However, through her determination and persistence, she continued and completed the first group. She has expressed how much she now enjoys the groups and as each group has finished, she has decided to attend the next one to continue to build her confidence and learn to better manage her feelings and emotions. Maria feels she can be open at AOC and has expressed how she feels comfortable around the session facilitators and other participants. Maria has developed new friendships, is now on her sixth course and is engaging well, she attends each week on time and participates fully in each session. She is looking forward to the future and intends to apply the skills she has learnt in her daily life.

19 | Evaluation Report 2020 - 2021

LEARNING KEY SUCCESSES Integrated Plus played a key role in the Covid-19 Community Support response lead by Dudley CVS. The two Urgent Care Link Workers lead one of 6 networks, triaging referrals and arranging emergency support for vulnerable people across the borough. Link Workers chaired weekly (now monthly) Community Support Network meeting with partners to ensure that support was arranged for individuals with more complex needs and to update on support being provided by partners.

Integrated Plus adapted quickly to providing remote support when home visits were not possible due to Covid-19. Urgent Care Link Workers were still able to have effective telephone conversations with patients and were surprised by the positive level of engagement.

Urgent Care Link Workers continued to support existing and historic clients throughout the pandemic in addition to arranging crisis support for 227 vulnerable individuals.

Between September 2020 and March 2021 Integrated Plus were successful in securing the NHSE Regional Learning Coordinator post for social prescribing. The team facilitated peer support sessions for Link Workers, leads and managers across the West Midlands. This helped to enhance the reputation of Integrated Plus both regionally and nationally, whilst being able to pass on learning from 3 years of experience to new schemes.

The two Urgent Care Link Workers were involved in facilitating a mental health regional learning event for Link Workers across the Midlands and the delivery of a webinar regarding supporting change resistant drinkers for Link Workers across the West Midlands.

Integrated Plus have maintained a positive reputation both locally and nationally, continuing to be one of the lead high intensity user projects around the county for NHS England and RightCare.

The Integrated Plus Project manager and two Urgent Care Link Workers have provided support to a new high intensity user social prescribing project being implemented in South Yorkshire.

Urgent Care Link Workers have connected, shared learning and offered peer support to other projects around the country via the high intensity WhatsApp group and a new yammer group The Dudley CVS Voluntary Sector Social Prescribing Fund has been vital in enabling Covid-19 safe activities and services to be delivered throughout the pandemic, providing much needed tailor made support to clients.

Five voluntary sector organisation shave been commissioned through the fund during year 3.

Through providing flexible remote support and more out of hours’ contact the two Urgent Care Link Workers have effectively managed to help most clients remain at home, not attend A&E and ensure they’re supported to prevent relapses in drug and alcohol addictions.

Urgent Care Link Workers have continued to employ skills such as motivational interviewing to help some clients abstain from alcohol abuse despite going through difficult times.

Due to mental health services being stretched at present, Link Workers have been able to provide ongoing support to patients in between interventions. These include befriending type approaches, practicing self-management techniques and encouraging healthy behaviours. Link Workers have been able to help clients with accessing their CBT online work and encouraging them to keep on top of it.

The social outcomes demonstrate a high impact in terms of the difference being made to people’s lives. This is reflected in the positive feedback received from clients accessing the service throughout the past 3 years.

Urgent Care Link Workers have continued to maintain strong rapport and relationships with key stakeholders such as the Hospital, social care, WMAS, the urgent care centre and the voluntary sector. Core group meetings have continued to happen virtually.

Urgent Care Link Workers have continued to utilise Personal Health Budgets commissioned by Dudley CCG

20 | Evaluation Report 2020 - 2021 MAIN CHALLENGES Covid-19 pandemic has restricted the array of opportunities and services that Link Workers could connect patients to within the community, especially patients who fell victim to digital exclusion.

Many patients have not left their homes for the past 12 months resulting in lower-than-average confidence levels, increased social anxiety and poor physical health. Urgent Care Link Workers have had to support patients for longer at times to help them overcome these barriers.

Urgent Care Link Workers were unable to carry out home visits for the major due to risks associated with Covid-19, other than in exceptional circumstances. Historically, home visits and unannounced doorstep conversations have been paramount to the success of this project. Covid19 has made it more difficult to engage new clients who do not answer the telephone, respond to text messages, letters etc.

Outcome and review data for this year has been based on a much smaller sample than previous years due to Covid-19 Community Support work having to take precedence throughout the first half of the year.

A&E attendances, inpatient admissions and cost avoidance data will have been influenced by Covid-19 pandemic. However, reductions and cost avoidance data has been significantly positive throughout the previous 2 years of delivery.

At times the client cohort can continue to present some challenges; for example working with people that have complex needs and/or chaotic lifestyles has brought about some challenges with getting client outcome assessments completed with them. This is due to concentration levels, basic literacy skills, dementia, learning disabilities, addictions etc.

Funding cuts to the voluntary sector has resulted in a lack of capacity in some areas such as longterm support workers, transport services etc. Some voluntary sector services have closed and some organisations have reduced the diversity of services offered such as LGBT support, refugee and migrant support etc.

Waiting times for other services in which to refer patients can result in the service working with patients for longer than anticipated. Staff have experienced waiting lists for social care assessments, carers assessments and mental health provision. The Covid-19 pandemic has led to further delays.

LESSONS LEARNT Previous years have shown that personal health budgets work particularly well for clients offering them more choice and control over the support that they receive. This has further enhanced the bespoke and flexible offer that the service provides. Opportunities to utilise personal health budgets throughout year 3 have been limited due to the pandemic and remote working but they will continue to be available throughout year 4.

Having funding specifically for the voluntary sector to spot purchase services based on gaps is really important for social prescribing schemes. This is enabling our service to be truly person centred and has been a lifeline throughout the pandemic as more outdoor opportunities have been commissioned in order to keep clients safe.

The acceptance rate is higher with clients contacted from the A&E frequent attender list as opposed to the WMAS 999 frequent caller list, as there is a much higher volume of patients on the WMAS 999 frequent caller list where their reasons appeared to be purely medical, the options for support from the service were therefore restricted, and less of an impact could be made. While the high intensity user core group do work to identify patients on this list that could benefit from the service, the majority of referrals continue to be taken from the A&E frequent attender list.

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There is a real need in Dudley borough for this support, targeting high intensity users of unplanned emergency care. Spending quality time with this patient cohort can help unlock the real reasons for them using emergency services frequently which other services have not been able to achieve.

Despite the pandemic causing challenges with offering the service to some new clients, those who have engaged in remote support, outdoor meetings etc. have responded well and have really benefitted from the support.

We continue to receive really positive feedback from clients in regards to the value of the bespoke support we offer.

Out of hours telephone support is important when working with clients offering an alternative option to the emergency services. We have realised that by getting to know the client we can predict when they will feel at their most vulnerable and will feel at risk of calling emergency services or attending urgent care. Throughout the pandemic there was a need for more out of hours support due to increased levels of anxiety and isolation.

Importance of collaboration with key stakeholders such as Dudley CCG, hospital staff, WMAS staff and getting these stakeholders on board with the model. Such staff are key to sharing patient lists and helping to resolve data sharing agreements and issues.

Our high intensity user patient core group that meets bi-monthly with key stakeholders is a very effective way to discuss patient care and to agree support interventions needed. The meeting now takes place virtually as continues to be as effective as it has always been.

Urgent Care Link Worker roles offers a spring board between services whereby staff liaise with statutory and voluntary services.

Urgent Care Link Workers have missed having the freedom to conduct home visits and knock on people's doors to encourage engagement. The face to face element of the role is extremely rewarding and this has been missed. Despite this, Urgent Care Workers have embraced different ways of working to make the best of a challenging period.

Along the way Urgent Care Link Workers have changed the language used with people as many have felt uncomfortable with the term high intensity user and feel that this stigmatises them in some way and can then act as a barrier to engagement.

FUTURE DELIVERY Dudley CCG have agreed to commission the service for a further year There will be no changes made to the way that the service is delivered as it continues to run smoothly and proves to be an effective model for supporting this patient cohort Integrated Plus have recruited a new Social Prescribing Project Development Worker who will recruit volunteer community buddies and pilot a peer mentor service within the high intensity user service. Integrated Plus hope that this will further enhance the offer to clients and provide them with an opportunity to help other clients through their social prescribing journey and shared lived experience.

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APPENDICES APPENDIX A - ADDITIONAL REVIEW/OUTCOMES ACHIEVED During a final review of the service, clients were asked about additional outcomes that had been achieved as a result of support from Integrated Plus. Due to the Covid-19 Community Support work, reviews were completed with a much smaller number of clients compared to previous years.

BENEFITS Clients were supported to access new benefits, have benefit payments backdated, benefits reinstated and to access other financial support as summarised below:

Personal Independence £1100 Payment

Total amount of benefits backdated

£4100

Universal Credit

£420

Employment Support Allowance

£250

Total amount of other financial help e.g. individual grants, food vouchers etc.

£1900

Total benefit amount reinstated

£320

Total amount

£11,470

OTHER OUTCOMES Accessed peer to peer support

2

Being more physically active

3

Made new friendships

5

Accessing training or education

4

Getting out and about more

3

Taking more notice of things around you

5

Volunteering

1

Gained employment

1

Reconnecting with friends

3