Self care toolkit
for professionals working with people with long term health conditions
Contents Overview of self care options..................................................................... II What is self care?...................................................................................... V Who is the toolkit aimed at?.................................................................... VI What is the aim of this toolkit?................................................................ VI A guide on how to use the toolkit........................................................... VII Map for self care for long term health conditions for practitioners when working with patients................................................. IX Self care pathway for practitioners working with people with long term conditions . ...................................................................................... X
Section 1 - For health professionals. ....................................... 1.1 Tools, training and resources Health Needs Assessment........................................................................1.3 Self Care Connect...................................................................................1.5 The Public Health Resource Centre..........................................................1.6 Congitive Behavioural Approaches training.............................................1.7
Section 2 - Programmes and services.............................. 2.1 Section 3 - Rehabilitation and education programmes.... 3.1 Section 4 - Other supportive services.............................. 4.1 Section 5 - Information and resources............................ 5.1 Section 6 - Coming soon................................................ 6.1
An electronic copy of this toolkit is available at
www.kirklees.nhs.uk/your-health/self-care-programme/self-care-toolkit/ For further copies of the toolkit or to inform us of any updates contact the self care project team at self.care@kirklees.nhs.uk or call 01924 816207.
I
Overview of self care options The tables below provide a summary of the self care tools and programmes outlined in the toolkit.
Programmes and services Description
Where provided
Target group
Referral mechanism
Active for Life
Kirklees
Referring agent
Better Health at Work
Kirklees
Adults with a mental illness All adults
Expert Patient Programme (EPP) Expert Patients Support Groups
Across Kirklees
Gateway Workers
Across Kirklees
Batley & Huddersfield
Get Food Wise Across and Exercise Kirklees Programme
II
Health Trainer Programme
Across Kirklees
Looking After Me Course for Carers Mind, Exercise, Nutrition‌ Do it! (MEND)
Across Kirklees
Practice Advice & Leisure Scheme (PALS) Stop Smoking Service
Across Kirklees
Worklink
Kirklees
Young PALS
Across Kirklees
Across Kirklees
Across Kirklees
Referral form
Page No.
No
2.15
No
2.23
Yes
2.1
No
2.6
No
4.1
Yes
2.5
Yes
2.21
No
2.7
Self Referral following recommendation
No
2.17
From GP or Health Professional
Yes
2.9
From Health Professional or Self Referral Self referral or health professional
Yes
2.19
Yes
2.25
Self Referral following recommendation
No
2.13
Self Referral or from partner organisation Adults with a long From GP or Health term condition Professional or Self Referral Adults who have Following EPP completed the course Expert Patient Programme Adults with low From Health level social care Professional or Self needs Referral Following EPP Adults who have course completed the Expert Patient Programme Adults with a long From Health term condition Professional or Self Referral Carers Self Referral
Unhealthy or overweight young people aged 7-13 yrs. Adults who want to be more physically active People who want to stop smoking Adults with disabilities/health problems in a position to find work Overweight or obese young people aged 5-16 yrs
Rehabilitation and education programmes Description
Where provided
Target group
Referral mechanism
Referral form
Page No.
Cardiac Rehabilitation Exercise Programme
North Kirklees
Adults following an acute cardiac event
Referral from Cardiac Rehab Nurse
Yes
3.4
Cardiac Rehabilitation Health Education Programme
North Kirklees
People with heart No referral disease necessary
Yes
3.3
Cardiac Rehabilitation Programme
Huddersfield
Adults following an acute cardiac event
Referral from Secondary Care or Primary Care
Yes
3.5
Continence Service
Across Kirklees
Anybody over the age of 4 years with a bladder, bowel or prolapse problem including incontinence.
Referrals accepted from health professionals and carers. Or Self Referral.
No
3.23
Community Rehabilitation
Across Kirklees
Adults with complex physical disabilities
Referral from Secondary Care or Primary Care
Yes
3.13
DESMOND
Across Kirklees
Adults recently diagnosed with Type 2 diabetes
Referral from Primary Care
Yes
3.9
Heart Failure Service
Kirklees
Adults with heart failure and their carers
Referral from Primary Care
Yes
3.6
Long Term Conditions Team
Across Kirklees
People with complex, multiple long term conditions
Referral from any health or social care professional
Yes
3.19
Primary Prevention Team (CHD)
North Kirklees
People at risk of cardiovascular disease
Team screens the clinical database
Yes
3.1
Pulmonary Rehabilitation
Cleckheaton, Dewsbury and Batley at the moment
Adults with From Health COPD or patients Professional waiting for a lung transplant
Yes
3.25
Secondary Prevention Team (CHD)
North Kirklees
Adults following an acute cardiac event
Yes
3.2
Referral from Primary Care or Secondary Care
III
Other supportive services
IV
Description
Where provided Target group
Referral mechanism
Referral form
Page No.
Batley Self Help Depression Group
Batley
Adults with depression or anxiety
No referral necessary
No
4.5
Breastfeeding Kirklees Support Group
New mums or women planning to breastfeed
Self referral
No
4.11
Cardiac Rehabilitation Group
People who are recovering from a heart attack
No referral necessary
No
4.8
Diabetes Huddersfield Support Group
People with diabetes
No referral necessary
No
4.9
Gateway Workers
Kirklees
Adults with Self referral or learning from health disabilities/ professional mental health needs/physical and sensory disabilities. Carers
No
4.1
Heartbeat
Batley
People with heart disease
No referral necessary
No
4.7
Heartline
Huddersfield
People with heart disease
No referral necessary
No
4.6
Kirklees Drug and Alcohol Action Team
Kirklees
Substance users
No referral necessary
No
4.13
Kirklees Kinfo
Kirklees
No referral necessary
No
4.2
Lifeline
Kirklees
Substance users
No referral necessary
No
4.14
Support to Recovery (S2R)
Huddersfield
Adults with depression or anxiety
From Health Professional
Yes
4.3
The Nerve Centre
Huddersfield
Adults with a neurological condition and their carers
No referral necessary
No
4.10
Batley
Information and resources Description
Where provided Target group
Referral mechanism
Referral form
Page No.
Help yourself to better health at the library
Batley, Dewsbury & Huddersfield
All adults
From Health Professional
No
5.3
Reading & You Across Kirklees Scheme (RAYS)
All adults
No referral necessary
No
5.1
Self help resources (public)
Across Kirklees
All adults
No referral necessary
No
5.5
Self help resources (professionals)
Across Kirklees
Health Professionals
No referral necessary
No
5.8
Coming soon Description
Where provided Target group
Referral mechanism
Referral form
Page No.
NHS Lifecheck
Nationwide
All ages
No referral necessary
No
6.1
Information Prescriptions
North Kirklees
Individuals with long-term health condition
6.2
Staywell
North Kirklees
Adults over 65 or with a long-term health condition
6.3
Additional self care information form...................................................................6.4 Evaluation form...................................................................................................6.5 Index...................................................................................................................6.6
Acknowledgments This toolkit provides valuable information for health professionals to promote self care. We would like to thank all the programmes and organisations for providing information and supporting the development of the self care toolkit. All the information contained in this toolkit is correct at time of print. Date produced: March 09 Review: March 10
V
What is self care? Self care is what we all do everyday to make sure we are looking after our health and well-being. This includes: staying fit and healthy, both physically and mentally; taking action to prevent illness and accidents; better use of medicines; treatment of minor ailments and better care of long term conditions. (Department of Health, 2006). Self care in a health and social care context focuses on helping health and social care professionals to develop active partnerships with patients to encourage them to: • Recognise and monitor their symptoms. • Allow people to undertake strategies to aid recovery. • Be involved in treatment decisions e.g.: understanding test results so they know what action is needed and why. • Enable people to book routine tests when they need them rather than only going through their GP for permission. • Support them in active management through problem solving, pacing and action planning. • Help them to become active members of society through work, leisure and the development of personal/social relationships. (DOH 2005/2006) The term ‘self management’ relates to the support for self care that increases the confidence of people with a long term condition to lead an independent and fulfilling life as possible.
Who is the toolkit aimed at? This toolkit has been written for anyone who is in a position to help promote self care in Kirklees. The toolkit is primarily aimed at frontline staff within primary care who are looking for new ways of working to improve outcomes for patients. It will also be of interest to other organisations who are in contact with people with long term conditions and who may be in a position to offer support to those people.
What is the aim of this toolkit? There is a wide range of work which supports self care in Kirklees including local programmes which serve to meet the needs of people with long term conditions, and training for professionals to increase their skills. The aim of this toolkit is to draw this information together and to act as a reference point for frontline staff to aid them to support patients to self care. The toolkit will: • co-ordinate information about the range of services and resources that can be used by professionals to support patients to self-care. • provide details of the referral process for each programme, giving the copy of the referral form where required
VI
The range of suggested options is not exhaustive or exclusive - the intention is to share some of the approaches that are known to the Self Care Team, and that are successfully running in Kirklees.
A guide on how to use the toolkit Users are invited to use the toolkit as a reference document. It is a practical tool which includes details about each programme or service.
Section 1 - Tools and information for health professionals. These will help you increase your skills and abilities to promote self care.
Section 2 - Programmes and services which professionals can refer and signpost patients on to.
Section 3 - Rehabilitation and disease specific education programmes which professionals can refer on to.
Section 4 - Other supportive services including local government and voluntary organisations
Section 5 - Information and resources for patients, such as ‘help yourself to better health’ scheme in Kirklees libraries and useful websites.
Section 6 - An overview of services which are under development. In some cases referrals to certain services need to come from a qualified health professional. This will be usually be a member of the primary health care team such as a GP or Practice Nurse. In other cases it may be other professionals such as voluntary sector workers who are in a position to signpost and refer people to the services outlined in this toolkit.
References Department of Health (2006) Our health, our care, our say: a new direction for community services Department of Health (2006) Supporting People with long term conditions to Self Care. Department of Health (2005) Supporting People with Long Term Conditions. An NHS & Social Care Model to support local innovation and integration.
VII
Tools for photocopying Throughout the toolkit you will find a number of tools which may be photocopied. The majority of these are Referral forms. They are: Tool........................................................................................... Page number MAP for self-care for long term health conditions for practitioners when working with patients................................................... IX Self care pathway for practitioners working with people with long term conditions . ................................................................................. X Health Needs Assessment Form........................................................ 1.3-1.4 Joint Referral Form: . ............................................................................... 2.3 • Expert Patient Programme • Looking After Me for Carers • Health Trainer Programme • Stop Smoking Service PALS Exercise referral form..................................................................... 2.11 Young PALS Invitation Postcard.............................................................. 2.14 MEND Flyer . ......................................................................................... 2.18 Stop Smoking Sessions........................................................................... 2.20 Worklink Referral Form ......................................................................... 2.26 DESMOND Referral Form....................................................................... 3.10 Community Rehabilitation Referral Form (Eddercliffe Centre).................. 3.15 Community Rehabilitation Referral Form (Barton Centre)....................... 3.17 Long Term Conditions Team Referral Form............................................. 3.21 Pulmonary Rehabilitation Referral Flowchart........................................... 3.26 Pulmonary Rehabilitation Patient Information Sheet............................... 3.27 The Heart Failure Service referral form...................................................... 3.3 Support 2 Recovery (S2R) Referral Form................................................... 4.4 Evaluation................................................................................................ 6.5
VIII
MAP for self care for long term health conditions for practitioners when working with patients FRCole 2007
Understanding the condition and its impact on health Understanding the impact of LTHC and making changes by:
•
Using a patient led health needs assessment (HNA)
•
Using the five areas model (person centred model), assess readiness for change
Understanding specific condition/s and how the body works Useful information, self-help, signposting to support and advice, self care tool kit
Managing moods & unhelpful thinking Challenging thoughts • Depression, guilt • Anxiety • Anger, frustration • Shame
Coping with physical symptoms • Using drugs better • Understanding sleep • Relaxation skills • Care for specific symptoms; fatigue • pain
Managing life situation difficulties • Investigations for LTHC • Understanding roles of health care professionals • Communication, relationships; assertiveness • solving difficulties e.g. finance, housing, work • Carers needs
Changing unhelpful behaviours • Pacing skills • Goal setting • Getting fitter, being more active • Increasing pleasurable activities/rewards • Using daily activity logs
Overcoming LTHC problems • Maintaining progress and managing setbacks • Acceptance with compassion • Staying or returning to work
IX
Contact with health care professional via self referral/adult specialist services/Health Trainer
Patient identifies their needs via HNA1 process and using HNA tool HCP2 with pt. plan care, +/- drug Rx and Health trainer + pt access self care support and resources Referral to specialist services +/scans, etc and/or prog. relevant to needs
Outcome
Step 1 Step 2
Step 3
Patient confident in self care skills with their toolkit for long term management
Knowledge and Skills: Expert patient Program, DESMOND, cardiac rehabilitation, pulmonary rehabilitation
Support groups e.g. Support 2 Recovery, diabetes
Signposting: Expert Patient Programme (EPP), Benefits Advice, Better Health at Work, Shaw Trust, Access to Work, DWP Work care, Health Trainers
Information sources: Local library, Multimedia, websites, self help groups, Kirklees Public Health Resource Centre, Kirklees Council Information Points
Resources: in community, Health Trainers, Kirklees PALS, NHS Kirklees Self care programme
Self care choices
Self care for people with long term conditions
Health care services input
GPs, pharmacists, associated health professionals
Hospital services clinic Specialist physio
Other health care services (private)
Occupational health care
HNA = Health Needs Assessment HCP = Health Care Professional
1 2
JH2363
X
Health Needs Assessment What is it? The patient journey should start with the Health Needs Assessment. The health needs assessment (HNA) is a tool which has been developed to assist patients to identify the things they require the most support with. It comprises of 24 generic questions and 15 questions which relate to long term conditions. The HNA helps health professionals to identify the needs of the patient and target resources more effectively, offering a more personalised support to patients with chronic health conditions. Clinical staff are encouraged to use the health needs assessment with patients to help them outline the problems that are important to them and which will impact on their lives and well-being. The HNA can also be used as part of the process of reviewing patients. There are quality-checked resources for each aspect of the Health Needs Assessment, which are available from the Public Health Resource Centre.
Who is it aimed at? The tool can be used by health professionals who are in a position to assist people with long term conditions.
Where can I find out more? A copy of the Health Needs Assessment is included in this toolkit. The HNA is used as part of the Cognitive Behavioural Approaches training (see page 1.7 for details). For further information on the Health Needs Assessment please contact the Self Care Team on 01924 816207. For more information about self care resources contact the Self Care Project Team on 01924 816207 or e-mail self.care@kirklees.nhs.uk
Section 1 - tools, training and resources for health professionals
1.1
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NHS Kirklees Mid Yorkshire Hospitals NHS Trust
Health Needs Assessment Form Name/ Patient no...................................................................................................................................... Address.................................................................................................................................................... ................................................................................................................................................................ Phone number.......................................................................................................................................... Health condition/s..................................................................................................................................... Referred from ............................................................................................ Date .....................................
Below is a check list of things that can affect a person’s health. We would like to provide you with as much support and information as possible. We have developed two lists below to help you highlight anything that is a concern for you. Please tick the boxes ďƒź below that are important to you and that you might need help with. We will use these lists to help provide you with the right information or to signpost you to the right service.
I have problems or difficulties with: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24.
My ability to cope with my limits and the things that stress me Coping with anxiety, anger or depression Being able to socialise Coping with daily activities e.g. washing, cooking, cleaning Feeling guilty or blaming myself for this condition The level of personal support I receive My carer understanding my condition If you ticked more My carer needing more help or support than 3 areas of Trying to stop smoking tobacco your life, please Eating the right types of food circle the 3 most How physically active I am important to help Any use of Illegal substances including mine and others e.g. cannabis etc with at present. How much alcohol I am drinking My sexual activity My level of reading, writing and coping with numbers My ability to use English My ability to physically access services e.g. steps etc Money worries e.g. difficulty in paying bills Any problems with housing Getting to local shops or leisure facilities Concerns about the impact of my job on my health or vice versa Maintaining or improving my oral health Controlling my bladder or bowels Anything important to you including hobbies, leisure or social events. Please describe: . ....................................................................................................................................................
Section 1 - tools, training and resources for health professionals
1.3
Now thinking specifically about your long term condition Please tick the boxes below that are important to you and you need help with I would like some help or support with: 1. Understanding what my condition is
What might happen in the future
2.
The tests used to assess or monitor my condition
Which tests I should be doing
3.
When I should I have routine tests
4.
The medication and therapies available for my condition
5.
The medication I take for my condition
• Their side effects.
• When to increase or decrease my medication.
• What happens if I don’t follow the instructions?
6.
Managing physical symptoms due to my condition e.g. breathlessness for respiratory conditions
7.
My sleep being disturbed by my symptoms
8.
Monitoring my symptoms regularly
9.
Managing bodily pain symptoms.
10.
Managing relapses
11.
Knowing who to contact if my condition gets worse or goes out of control
12.
Booking appointments
13.
Travelling to appointments
14.
Health professionals understanding me and my condition and helping me to cope
15.
Where to get information about my condition
Again: if you ticked more than 3 areas regarding your condition then please circle the 3 most important to help with at present. Thank you for helping us to understand your needs.
Please remember to take this with you when you go for your appointment at the clinic.
1.4
Section 1 - tools, training and resources for health professionals
Self Care Connect Self Care Connect is an online resource for colleagues to share and discuss self care. It is a new resource and networking organisation that aims to be a key driver for self care. It provides fast access to information and resources on self care including key developments, policy drivers, up-to-date news and also provides an area where views and experiences can be exchanged The site aims to bring together research and resources from across the world for colleagues to share and discuss. It is continuously being updated and users are encouraged to submit their own research, findings and resources for publication. Self Care Connect offers the following: • Interactive tools • Training Courses • Details of forthcoming events and conferences • Discussion forums • Assistive technology updates • Signposting to services • Latest self care research • Self Management Focus Visit the website for more information www.selfcareconnect.nhs.uk
Section 1 - tools, training and resources for health professionals
1.5
Public Health Resource Centre What is it? The Public Health Resource Centre at Woodkirk House is a free service which offers a wide range of information on public health and self care topics. A range of free posters and leaflets are available, and other resources include books, DVDs, models and training packs. The resource Centre has a web-based catalogue which allows health and social care professionals to order health promotion resources online.
Who is it aimed at? The service is available to anyone working to promote health in Kirklees. Any professional in Kirklees can register as a member of the public health resource centre and is entitled to use the resources.
How can you access this service? To gain access visit www.phrc.kirkleespct.nhs.uk To order materials you need to register yourself as a member with the Public Health Resource Centre. You can visit the resource centre in person or telephone to place an order or to find out more information.
For more information Public Health Resource Centre Woodkirk House Dewsbury & District Hospital Halifax Road Dewsbury WF13 4HS Tel: 01924 816186
www.phrc.kirkleespct.nhs.uk
1.6
Section 1 - tools, training and resources for health professionals
Cognitive Behavioural Approaches Training What is it? The Cognitive Behavioural Approaches Training is a modular course, which is free to any frontline worker in Kirklees. The course aims to increase the range of communication and psychological skills of health and social care practitioners through: • Developing a partnership with the patient • Helping the patient to identify the problems important to them using the health needs assessment form • Helping patients to work through and prioritise problems using the five areas model (CBA model) • Understanding the emotional impact of a long term health condition • Helping patients develop pacing skills and relaxation skills
• Helping patients to set SMART (specific, measurable, achievable, realistic, timely) goals • Helping patients develop problem solving skills • Motivating effective behaviour change • Using diaries to help patients map behaviour patterns • Developing self-care plans or actions plans • Helping patients identify negative thinking patterns and work towards developing more balanced thinking patterns
This modular training course runs over 4 full days
Introductory module 1: Core skills: person-centred assessments, motivational interviewing, enabling skills to support behaviour change (2 days)
Module 2: Coping better with mood and relationship change (1 day) Module 3: Acceptance, return to work, sustaining change and managing setbacks (1 day) NB: to access modules 2 and/or 3, participants must attend module 1.
Who is it aimed at? Any health care and social care practitioner who wishes to support and motivate patients to make behavioural change in order to stay well, and to work with patients who wish to improve confidence to manage their long-term condition(s).
How can you sign up to the training? Information about the course is sent out to all practices and to frontline workers in the PCT. The courses have been running since November 2005 until present. Contact: Admin Officer for Self Care on 01924 816106 or the Self Care Project Team self.care@kirklees.nhs.uk for more details and an application pack OR Julie Bottomley, Public Health Training Administrator on 01484 343451.
Section 1 - tools, training and resources for health professionals
1.7
CASE STUDY After attending the self care skills training course, Polly*, a physiotherapist was visited by a lady, Irene* in her sixties who had suffered a heart attack 4 weeks prior. She was previously very active, engaging in activities such as line dancing, swimming, and shopping. Her first appointment with cardiac rehabilitation was the first time she had left the house in four weeks, other than many presentations at accident and emergency with symptoms of angina. Irene scored very highly on the anxiety and depression tests administered. Polly used many of the tools from the course with Irene, which made her realise how her health condition was taking over her life. Whilst Polly was explaining the tools, Irene had a ‘lightbulb moment’ as she realised how the condition had changed her life. Polly and Irene began setting goals. Firstly Irene decided to visit the hairdresser at the end of the road. It was established from using the five areas model that Irene’s confidence and self esteem was very low and both agreed this would help with her self esteem and with her confidence to leave the house. Polly then used the tools when Irene returned to clinic to highlight how she had managed to ‘move the condition one seat back on the bus’ by achieving her goal. Irene continued to set goals such as going out with friends, going shopping with her daughter and resuming her line dancing hobby; all of which she achieved and even surpassed. The daily activity log made Irene realise that it was during her time spent sitting and doing nothing that she developed chest pain and all involved realised that Irene was experiencing symptoms of angina pain due to anxiety. Irene no longer experiences chest pain, and is continuing to set her own goals post-discharge. She has even gone on to take part in a GP exercise referral scheme. Polly asserts that she feels due to her moving away from her previously held medical model of pain and using cognitive behavioural approaches that she was able to have such an impact on Irene’s rehabilitation. She feels that without the new techniques learned on the self care skill training course that this would not have happened. *name changed
1.8
Section 1 - tools, training and resources for health professionals
Expert Patients Programme What is it? The Expert Patients Programme (EPP) is a self management course of between 8 and 10 weeks in length that provides opportunities for people who live with long-term health conditions, or care for someone with a long-term health condition, to develop new skills to better manage their health and well-being. The course is led by trained volunteer tutors, in many instances volunteers, who all have experience of living with a long term health condition. Participants get the opportunity to meet other people who share similar experiences. The course covers a range of self management skills, including symptom management, dealing with difficult emotions, problem-solving, and action planning. It also informs participants how to access resources, and how to work with health professionals. Each session is run by two tutors. All the tutors have previously attended an expert patient programme. To become a tutor the volunteers have attended a short training course and are assessed in practice. Each programme starts with a pre-course meeting for all participants which is held a week before the date of the first session. The pre-course meetings are an opportunity for participants to: • visit the venue • meet the Tutors who will be delivering the programme • find out about what will be covered in the programme • ask any questions.
What about housebound people? For people who are housebound or unable to attend regular sessions, the programme is available on line – click onto www.expertpatient.nhs.uk and pick up the ‘on-line’ link on the left hand side of the page.
Who is it aimed at? Adults with chronic or long term health condition(s) or carers, who want to learn skills for managing and improving their health.
tients Progra mm rt Pa e p e Ex
Where does this programme operate? The programmes operate in both north Kirklees and south Kirklees at good quality, local venues with good access and parking.
Section 2 - programmes and services for patients
2.1
How can you refer to this programme? Participants can self-refer by completing a registration form which can be found in the EPP leaflet. The leaflets are widely distributed across GP Practices, Health Centres, community venues, and public buildings e.g. Job Centre Plus and Social Services Information Points. Health professionals can also complete the form on behalf of the patient and send to the following address: Expert Patient Programme NHS Kirklees FREEPOST NEA 13086 Batley WF17 5BR A joint referral form which allows you to refer someone to this programme is enclosed in the toolkit (see page 2.3).
Where can I find out more? For further information please contact: Julie Lawes on 01924 351448 or Julie.Lawes@kirklees.nhs.uk
What opportunities are available following The Expert Patients Programme? When participants have completed the Expert Patients Programme, they have a range of opportunities available to them. These are as follows: • The Get Food Wise and Exercise Programme (see page 2.5 for details) • Support Groups for EPP Participants (see page 2.6 for details)
“It’s wonderful to see how the participants become more and more confident as the weeks go by – their achievements are astonishing” – tutor
2.2
I thought I was a poorly person until I joined the Expert Patients Programme – now I realise I am not on my own and I feel much better about myself.
By taking part in the programme, I have learned such a lot and now I have the skills and confidence to talk to my GP about my condition and make plans for the future.
Section 2 - programmes and services for patients
Kirklees Health
Expert Patients
Programme
Kirklees Stop Smoking Service
Joint referral form Please use this form if you wish to refer a patient to one or more of the following services: Expert Patients Programme Course Looking After Me for Carers Course Please post or fax to: Julie Lawes, EPP Admin and Support Officer NHS Kirklees FREEPOST NEA 13086 Batley, WF17 5BR Tel No: 01924 351448 Fax No: 01924 472097
Health Trainer Service Please post or fax to: The Health Trainer Team at Dewsbury:
Tel: 01924 816176 Fax: 01924 816031 Woodkirk House, DDH
OR Huddersfield: Tel: 01484 344349 Fax: 01484 344281 Princess Royal Health Centre
Stop Smoking Service Please post or fax to: Dewsbury: Tel: 01924 351498 Fax: 01924 463281 Woodkirk House, DDH OR Huddersfield: Tel: 01484 344285 Fax: 01484 344273 Princess Royal Health Centre
Better Health at Work Better Health at Work Team Kirklees Environmental Services West Riding House 9 Manchester Road Huddersfield HD1 3HH Tel: 01484 416777 Fax: 01484 414883
Section 2 - services for patients
2.3
Instructions for use • Indicate which service(s) you require (over the page) • Complete the entire form • Send a copy of the form to the required service using the relevant fax numbers or addresses (for referral to more than one service, the form will need to be photocopied) Patient Name: Mr/Mrs/Miss/Ms ............................................................................................................................................................. DOB: ....................................................................
NHS No:.................................................................
Daytime Contact Number:...................................................
Mobile Contact Number:...................................................
Address:................................................................................................................................................ ............................................................................................................................................................. ............................................................................................................................................................. Postcode:...............................................................................................................................................
First Language:.......................................................
Sex :
Name of GP: ............................................................................
Is this person at risk of, or has a long term condition?............................................................
............................................................................
.............................................................................
If a smoker; Is the client ready to stop smoking now?
M
Yes
F
No
For Better Health at Work Referrals: Company/organisation:........................................................................................................................... Job Title:................................................................................................................................................. Completed by/designation: ................................... Signature:.............................................................. Date:..................................................................... Comments:
2.4
Practice details / originator stamp:
Get Food Wise and Exercise Programme What is it? This 10 week programme has been designed specifically for people that have attended the Expert Patients Programme. It is all about healthy eating and incorporates a tailored physical exercise regime to suit the patient. It also has social elements where participants can share experiences, and there are regular weighing and measuring sessions. The Programme is led by trained Physical Activity Development Officers who are part of KMC’s Practice Activity and Leisure Scheme From this programme, participants can automatically graduate onto PALS – Practice Activity and Leisure Scheme – The Exercise Referral Scheme which is run by Kirklees Council.
Who is it aimed at? This programme is available to adults who have completed any one of our Expert Patients Programmes.
Where does this programme operate? Programmes are held in a variety of easily accessible vnues across Kirklees.
How can you refer to this programme? Referral onto this programme can be arranged following completion of the Expert Patients Programme course. The Admin and Support Officer will write to the GP to get a referral for the Get Food Wise & Exercise Programme.
atients Program ert P me p x E
Once this programme has been completed, the patient can go on to attend the full PALS programme with no extra referral needed. (See Page 27 for PALS details.)
Where can I find out more? For further information please contact Julie Lawes on 01924 351448 or Julie.Lawes@kirklees.nhs.uk
Section 2 - programmes and services for patients
2.5
Expert Patients Support Group What is it? Expert Patients Support Groups have been established to offer ongoing support and continued involvement in matters relating to health and social care services.
For people with chronic health conditions and carers
The Support Group members are people who have completed an Expert Patients Programme. It is a social environment: • where information and support is provided to help members improve their health and well being • where members can meet health service staff to hear about how local health services operate and to have a ‘say’ • where experiences can be shared with other members of the group
Who is it aimed at? The Support Groups are for people who have completed any Expert Patients Programme.
Where do the Support Groups meet? There are 2 Support Groups, one in Batley and one in Huddersfield. They meet at the following venues each month:
The Salvation Army, Bradford Road, Batley.
12.00 – 2.00pm on the third Thursday of every month.
Brian Jackson House, National Children’s Centre, New North Parade, Huddersfield
12.30 – 2.30 on the 1st Wednesday of every month.
Where can I find out more? For further information please contact: Julie Lawes on 01924 351448 or Julie.Lawes@kirklees.nhs.uk
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A course for carers What is it? NHS Kirklees and Kirklees Council’s Carers Gateway are working together and have established a Looking After Me programme. The Looking After Me Course is a course for carers. The eight week programme gives people the skills to help them cope with their caring situation and increases their confidence to take more control of their life. The course is led by trained Tutors who themselves have experience of caring for a relative. Participants get the opportunity to meet other carers who share similar experiences. The course covers relaxation techniques, dealing with tiredness and coping with depression. Communicating with professionals and planning for the future are also elements of the course. Each programme starts with a pre-course meeting for all participants which is held a week before the date of the first session. The pre-course meetings are an opportunity for participants to: • visit the venue • meet the Tutors who will be delivering the programme • find out about what will be covered in the programme • ask any questions.
Who is it aimed at? The Looking After Me is a course for adults who care for someone living with a long term health condition or disability. Any adult who gives help to a relative or friend who is ill, disabled, elderly or in need of emotional support can take participate in this course.
Where are the programmes held? In a variety of accessible venues across Kirklees.
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2.7
Where can you find out more information and how to refer to this programme? Please contact:
Julie Lawes, Expert Patients Programme Admin and Support Officer
By phone:
01924 351448
By e-mail:
Julie.Lawes@kirklees.nhs.uk
In writing to:
Julie Lawes NHS Kirklees FREEPOST NEA 13086 Batley WF17 5BR
Or
Farah Haq, Carers Gateway Support Officer
By phone:
01484 226050
By e-mail:
farah.haq@kirklees.gov.uk
In writing to: Farah Haq, Carers Support Officer Looking After Me Programme Carers Gateway 30 Market Street Huddersfield HD1 2HG A joint referral form which allows you to refer someone to this programme is enclosed in the toolkit. (See page 2.3)
What opportunities are available following The Looking After Me Programme? People who have done the Looking After Me course can receive the same benefits as those who have completed the Expert Patient Programme such as the Support Group and the Get Food Wise and Exercise Programme
Support Group specifically for Carers In addition, to the generic EPP Support Group, there is a Support Group especially for those people who have attended the Looking After Me programme
South Kirklees: The group meets in Huddersfield every 3rd Monday in the month, 12 - 2pm at Gateway to Care, 30 Market Street, Huddersfield, HD1 3HG for light lunch and refreshments, guest speakers and activities. The Carers Support Officer is on hand to help with any enquiries or give information.
North Kirklees: This group is still in the developmental stage. One meeting has been held and we looking to establish a permanent group during 2009.
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Section 2 - programmes and services for patients
PALS (Practice, Activity & Leisure Scheme) What is it? PALS is the Kirklees Exercise Referral Scheme which offers support and encouragement to inactive people who would benefit from becoming more active. Throughout the 45 week scheme, participants can take part in group or individual activity programmes. PALS provides the opportunity to have up to four one-one sessions based on the motivating behaviour change model to encourage people to become more active. There is the opportunity to try out a range of activities, with weekly drop in sessions for continued support. As well as the benefits to health, many PALS enjoy the social side of meeting others and supporting one another. Many of the group activities have social time at the end of the session. The scheme also offers specialised activity sessions aimed at specific health conditions. Classes include:• cardiac rehabilitation exercise circuits • pulmonary rehabilitation exercise circuits • chair-based activity sessions • follow on from Falls rehabilitation i.e. postural stability • neuro circuit • activity opportunities for clients with persistent pain The service is run by Culture & Leisure Services, Kirklees Council, in partnership with the NHS and Kirklees Active Leisure.
Who is it aimed at? PALS is aimed at people aged 16 years plus, who are residents in Kirklees or registered with a GP within the Kirklees locality. They should be inactive and need support and motivation to become more active. People who are referred should also be at risk of developing certain health conditions, or currently have health conditions such as: • • • •
low self esteem heart disease hypertension asthma and other respiratory problems • joint pain, back pain, arthritis or similar
• • • •
Diabetes Stroke BMA >25 Fallen / at risk of falling
• Chronic pain • Pregnant - north Kirklees midwife referral only
Individuals should also be motivated and compliant to exercise.
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2.9
Where does this programme operate? The PALS programme operates in leisure centres across Kirklees and in some community venues.
How can you refer to this programme? Referral onto PALS must be by a GP, Practice Nurse, or other health professional that are registered as a Referring Agent. There are four essential criteria which must be met in order for a patient to qualify for PALS. (Guidance on the inclusion and exclusion criteria can be found in the Guide for Referring Professionals which all practices and referring agents have a copy of). The referral forms are located within all practices. A copy of the referral form is enclosed in this toolkit, however the original form must be used as it is a triplicate form. If you require further referral forms please phone the PALS Office on the number below.
Where can I find out more? For more information, please contact: The PALS Office Kirklees Culture and Leisure Services The Stadium Business & Leisure Complex Stadium Way, Huddersfield, HD1 6PG Tel: 01484 234095.
CASE STUDY Mark Crosland was just 30 when he joined the PALS scheme in 2002, suffering from chronic back pain due to a lifting injury. From one ‘stretch and flex’ session a week, Mark was soon doing three activity sessions a week. In 2004, he became one of the PAMS and trained as a walk leader. Unfortunately, Mark suffered a set-back in 2005 when his back flared up. But, following a spinal fusion operation in 2006, Mark was back exercising with PALS within two weeks. He was off medication within 12 weeks and over a year lost three stones in weight. Now, every week, Mark goes to the gym three times, does Pilates, attends a mainstream activity class at Huddersfield Sports Centre and helps as a PAM. As well as the physical benefits, Mark said PALS helped him get through the occasional bouts of depression brought on by his back pain. He said: “Getting out of the house and meeting people lifted my mood.”
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Exercise Referral form Patient details Name:................................................................................................................... P R AC T I C E AC T I V I T Y & LEISU CHEME RE S
Address:...............................................................................................................
Declarations
.............................................................. Postcode:...............................................
I have been informed about PALS and have not withheld any relevant information. I will advise my referring agent of any further changes to my health.
Tel no:......................................................... D.O.B.:...............................................
Patient’s signature Date:
Patient’s GP...........................................................................................................
Essential criteria Yes 16 years plus Resident in Kirklees and/or a patient Inactive registered with one of the General Motivated/compliant Practices responsible to NHS Kirklees
Yes
Selected criteria Please tick one or more
Yes
a Low self esteem, mild anxiety or depression b At risk of/have CHD (Must have two or more risk factors) Please indicate.
Referring agent I have fully briefed this patient and I now refer his patient to PALS Name (print) Signature Profession Surgery/Department Date
1)
c Hypertension Blood Pressure
2) Resting HR
Must not exceed 190/100
d e f g h
Asthma and other respiratory problems Joint pain, back pain, arthritis or similar At risk of/have diabetes Stroke B.M.I. >25 Please state
i Fallen/at risk of falling
Re-referral
Yes
No
Has this patient had a previous referral? If yes, why has this person been re-referred?
Medication
Once signed by both parties the patient should wait approximately 5 days then contact the PALS Administrator to make and appointment. Call between 9.30am and 1.30pm on 01484 234095.
Is this patient taking any medication? Yes/No (please delete). If yes, please tell us how this may affect the patient’s ability to undertake physical activity/exercise.
Health and medical factors It is important that the instructor is aware of any past/current health and medical factors which may affect the patient’s ability to undertake physical activity/ exercise. Please give details if appropriate and attach relevant information if necessary.
Prohibited activity This patient should NOT take part in the following types of activity.
PALS, Kirklees Culture and Leisure Services, The Stadium Business and Leisure Complex, Stadium Way, Hudersfield HD1 6PG. Contact no: 01484 234095
Section 2 - services for patients 2.11
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Young PALS (Practice, Activity & Leisure Scheme) What is it? Young PALS is the Kirklees Exercise Recommendation Scheme for inactive young people who are overweight and obese. The scheme directs young people through an activity programme devised by an appropriately qualified exercise specialist. The scheme gives young people the opportunity to try out lots of different activities including sports, dance and fitness activities. Specific sessions called Fusion are also offered to Young PALS which give the young people the opportunity to learn new skills and be more active in a fun, social setting. Family support and involvement is also encouraged and educational elements about healthy eating are combined with active games, where parents and children can participate.
Who is it aimed at? Overweight or obese young people aged 5-16 yrs, who are residents in Kirklees or registered with a GP within the Kirklees locality. They should also be motivated and compliant to exercise.
Where does this programme operate? The Young PALS sessions take place in a range of different venues in north and south Kirklees.
How can you recommend to this programme? If a recommending agent identifies a young person, and is concerned about their weight and low activity levels, then they can give a Young PALS leaflet and invitation to the young person, encouraging them to contact the Physical Activity Development Team to join the scheme. The invitation to join Young PALS is included in this toolkit, and can be photocopied for use within your practice.
Where can I find out more? For more information, please contact: The Physical Activity Development Team The Stadium Business & Leisure Complex Stadium Way, Huddersfield, HD1 6PG Tel: 01484 234096.
Section 2 - programmes and services for patients
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2.14
Section 2 - programmes and services for patients
Active for Life Becoming more active is not just good for physical health, regular physical activity can also benefit mental health. Being regularly active can help reduce feelings of anxiety, stress and depression and generally boost how you feel about yourself. Other benefits may include improved energy levels during the day and better sleep at night. What’s more regular physical activity can provide an opportunity to try something different, meet new people and have fun, all whilst doing something that is good for you!
What is Active for Life? Active for Life is designed to enable people experiencing mental ill health to enjoy the benefits of regular physical activity. Activities may include going to the gym, swimming, attending an exercise class, walking, trying a sport or something else entirely. The amount and type of activity depends on what the individual enjoys, but the emphasis is always of supporting people to eventually be able to exercise independently. So whether they are looking to try some physical activity for the first time, or get back into exercise following some time out, Active for Life can provide support in finding a suitable way of achieving this.
How does the scheme work? Following referral clients meet with an Active for Life Officer to learn more about the benefits of physical activity and the scheme itself. By working together to agree goals and a personal activity plan the Active for Life Officer can establish effective ways of offering support, motivation and encouragement. Throughout a 45 week period the scheme regular reviews take place enabling the client and the Active for Life Officer to track progress and plan future challenges as clients gradually develop the confidence, skills and support necessary to undertake regular independent physical activity.
How much does Active for Life cost? The basic Active for Life service is free of charge. This includes regular one to one consultations, exercise prescriptions, information, support and motivation as agreed between the client and the Active for Life Officer. Some activities, including walking and cycling are also free. There is a (subsidised) charge for other activities, such as exercise classes, swimming and gym usage.
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2.15
Who is Active for life aimed at? To be referred to Active for Life individuals should be • Experiencing severe mental illness and sufficiently stable to engage in and benefit from regular physical activity • 18-64 years old • Motivated to become more active and have a sport/physical activity need identified as part of their care plan • Resident in Kirklees and/or a patient registered with one of the General Practices responsible to NHS Kirklees
Where does Active for Life Operate? The scheme operates throughout Kirklees using a range of Kirklees Active Leisure, community and private sport/leisure facilities. The scheme is flexible and will endeavour to operate at those locations most convenient to individual clients.
How can clients be referred to Active for Life? As an exercise referral scheme, Active for Life requires that participants are referred by a medical professional (usually a Community Psychiatric Nurse) registered as a Referring Agent. This is because some medical information about the client’s physical and mental health is required to ensure the exercise prescribed can be made as safe, appropriate and effective as possible. Referral forms and Referrer Information Pack along with further information on becoming a Referring Agent can be obtained by contacting the Active for Life Officer (details below).
Where can I find out more? For further information about Active for Life, please contact; Saul Muldoon Senior Physical Activity Development Officer for Mental Health Active for Life Kirklees Culture and Leisure Services The Stadium Business & Leisure Complex Stadium Way, Huddersfield, HD1 6PG Tel: 01484 234097 Email: saul.muldoon@kirklees.gov.uk
2.16
Section 2 - programmes and services for patients
MEND Programme (Mind, Exercise, Nutrition‌ Do it!) What is it? MEND is a programme run by the Young PALS. MEND is a free 9 week family based programme for children to become fitter, healthier and happier. The fun interactive programme covers two sessions a week. This involves two physical activity sessions (1 dry side and 1 wet side) and two theory sessions which they must attend with a parent or guardian on the Mind and Nutrition.
Who is it aimed at? Unhealthy or overweight young people aged 7-13 yrs.
Where does this programme operate? MEND sessions take place in a range of different venues in north and south Kirklees.
How can you recommend to this programme? Recommending agents, e.g. health professionals, schools, can give out MEND flyers to any child. When a parent/guardian enquires about the programme by ringing the Physical Activity Development Team they will screen their child’s height and weight over the phone. If the child is over the 91st centile on the BMI chart they qualify for the programme. Parents can also self refer their children to MEND. The MEND flyer is included in the toolkit and can be photocopied for use within your practice.
Please note: Every child who enrols on to the MEND programme must access the Young PALS scheme.
Where can I find out more? For more information, please contact: The Physical Activity Development Team Tel: 01484 234096. www.mendprogramme.org
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2.17
FREE fun programme for kids to become fitter, healthier and happier! Do you have children 7 to 13 years old? Are you worried they might be unhealthy or even overweight? Then call us on 01484 234 096 and join the MEND Programme!
The MEND Programme gets kids healthy and fit in only 10 weeks and helps them stay that way! Find out about other children having fun on the MEND Programme www.mendprogramme.org
What happens on the MEND Programme?
The Programme consists of 18 sessions (twice a week for 2 hours/session). Programme highlights include: • Weekly games, activities and swimming for kids. • Learning that being active can be a lot of fun! • Fun, interactive discussions that will teach you easy, effective ways to improve your child’s behaviour and improve his/her self-confidence. • Practical demonstrations, games and tips about healthy foods, label reading and portion sizes There is even a fun supermarket tour and a chance to try delicious new foods! PROGRAMME DETAILS WHERE: DATES:
PLACES ON THE PROGRAMME ARE LIMITED, SO RING TODAY AND MAKE SURE YOU DON'T MISS OUT! Call the MEND team on 01484 234 096 to see whether your child qualifies and to get more details on how to register.
TIMES:
How do I know if I qualify?
Although there is no cost to attend the programme,we will need to assess whether your child qualifies based on their age, weight and health.
2.18 This MEND Programme will be run and supervised by qualified MEND Trainers. MEND is both evidence-based and outcome-driven, and is currently being researched in the form of a Randomized Control Trial at the Institute of Child Health in London. © MEND Central Limited
Kirklees Stop Smoking Service What is it? The Kirklees Stop Smoking Service is the local NHS support service for smokers wanting to stop. It is a free, confidential service provided by specialist advisors who offer help with obtaining Nicotine Replacement Therapy on prescription, and advice on how to stay stopped. A choice of individual or group appointments are offered, both during the day and in the evening. Drop in sessions, home visits, and workplace quit groups are also part of the service. Dedicated specialist advisors are also available to help and encourage pregnant women to quit, offering support and advice to their family also.
Who is it aimed at? It is aimed at anyone who is motivated to give up smoking.
Where does this programme operate? Sessions operate in health centres, hospitals and community venues across Huddersfield, Batley, Dewsbury & Spen. ** See information sheet over the page
How can I refer to this programme? Many GP practices have practice nurses who are trained to help smokers wanting to stop. However, if an individual requires more specialist advice and support, or would find the drop-in sessions more convenient, you can refer to the Stop Smoking Service either by calling the numbers below, or completing a simple referral form*. People can also self refer to the service. A joint referral form which allows you to refer someone to this programme is enclosed in the toolkit. (See Page 2.3)
Where can I find out more? For more information contact the Kirklees Stop Smoking Service on the following numbers: • 01924 351498 (Dewsbury, Batley & Spen) • 01484 344285 (Huddersfield)
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2.19
Ready to quit? Kirklees Stop Smoking Service programme of sessions We provide free, confidential, practical, help and support from dedicated NHS professionals when you are ready to stop. Below are the locations of our stop smoking sessions. Some of these are drop-in sessions and you are welcome to just turn up. If you would prefer a 1:1 appointment or are pregnant please contact us and we will do our best to arrange a convenient appointment for you.
Daytimes - Huddersfield Chestnut Community Centre (Maternity/relatives only)
Fartown Health Centre
Mill Hill Health Centre
Wednesday 1 – 5pm 1:1 sessions
Mondays 9am – 12pm 1:1 sessions
Gateway to Care
Elmwood Health Centre, Holmfirth
Wednesdays 1pm Drop-in session
Mondays 1pm – 7.30pm 1:1 sessions Tuesdays 1pm – 5pm 1:1 sessions Thursdays 1pm – 5pm 1:1 sessions Fridays 1pm – 4pm 1:1 sessions
Wednesdays 12pm Drop-in session
Tuesdays 9am – 12pm 1:1 sessions Thursdays 4pm – 7.30pm 1:1 sessions
Huddersfield Royal Infirmary
Daytimes - Batley, Dewsbury & Spen
Evening drop-in clinics
Batley Health Centre
Dewsbury & District Hospital
Mondays 2pm Drop-in session Tuesdays 9am – 1pm 1:1 sessions Fridays 1pm – 4.30pm 1:1 sessions
(Antenatal only)
No need to book, just come along at the time stated and find out more.
Cleckheaton Health Centre Tuesdays 2pm Drop-in session Thursdays 1pm - 4pm 1:1 sessions
Dewsbury Health Centre Tuesdays 9am – 11am 1:1 sessions Wednesdays 2pm – 5pm 1:1 sessions Fridays 9am – 12pm 1:1 sessions
Tuesdays 10am – 12pm Drop-in session Tuesdays 2pm – 4pm Drop-in session
Brian Jackson House, Huddersfield Every Tuesday, 7pm
Mill Hill Health Centre, Huddersfield
Ravensthorpe Health Centre
Every Wednesday, 6.30pm
Thursdays 2pm Drop-in session 1:1 sessions – please check availability
Cleckheaton Health Centre Every Thursday, 7pm
Dewsbury Health Centre Every Wednesday, 7pm
Sessions are subject to change, please ring for up-to-date information.
For more information contact the Kirklees Stop Smoking Service on: 2.20
Huddersfield - 01484 344285 Batley/Dewsbury/Spen - 01924 Section 2 - services for patients
351498
AHA2332
Health Trainer Programme Who are the Health Trainers?
Kirklees Health
Health Trainers are members of the local community who are employed by NHS Kirklees. They provide one to one support to individuals with a long term condition by encouraging healthy lifestyles and signposting to relevant services so they can take control and manage their health condition better. Health Trainers receive internal brief interventions training, focused on cognitive behavioural approaches to behaviour change. They also produce a portfolio of competencies which is assessed by the University of Huddersfield before they become an accredited health trainer. Once practising, health trainers receive regular monitoring and supervision.
What will Health Trainers do? The health trainers will help individuals access information and advice about services including staying fit and healthy, both physically and mentally; information about taking action to prevent illness, coping with long term conditions and promoting independence.
Who is it aimed at? Adults with long term health conditions who would benefit from extra support with self care, self management or behaviour change.
Where does this programme operate? Health trainers are based in Huddersfield and Dewsbury, and consultations at suitable venues across Kirklees can be arranged to suit the client. Health Trainers are also available for consultations with patients in GP surgeries if there is a suitable space.
How can you refer to this programme? People can self refer to the Health Trainer Programme by calling the telephone numbers below, or they can be referred by a GP or health professional, or partners working in the community and voluntary setting, by completing a referral form. A joint referral form which allows you to refer someone to this programme is enclosed in the toolkit. (See Page 2.3)
Where can I find out more? For more information please call the following numbers: 01924 816176 (Dewsbury, Batley or Spen) or 01484 344349 (Huddersfield)
Section 2 - programmes and services for patients
2.21
CASE STUDY Josie* is a pensioner living on her own. She met with a health trainer at a local community group as she had been suffering with high cholesterol. Determined she didn’t want to take any more medication, Josie decided she wanted to make some changes to her lifestyle. By setting some SMART goals with the health trainer and being given some information, Josie worked towards her main aim of reducing her cholesterol. Six months later Josie returned to her practice nurse to be informed that her cholesterol had significantly reduced to a satisfactory level. “Meeting with a health trainer has been great, it has really helped me with my diet. The leaflets have been brilliant, I keep them altogether and read them regularly.� Josie *name changed
2.22
Section 2 - programmes and services for patients
Better Health at Work What is it? The Better Health at Work project is a partnership between Kirklees Environmental Services, NHS Kirklees, Job Centre Plus and the Health and Safety Executive (HSE). The Health at Work Advisors provide a FREE and CONFIDENTIAL support service for individuals who live and/or work in Kirklees and feel that work does, has or could contribute to ill health. They can also answer enquiries on health and safety issues. The team work alongside local GPs, Health Professionals and other agencies to provide information, advice and guidance to support people in addressing their workplace health concerns.
Who is it for? People who live or work in Kirklees and may be experiencing work related ill health.
Where does this programme operate? The Better Health at Work project operates throughout Kirklees.
How can you access this service? If your GP, Health Professional or other partner organisations such as Job Centre Plus feels that you could benefit from this service, they can refer you directly or provide you with contact details. Contact information is readily available at GP surgeries and Job Centre Plus branches throughout Kirklees. You can also self refer by contacting the advice line or by talking directly to an advisor within certain GP surgeries. See your surgery for details.
Where can I find out more? For more information about the Better Health at Work programme, please call the advice line on 01484 416777, email env.betterhealth@kirklees.gov.uk or visit www.betterhealthatwork.org.uk The service is available in community languages on request.
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CASE STUDY “I suffered a ‘breakdown’ 3 years ago which was caused by stress at work and I was diagnosed with severe depression. The Health at Work Advisor from the Better Health at Work Team has principally rebuilt my confidence and given me hope. She has given practical and credible advice and support on employment issues, legal issues, benefit and support issues and helped to reconnect with the world. She has helped me set realistic objectives and let me set long term goals. If you recognise the symptoms of stress I strongly recommend you to contact the Better Health at Work team for a free and confidential discussion - if I had contacted this service before the breakdown, I and my family may not have had to experience all the consequent pain, suffering and financial hardship”
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Section 2 - programmes and services for patients
Worklink What is it? Worklink is an employment service for people with disabilities or health related problems. There is a team of specialist employment advisors who can offer impartial advice and information on training and employment opportunities. The advisors can assist with application forms and interview techniques, arrange work placements with local employers, signpost to relevant training courses and offer ongoing support. A range of programmes are offered for people who have been on incapacity benefit for a period of time, or who may need assistance to return to work.
Who is it aimed at? Worklink is aimed at people with disabilities or health related problems that are in a position to find employment.
Where does this programme operate? The service operates across the whole of Kirklees and has office bases located in Huddersfield, Batley and Dewsbury.
How can you access this service? People can self refer to this service by calling the numbers below. Alternatively, they can be referred from other employment organisations such as Job Centre Plus. GPs and other health professionals can also refer by completing a referral form. This referral form is enclosed in the toolkit.
Where can I find out more? To find out more, please contact 0845 6039740.
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2.25
Worklink
Referral Form
Name and Telephone number of referring staff member and agency (if appropriate) Customer Name:
D.O.B.
Address:
Contact Telephone Number (s)
Post Code: What is their health issue or disability? What is the customer hoping to achieve by being referred to Worklink?
What other agencies/professionals are they working with?
Any other comments?
Signature of Referrer: For office use only EA Comments:
Please return this form to one of the offices below Batley Office Batley Resource Centre 90 Commercial Street Batley WF17 5DS
Dewsbury Office The Walsh Building Town Hall Way Dewsbury WF12 8EE
Tel: 01924 326291
Tel: 01924 325060
Huddersfield Office Unit 5, Silver Court Silver Street Aspley Hudderfield HD5 9AG Tel: 01484 223520
2.26
Primary Prevention Team What is it? A team of Primary Prevention Nurses are based within GP practices in North Kirklees. They systematically screen people at risk of cardiovascular disease, and those with premature heart disease within their family and provide advice regarding risk reduction and appropriate lifestyle changes.
Who is it aimed at? Adults aged 40 – 75 years who are at risk of Coronary Heart Disease.
Where is this programme available? Most of the GP Practices in North Kirklees have a primary prevention nurse attached to their practice. This service is not currently available in Huddersfield.
How can you refer to this programme? The nurses will search for people within practices, but if a GP or Practice Nurse feels a patient could benefit from this service, then they are able to refer to the nurse within the practice. Posters are also displayed in surgeries where the nurses operate so that patients can self refer.
Where can I find out more? For more information on the work of the Primary Prevention Nurses, please contact Brenda Devey; Clinical Lead for Primary Prevention. Brenda.devey@kirkleeschs.nhs.uk Tel: 01924 351508 or 07720 463095
Section 3 - rehabilitation and education programmes
3.1
Secondary Prevention Team What is it? There is a Cardiac Rehabilitation Nurse based within the localities of North Kirklees. They assess and refer people who have suffered an acute cardiac event for cardiac rehabilitation. The team will visit patients at home or in clinical settings and provide secondary prevention of coronary heart disease.
Who is it aimed at? Any individual who has just experienced an acute cardiac event.
Where is this programme available? The cardiac rehabilitation nurse team operate in North Kirklees.
How can you refer to this programme? Health Professionals from both primary care and secondary care can refer to the cardiac rehabilitation nurse team by completing a referral form. A single referral form is currently being developed for use across Kirklees. See contact details for more information.
Where can I find out more? For more information on this service, please contact Brenda Devey, CHD Lead Nurse Mobile No. 07720 463095 Brenda.Devey@kirkleeschs.nhs.uk
3.2
Section 3 - rehabilitation and education programmes
Cardiac Rehabilitation Health Education Programme What is it? Health Education Sessions run each week for anyone with heart disease who would like to know more about their condition and meet other people who live with heart disease. There are guest speakers each week and topics covered include; Stress Management, Eating for your Heart, What happens in Primary Care, How to be an Expert Patient and Incorporating Cardio Pulmonary Resuscitation. A cardiac nurse is present each week to answer any questions.
Who is it aimed at? Anyone with heart disease and their friends and families who live in North Kirklees.
Where is this programme available? This service operates from Dewsbury Health Centre. Sessions are held every Tuesday at 10.30 – 12.00. It is an 8 week rolling programme.
How can you refer to this programme? No referral is necessary and there is no need to make an appointment. People are invited to attend the sessions at their convenience.
Where can I find out more? For more information on this service, please contact the CHD Lead Nurse, Brenda Devey on 01924 351508 or e-mail Brenda.Devey@kirkleeschs.nhs.uk
Section 3 - rehabilitation and education programmes
3.3
Cardiac Rehabilitation Exercise Programme (Dewsbury) What is it? This cardiac rehabilitation exercise programme operates both in the hospital setting and in the community.
Who is it aimed at? Any individual following an acute cardiac event who live in North Kirklees.
Where is this programme available? This service operates from Dewsbury & District Hospital, Whitcliffe Mount Sports Centre, and Batley Baths.
How can you refer to this programme? The cardiac rehabilitation nurse team assess and refer patients for this exercise programme. See contact details below.
Where can I find out more? For more information on this service, please contact: Brenda Devey, Coronary Heart Disease Lead Nurse on 01924 351508, Kirklees Community Healthcare Services, Brenda.Devey@kirkleeschs.nhs.uk Or Caroline Lane, Cardiology Nurse Specialist on 01924 816129. Mid Yorkshire Hospital NHS Trust Caroline.Lane@midyorks.nhs.uk
3.4
Section 3 - rehabilitation and education programmes
Cardiac Rehabilitation Programme (Huddersfield) (Exercise and Education) What is it? This is a comprehensive cardiac rehabilitation programme which has an exercise component and a health education component. The exercise component involves a weekly Tai Chi, and twice weekly Aerobics sessions. The service is run by Cardiac Rehabilitation Nurses and physiotherapists.
Who is it aimed at? Adults over the age of 18 following an acute cardiac event who live in Huddersfield.
Where is this programme available? This service operates from Huddersfield Royal Infirmary and also uses St. Luke’s Hospital and a venue in the community.
How can you refer to this programme? The cardiac rehabilitation nurse team normally operates as a secondary prevention service, however they accept referrals from GPs and Practice Nurses for patients following a cardiac attack and the team assess and refer patients for most suitable programme. See contact details below.
Where can I find out more? For more information on this service, please contact the Cardiac Rehabilitation Sister/Team Leader, Michelle Cowgill on 01484 342174 or e-mail Michelle.Cowgill@cht.nhs.uk
Section 3 - rehabilitation and education programmes
3.5
The Heart Failure Service What is it? The Heart Failure Nurse Specialist Service (HFNS) provides services to patients with heart failure and their carers across Kirklees.
Who is it aimed at? The HFNS service aims to support patients and their carers in the community following hospital admission with a primary diagnosis of heart failure. It also aims to help manage patients referred by the primary care team whose heart failure has become unstable, in order to try and prevent admission.
Where is the programme available? The heart failure nurse service is available across Kirklees.
How can you refer to this programme? All patients referred to the Heart Failure Nurse Specialist service will have had their diagnosis of heart failure confirmed by Echocardiogram or Angiogram. Referral can be made by completing the referral forms but if in doubt please contact the heart failure nurses. If you are unsure if the patient fulfils the criteria for referral please contact the HFNS and discuss the individual case.
Where can I find out more? Anne Molloy is the heart failure nurse based in the south at Fartown Health Centre. Contact No. 07507595081. anne.molloy@kirkleeschs.nhs.uk David Fearnley is the heart failure nurse specialist based in the North at Dewsbury Health Centre. Contact No 07773364028. david.fearnley@kirkleeschs.nhs.uk
3.6
Section 3 - rehabilitation and education programmes
Referral to Kirklees Community Heart Failure Nurse Referral Criteria In order for patients to be accepted into the service they must have a confirmed diagnosis of heart failure made by one of the following methods:
Echo
Angiogram
Myoview scan
Plus 1 or more of the following; • 1 or more hospital admissions with heart failure including A&E attendances
• Poor understanding of heart failure and or drug therapies
• Significant impairment in 1 or more major activities of daily living
• Risk of readmission
• Frequent attendances at GP practice
• Poor symptom control despite optimising heart failure medication
Hospital Number
GP
DOB
Consultant
Forename
Patient Tel No
Surname
Diagnosis
Address/ Telephone No
Past medical history
Presenting history
Section 3 - rehabilitation and education programmes
3.7
Medications Please attach most up to date list including allergies and adverse drug reactions
Social history
Additional Information / Reason for Referral Please attach any relevant clinic letters
Referring Dr / Nurse................................................................................................................................. Signature................................................................................................................................................. ECG Attached
Echo Attached
Please fax your referral to one of the following numbers: For Huddersfield GPs 01484 347811, FAO Anne Molloy, Tel 07507595081 For Dewsbury GPs 01924 463281, FAO David Fearnley, Tel 07773364028
Please don’t hesitate to ring the Heart Failure Nurse Specialist if you wish to discuss the patient prior to completing the referral form
3.8
Kirklees Community Healthcare Services is responsible for providing NHS services in Kirklees and is part of Kirklees Primary Care Trust.
(Diabetes Education and Self Management for Ongoing and Newly Diagnosed) What is it? DESMOND is a structured group education programme for people newly diagnosed with Type 2 diabetes. The programme has a sound theoretical and philosophical basis designed to empower people to self manage their own diabetes. Each programme is run in a group setting, consisting of not more than 10 people, accompanied, if they so choose, by a partner, family member, or friend. The programme in Kirklees is run as 2 half-day courses. The DESMOND programme is facilitated by two health care professionals who have been formally trained to deliver the programme in the community.
Who is it aimed at? Adults who are newly or recently diagnosed with Type 2 Diabetes.
Where is this service available? The DESMOND education programme is provided in various venues across Kirklees. Sessions are currently provided in Batley, Dewsbury & Cleckheaton health centres.
How can you refer to this programme? To refer someone to DESMOND, GPs or other health professional in primary care need to complete the referral form and the biomedical data collection form. The forms need to be returned to the network coordinator for the relevant area (See enclosed copy)
Where can I find out more? For more information please contact Gillian Longbottom Diabetic Project Co-ordinator Gillian.longbottom@kirklees.nhs.uk Tel: 01484 466049 The DESMOND website is www.desmond-project.org.uk
Section 3 - rehabilitation and education programmes
3.9
(Diabetes Education and Self Management for Ongoing and Newly Diagnosed)
Referral form Patient details Surname:............................................................. First name:..................................................................... Address:.................................................................................................................................................... ................................................................................................................................................................. ............................................................................Post Code:..................................................................... Telephone No:............................................................................................................................................ Date of Birth:............................................................................................................................................. Sex:...........................................................................................................................................................
Date of diagnosis .................................................................................................................................................................
Practice details GP Name:.................................................................................................................................................. PN Name:.................................................................................................................................................. Address:.................................................................................................................................................... ................................................................................................................................................................. ............................................................................Post Code:..................................................................... Telephone No:............................................................................................................................................
Date of completion of form ................................................................................................................................................................. PLEASE ATTACH BIOMEDICAL DATA FOR PATIENT TO THIS FORM IF AVAILABLE OR AS SOON AS POSSIBLE AFTER RESULTS HAVE BEEN RECEIVED (It is crucial these results are available prior to the patient commencing the DESMOND programme).
Return to: Gillian Longbottom, Diabetes Project Co-ordinator, NHS Kirklees, St Luke’s House, Blackmoorfoot Road, Crosland Moor, Huddersfield, HD4 5RH
3.10
Section 3 - rehabilitation and education programmes
DESMOND Patient Data Collection Form Patient Name:
Date measure taken (dd/mm/yy): HbA1c (%):
BP (mmHg): Systolic
Total Cholesterol (mmol/l):
BP (mmHg): Diastolic
HDL (mmol/l):
Weight (kg): without shoes
LDL (mmol/l):
Height (cm): without shoes
Triglyceride (mmol/l):
Waist (cm):
Mark ‘X’ in the box if NOT fasting
Is the patient currently taking one of the following? Yes Medication Type
Tick (�)
No
If yes, please give details
Name of Medication
Dose
ACE – Inhibitor Alpha Blocker ARB Beta-blockers Calcium Channel Blockers Diuretics/Thiazides Aspirin Lipid Lowering – Statin Lipid Lowering – Fibrate Metformin Sulphonylurea Glitazone Prandial Glucose Regulator Steroids Please state whether Steroids are oral, injected or inhaled:
Oral
Injected
Inhaled
Please return this form to your local DESMOND Team:
© The DESMOND Collaborative 2006
3.11
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Community Rehabilitation What is it? The Community Rehabilitation Team provides a multi-disciplinary community rehabilitation service that works in partnership with existing services and other agencies. They assess and advise and provide multi-disciplinary rehabilitation for adults with complex physical disabilities. The team aims to • Reduce the need to readmission to hospital following discharge. • Enable people to remain living independently at home for as long as possible. • Prevent hospital admission for problems that could be managed in the community. • Enable people to reach their optimal functioning irrespective of their circumstances, environment or diagnosis. • Encourage clients to take an active role in managing their condition. The team is multidisciplinary and consists of dieticians, rehabilitation assistants, occupational therapists, physiotherapists and speech and language therapists. They work in partnership with clients and their carer(s) to address their agreed rehabilitation goals and provide education and support to clients, carers and primary health care workers.
Who is it aimed at? Clients can be referred who: • Are 16 years and above • Agree to be referred • Have specific rehabilitation goals and would benefit from a multi-disciplinary approach • Can make functional changes through rehabilitation to improve the quality of life • Cannot have their rehabilitation needs met by existing services • Will benefit from rehabilitation in the community • Are medically stable • Have had an episode of change that has resulted in significant difference in their functional ability
Section 3 - rehabilitation and education programmes
3.13
Where is this service available? This service operates in Birkenshaw, Gomersal, Cleckheaton, Mirfield, Batley, Dewsbury, Heckmondwike and Liversedge. The service also operates across Huddersfield.
How can you refer to this programme? Referrals are accepted from GPs, hospital and community nurses, social services, allied health professionals and hospital consultants. You must complete a form to make a referral and verbal referrals must be followed up by a completed form. This referral form is enclosed in the toolkit (Page 3.15 north Kirklees, page 3.17 - Huddersfield).
Where can I find out more? For more information, contact the Community rehabilitation Team at: Eddercliffe Centre Bradford Road Liversedge WF15 6LT Tel: 01924 351563
Barton Rehabilitation Centre St Luke’s Hospital Blackmoorfoot Road Huddersfield HD4 5RQ
Fax: 01274 869206
Tel: 01484 343448 / 343566 Fax: 01484 343204
3.14
Section 3 - rehabilitation and education programmes
NB: Form will be returned if incomplete Version 2 Sep 08
Eddercliffe Centre
Single point of referral to rehabilitation services Patient details
Male
Female
Name ............................................................................................................. Address .......................................................................................................... ....................................................................................................................... Tel................................................................................................................... NHS number ...................................................................................................
Date of birth................................................
Next of kin/carer Name............................................................. Relationship ...................................................
GP details
Address .........................................................
Name..............................................................................................................
......................................................................
Address ..........................................................................................................
......................................................................
Tel...................................................................................................................
Contact number ............................................
Consultant (if known) .....................................................................................
Has this referral been discussed with the patient and agreed?
Yes
No
Communication issues e.g. Need an interpreter or carer/advocate? ......................................................................................... ................................................................................................................................................................................................ Patient lives alone?
Yes
No
Contact details for patient if currently different from above ..................................................................................................... ................................................................................................................................................................................................
Reason for referral - new difficulties, aims of referral ................................................................................................................................................................................................ ................................................................................................................................................................................................ ................................................................................................................................................................................................
New presenting problems Please indicate which of the following areas the patient is having recent difficulties with. Mobility Feeding / swallowing Nutrition
Transfers Communication Pain
Positioning Work/ leisure
ADLs Cognition / perception
Please elaborate on the main problems / presenting conditions indicated above ................................................................................................................................................................................................ ................................................................................................................................................................................................ ................................................................................................................................................................................................ ................................................................................................................................................................................................
3.15
Falls Risk of falls Falls in the last six months .................................................................................................................................................. Requires specialist assessment of unexplained falls .............................................................................................................
Diagnosis ................................................................................................. Date (if known).......................................... Past medical history ................................................................................................................................................................................................ ................................................................................................................................................................................................ ................................................................................................................................................................................................
Medication ................................................................................................................................................................................................ ................................................................................................................................................................................................ ................................................................................................................................................................................................
Environmental (please elaborate on each of the following) Stairs ...................................................................................................................................................................................... ................................................................................................................................................................................................ Access..................................................................................................................................................................................... ................................................................................................................................................................................................ ................................................................................................................................................................................................ Moving and handling (please indicate any risks to client, staff, carers).................................................................................. ................................................................................................................................................................................................ ................................................................................................................................................................................................ Please highlight any known risk areas for staff or patient .............................................................................................. ................................................................................................................................................................................................ ................................................................................................................................................................................................ Has the patient been involved with any of the following services in the past? Jubilee
Westmoor
Other rehab team
Intermediate care team
Community OT
Speech and language therapy
Dietetics
Physiotherapy
Other
Is the patient able to make their own way to the Eddercliffe Centre for assessment?
Yes
No
Referrer details (please print) Name............................................................................................... Job title ......................................................................... Address ................................................................................................................................................................................... Contact number .............................................................................. Date of referral..............................................................
Please return all completed forms to: Single Point of Access: Community Rehabilitation, Jubilee Rehabilitation and Domiciliary Physiotherapy Eddercliffe Centre, Bradford Road, Liversedge WF15 6LT Tel: 01924 351544 Fax: 01274 869204
In order to prioritise this referral correctly, we need this form to be completed as fully as possible.
REF: LC2225 V2 Sep08
Date Received
Appointment made
In Person
By Phone
By Post
1st appointment
Time
Date
Calderdale and Huddersfield NHS Foundation Trust
Clinical Therapy and Rehabilitation Referral form Name
Referred by
Primary Care Trust
Consultant
Sex: Male / Female
Postcode
Hospital No
D.O.B.
GP
Date of referral
Telephone
Diagnosis / presenting symptoms
Other information (Drugs, Reason for Referral etc.)
Address
Urgent
Priority
Non urgent
Duration of symptoms
Is there any reason to suspect a home visit by a lone team member may be unsafe Yes / No
Has the individual given consent to this referral? Yes / No At work
Unemployed
Interpreter required? Yes No
Off sick
Retired
Language
Hearing loss?
Yes No
Service required N.B. one service per form Rehabilitation Services
Barton Rehabilitation Centre
Parkinson’s Disease Nurse Specialist
Department of Foot Health
Clinic
Home Visit
Nutrition & Dietetics
Community Rehabilitation Team
Site required: SLH / HRI / Kirkburton / Elmwood / Slaithwaite / Fartown / Skelmanthorpe Dietary Advice: ........................................................................................................................... Biochemistry: ..............................................................................................................................
Occupational Therapy
Out-patient
Community
Children’s Services
Physiotherapy
Occupational Therapy
Speech & Language
School ........................................................................................................................................ Physiotherapy
Out-patient
Community Physiotherapy
Cardiac Rehab Speech & Language Therapy Transport required: NB: Barton Rehabilitation Centre / Physiotherapy / Occupational Therapy / Dietetics HRI / SLH / Speech & Language Therapy SLH ONLY Saloon Car
Single Escort
Double Escort
Tail Lift Vehicle
3.17
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Long Term Conditions Team What is it? The long term conditions team provide support for people with complex long term conditions. The team is made up of Case Managers and Community Matrons. Case Managers are social workers, community matrons or nurses who work with individuals who have complex multiple long term conditions and intense needs and whose care requires coordination. The team provides a full case management service for patients who are very high intensity users of secondary care services. With support from the long term conditions team, patients are able to remain in the home for longer, having more choice about their future. By using the case management approach, the team can: • Combine high level assessment of physical, mental and social care needs • Review medication • Provide Clinical care and health promoting interventions • Co-ordinate inputs from other agencies • Teach and educate patients and their carers regarding complications or crisis • Enable patients to make choices about their needs. The benefits to case management are: • Helps to prevent unnecessary admissions to hospital • Reduces length of stay of necessary hospital admissions • Improves outcomes for patients • Integrates all elements of care • Improves quality of life for patients • Helps patients and their families plan for the future • Increases choice for patients • Enables patients to remain in their homes and communities • Improves end of life care.
Who is it aimed at? People who have one or more long term condition, with complex needs, and who are high intensity users of secondary care services.
Where is this service available? Community Matrons and Case Managers work across Kirklees. They have offices in the Eddercliffe Centre in Liversedge and Fartown Health Centre in Huddersfield, but are based in practice units with district nurses, practice nurses, and GPs.
Section 3 - rehabilitation and education programmes
3.19
How can you refer to this programme? Any health or social care professional can refer to this service by completing the enclosed referral form, or writing a letter with the required information. This referral form is enclosed in the toolkit. (Page 3.21) Referrals should be posted or faxed to the relevant address (either Huddersfield or Liversedge) which are set out below.
Where can I find out more? Contact the Long Term Conditions teams in the area: Long Term Conditions Team Eddercliffe Centre Bradford Road Liversedge WF15 6LT Tel: 01924 351582
Long Term Conditions Team Fartown Health Centre Spaines Road Fartown Huddersfield HD2 2QA
Fax: 01274 869206
Tel: 01484 347816 Fax: 01484 347864
3.20
Section 3 - rehabilitation and education programmes
For Yourcare office use only Diagnosis (LTC’s)
Date received
Notes
Priority
Date allocated
Long Term Conditions (LTC) referral form In order to correctly prioritise this referral, we need this form to be completed as fully as possible. If you have any queries please do not hesitate to contact us.
Checklist referral criteria Is the patient over 18 years old?
With one or more long term conditions?
With more than one emergency admission due to their LTC? And is on four or more prescribed medications? (not including topical preparations)
Client details Title . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
First name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..............................................
Surname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
..............................................
Sex
Male
Female . . . . . . . . . . . .
Post code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DOB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
GP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Consultant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NHS number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Unit number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Next of kin Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Relationship to client . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Communication First language (specify). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Visual problems
Yes
No
Hearing
Long term medical conditions . . . . . . . . . . . .
Yes
Interpreter required No
Communication
Yes
No
Yes
No
Other presenting medical conditions
.............................................
..............................................
.............................................
..............................................
.............................................
..............................................
Social Services Known to Social Services Lives alone
Yes
Yes
No
No
Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name of social worker . . . . . . . . . . . . . . . . . . . . . . . . . . . Lives with partner/carer
Yes
No
Tel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Section 2 - services for patients
3.21
Social support (Please tick which services apply and indicate how often the service is received). Home care
Bath nurse
Family
Day care
Physio
Macmillan nurse
District nurse
CPN
Specialist nurse
Community rehab team
Social worker
Care phone
Admission details Number of admissions in last 12 months with long term conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Details of admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .............................................................................................. .............................................................................................. ..............................................................................................
Current medication ............................................................................................... ............................................................................................... ............................................................................................... ............................................................................................... ...............................................................................................
Please highlight any known risk areas to staff for home visits: ............................................................................................... ...............................................................................................
Referrer details Title . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Designation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date of referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Signed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please note any further information you think might be relevant below: ............................................................................................... ...............................................................................................
Any queries regarding this referral please contact: Long Term Conditions team, Eddercliffe Centre, Bradford Road, Liversedge WF15 6LT. Telephone: 01924 351582 Fax: 01274 869206
Ref: MH1840
Long Term Conditions Team, Fartown Health Centre, Spaines Road, Fartown, Huddersfield HD2 2QA. Tel: 01484 347816 Fax: 01484 347864
Continence Service What is it? The continence service promotes continence and manages incontinence. Anybody with a bowel, bladder or prolapse problem is welcome to have a full assessment with the team. The continence service is a specialist nurse led service that holds clinics at various health centres across Kirklees. Home visits may be made if appropriate. The continence service aims to cure, improve or promote self management of continence problems. The continence service is proactive offering comprehensive assessment, management and treatment to manage and improve all issues relating to bladder, bowel and prolapse problems.
Who is it aimed at? Anybody over the age of 4 years who is incontinent or suffers with excessive bladder or bowel problems.
Where is this programme available? Clinics are held at health centres across Kirklees each week.
How can you refer to this programme? The continence service has an open referral system and accepts referrals from individuals themselves, carers, health professionals and the independent sector. Contact the Continence Nurse Specialist for more advice, information or a clinic appointment on 01924 351568 (Liversedge) or 01484 347764 (Huddersfield).
Where can I find out more? For more information, please contact: Continence Service The Eddercliffe Centre Bradford Road Liversedge WF15 6LP Tel: 01924 351568
Continence Service Fartown Health Centre Spaines Road Fartown Huddersfield HD2 2AQ Tel: 01484 347764
Section 3 - rehabilitation and education programmes
3.23
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Pulmonary Rehabilitation What is it? Pulmonary Rehabilitation is an eight week programme of exercise and education designed specifically for people with breathing problems. The programme aims to help the patient take control of their condition by giving them the skills and confidence to approach life positively. It is provided by a range of staff, including respiratory nurse specialists, dieticians, physiotherapists and physical activity advisors.
Who is it aimed at? The programme is for patients with Chronic Obstructive Pulmonary Disease (COPD) or for patients who are awaiting a lung transplant.
Where is this programme available? The programme currently operates within the north side of Kirklees, rotating between Cleckheaton, Dewsbury and Batley Health Centres. The pulmonary rehabilitation programme will be rolled out across the rest of Kirklees in 2009.
How can you refer to this programme? Referral is via the GP or other health professional (See Referral Pathway). Patient consent is required to generate an assessment by the Pulmonary Rehabilitation team to make sure the programme is suitable for the patient. A sample of the referral form and patient information leaflet is included in this toolkit, however Referral Forms must be obtained from the Pulmonary Rehabilitation Team Secretary as the forms are triplicate print and photocopies cannot be accepted. Please call 01924 512075 for referral forms.
Where can I find out more? For more information about the programme, please contact the Respiratory Nurse Specialist Team, based at Dewsbury & District Hospital on 01924 512156 / 512075.
Section 3 - rehabilitation and education programmes
3.25
Mid Yorkshire Hospitals NHS Trust and Kirklees Primary Care Trust
Pulmonary Rehabilitation
Outside Agency ie occupational therapist, dietitian
If you would like more information contact the Respiratory Nurse Specialist Team on 01924 512156 Healthcare professional
General Practitioner
Exclusion Criteria Discharge from hospital within last 4 weeks, uncontrolled blood pressure, uncontrolled angina, heart attack or stroke or an acute neurological incident within last 3 months, pulmonary embolism, deep vein thrombosis (within the last 3 months not receiving treatment), surgery within 6 weeks. An acute / current psychotic episode, alcoholism affecting life. Flare up of rheumatoid arthritis. Attending other rehabilitation.
YES
MRC 1 and 2 consider mainstream PALS referral.
Other respiratory conditions ie asthma, fibrosing alveolitis, bronchiectasis.
Not referred. GP decides on alternative approach
Inclusion Criteria
Refer to mainstream PALS
NO
Confirmed COPD (with spirometry) MRC 3, 4, and 5 Maximise medication as per COPD Guidelines.
Suitable Start PALS programme Not suitable Refer to RSN to establish individual need
YES
In- patient / Out-patient non-respiratory
Out-patient respiratory and primary care
Arrange OPD with Respiratory Nurse Specialist (RSN) or Respiratory Consultant or Physiotherapist. Provide pulmonary rehab leaflet.
Referral sent to pulmonary rehabilitation administrator. Seen by RSN.
Not Suitable Letter sent to patient who advised to see GP for alternative approach (Referrer/ GP sent copy).
Suitable Letter sent to invite patient for assessment (Referrer/ GP sent copy).
Not Suitable
Attends for assessment
Suitable Attend and complete pulmonary rehab program. Undertakes post assessment. Copy of outcomes sent to GP. Program completed. Patient attends pulmonary PALS.
Program completed. Client attends mainstream PALS. * PALS = Practice Activity and Leisure Scheme
3.26
Section 3 - rehabilitation and education programmes
Respiratory Nurse Specialist Team Kirklees Primary Care Trust / Mid Yorkshire Hospitals NHS Trust Tel: 01924 512156
www.kirklees.nhs.uk
© Kirklees Primary Care Trust
Date of publication: Sep 2008
Reference: mh1753
This information can be made available in other formats including large print and other languages.
For further copies of this leaflet contact the communications team, Kirklees PCT on 01484 466044.
Breathe Easy Dewsbury Tel: 01924 400116
The British Lung Foundation Tel: 0845 8505020 Email: enquiries@blf-uk.org
You can speak to your health professional or contact:
How can I find out more about COPD or respiratory disease?
• had surgery in the last six weeks
• had a pulmonary embolus (blood clot in your lung) or a deep vein thrombosis (blood clot in your leg) within the last three months unless you are receiving treatment
• had a heart attack within the last three months
• uncontrolled angina
• been discharged from hospital in the last four weeks
• uncontrolled blood pressure
The programme will not be suitable for you at the moment if you have:
Is the programme suitable for everybody?
A guide for patients
Pulmonary Rehabilitation
Who runs the course?
• A doctor
• Expert patient tutors
• An occupational therapist
• A psychologist
• A physiotherapist
The programme will be provided by:
• Respiratory nurse specialists
• A physical activity advisor
Do you have Chronic Obstructive Pulmonary Disease (COPD) or a respiratory disease?
• A dietician
Are you too breathless to go shopping or do housework?
Do you wish you could do more?
What will happen at the course?
Do you feel isolated?
Are you frightened you will get out of breath if you do too much?
If you have answered yes to any of these questions, pulmonary rehabilitation may be suitable for you. What is pulmonary rehabilitation? Pulmonary rehabilitation is a six week programme of exercise and education designed specifically for people with breathing problems. Before the programme you will have to be assessed to make sure this programme is suitable for you. You will also have a follow up assessment on completion of the programme. The programme aims to help you take control of your condition by giving you the skills and confidence to approach life positively. It is not a cure but might help you feel better, more in control and increase your levels of activity.
How often do I have to attend? The programme runs twice a week with one hour of exercise and one to two hours of discussion to help you manage your condition. You will be encouraged to put what you have learnt into practice.
Speak to your GP, practice nurse, hospital nurse or doctor or any other healthcare professional. They will refer you for an assessment to make sure the programme is suitable for you.
How do I get on a programme?
Comfortable clothing and flat shoes.
What should I wear?
Please bring your blue inhaler with you to each session.
All we ask is that you commit to attending and participate in the programme.
There will be approximately 12 people with similar problems on the course.
Courses usually take place in a local health centre or another designated site but we will tell you the exact location before the programme starts. The sessions are free, informal and friendly.
Section 3 - rehabilitation and education programmes
3.28
Pulmonary Rehabilitation Referral Form Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Date Of Birth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Telephone Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.........................................................
GP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.........................................................
GP telephone number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inclusion Criteria : Chronic Obstructive Pulmonary Disease (✓ tick as appropriate) Spirometry within the last year
Yes
Mild FEV1% > 50%
No
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Copy enclosed FVC
Yes FEV1
No
MRC Score
Grade 1 2 3 4 5
FEV1%
Severe FEV1% <30
Moderate FEV1% 30 â&#x20AC;&#x201C; 50%
Medical Research Council Dyspnoea Score Chart (MRC) Not troubled by breathlessness except on strenuous exercise Short of breath when hurrying or walking up a slight hill Walks slower than contemporise on level ground because of breathlessness, or has to stop for breath when walking at own pace Stops for breath after walking about 100m or after a few minutes on level ground Too breathless to leave the house, or breathless when dressing or undressing
Exclusion Criteria (tick any relevant) Discharged from hospital within last four weeks Cerebral vascular accident/ neurological incident within last three months
Uncontrolled angina
Heart attack within last three months
Pulmonary embolus/Deep vein thrombosis within the last 3 months not receiving treatment
Surgery within six weeks
Acute/ current psychotic episode *
Alcoholism affecting life
Flare up of rheumatoid arthritis
Attending another other rehabilitation programme
MRC 1+2 consider referral to main stream PALS
* further details required
02 saturations % on air. . . . . . . . . . . . . . . . . . . . . . . . . . Smoking history
Current smoker
Long term oxygen
Yes
No
Prescribed dose . . . . . . . . . . . . . . . . . . . .
Number smoked per day. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ex smoker
Number of years smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Never smoked
Attended Pulmonary Rehabilitation programme: Where and when?
Current medication
Sample only. Please call 01924 512075 for referral forms. Discontinued respiratory treatments
Rationale
Past medical history Current psychological well being Patient objective / expectation Patient consent for referral to programme Referrers signature . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Print name . . . . . . . . . . . . . . . . . . . . . . . . . .
Patient signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Preferred site
Batley
Patient provided with rehabilitation leaflet
Yes
No
Job title . . . . . . . . . . . . . . . . . . . . . . .
Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cleckheaton
Please return white copy to: The Pulmonary Rehabilitation Secretary, Respiratory Unit, Dewsbury & District Hospital, Halifax Road, Dewsbury, WF13 4HS
Dewsbury
Any
Blue copy - for patient notes Pink copy - for patient
Section 3 - rehabilitation and education programmes
3.29
Gateway Workers What is it? Gateway workers offer one to one support to people, particularly those with low level social care needs. They give health and social care advice about health and council services, voluntary groups and community groups. The aim is to help people stay independent, promoting health and well-being, and reducing peopleâ&#x20AC;&#x2122;s feelings of loneliness and isolation. The service is run by Kirklees Adult Services.
What can Gateway workers do? When a gateway worker receives a referral, they visit the client in their home, and discuss the things they might need help with or like to do. The worker will adapt their way of working to suit the individual. The gateway worker will organise services around the individuals needs, and introduce the individual to appropriate services. They will continue to support the individual for a limited time to ensure the suitability of the service provided.
Who is it aimed at? The Gateway workers work with people aged 18 years and above, supporting older people, people with learning disabilities, people with mental health needs, physical and sensory disabilities, or people who may be socially isolated. Support is also given to carers.
Where does this programme operate? There are Gateway Workers working across the whole of Kirklees.
How can you refer to this programme? Health professionals can refer patients to Gateway Workers by calling Gateway to Care on: 01484 223000. Patients can also self refer using the same telephone number above.
Section 4 - other supportive services
4.1
Kirklees Information (KInfo) There are a number of support groups in operation throughout Kirklees, which offer support to people suffering with specific health conditions. On behalf of Kirklees Council, Kirklees Information maintains a directory of local voluntary groups, community-based organisations, clubs, and societies. This local information on many of the support groups in operation can be accessed via: http://www.kirklees.gov.uk/community/localorgs/localorgs.asp For enquiries about the local organisations database please contact: Kirklees Information Huddersfield Library Princess Alexandra Walk Huddersfield HD1 2SU Tel: 01484 221963 Fax: 01484 221952 Email: kinfo@kirklees.gov.uk This toolkit outlines some of the support groups for a number of long-term health conditions.
4.2
Section 4 - other supportive services
Support 2 Recovery S2R (DASH & CMH) What is it? Support 2 Recovery provides services for people experienceing mental health problems. There are three services: Out of Hours, Health and Wellbeing and Community Links Day Services. The services offer facilitated self help, skills development and social inclusion based on the Recvoery model.
Who is it aimed at? Adults suffering from mental health problems.
Where does this group operate? Support 2 Recovery operates from 1st floor, Revenue Chambers, St Peterâ&#x20AC;&#x2122;s Street, Huddersfield and 9 Wellington Road, Dewsbury.
How can you refer to this group? To refer someone to S2R, the health professional or GP can complete a referral from with the patient. This referral form is enclosed in the toolkit (page 4.4).
Where can I find out more? For more information contact: S2R 1st floor, Revenue Chambers St Peterâ&#x20AC;&#x2122;s Street Huddersfield HD1 1DL Email: contact@s2r.org.uk Tel: 01484 539531
Section 4 - other supportive services
4.3
DASH at S2R
REFERRAL FORM
S2R provides services to Kirklees residents, 18+ experiencing depression or anxiety Name........................................................................... DOB...................................................................... Address .................................................................................................................................................... ................................................................................... Postcode............................................................... Ethnicity.......................................................................
Male
Female
Telephone.................................................................... Mobile.................................................................. Referrer....................................................................... Telephone............................................................. In order for us to effectively support people moving towards recovery, we request referrers provide details of the care plan (please attach a copy). CPN/contact for care plan............................................................... Consultant.......................................... GP ................................................. Practice............................................... Tel............................................ Mental health details/reason for referral..................................................................................................... ................................................................................................................................................................. ................................................................................................................................................................. Is attendance at DASH part of the care plan? CPA
Standard
Enhanced
Yes
Not on CPA
No
Section 117:
Are you aware of anything which may suggest any risk to individuals or others?
Yes
No
Yes
No
If Yes, please give details........................................................................................................................... ................................................................................................................................................................. NB We are unable to offer a service to people with high risks or challenging behaviour Any other relevant information eg: diabetes, angina................................................................................. ................................................................................................................................................................ What services do you feel would be most useful at this time? (please circle) Self Help Workshops
Relaxation
Social Confidence
Employment/Training Advice
Counselling (please note: there is usually a high waiting list)
Other (please give details)........................................................................................................................ ................................................................................................................................................................ Please tell us if you require feedback for this referral eg if attended, frequency of attendance ................................................................................................................................................................ ................................................................................................................................................................ Signed (referrer)........................................................................... Date..................................................... I would like to visit and find out more. (You are welcome to come with your CPN, or with a friend. If there is no one you can ask, please tell us and we will try to help.) Signed...................................................................................................................................................... S2R, 1st Floor, Revenue Chambers, St. Peterâ&#x20AC;&#x2122;s St, Huddersfield HD1 1DL Tel: 539531 / 537453
4.4
Batley Self Help Depression Group What is it? Batley Self Help Depression is a registered charity, supporting people with depression throughout north Kirklees. Weekly sessions are held, which include talking therapy, living with loss group, art and writing groups, evening group and workshops i.e.: anger management, self confidence and self esteem. We also offer low cost open ended one to one counselling.
Who is it aimed at? People suffering from depression and related illness, bereavement or other mental stresses and their carers.
Where does this group operate? The Family Resource Centre in Batley.
How can you refer to this group? No referral is necessary, people can either attend the drop-in session on a Monday 12 - 1 pm or contact the organisation for an initial appointment. Telephone 01924 446413, email enquiries@batleyselfhelp.org.uk or visit www.batleyselfhelp.org.uk
Where can I find out more? Batley Self Help Depression Group The Batley Family Resource Centre 90 Commercial Street Batley WF17 5DS Tel: 01924 446413 Email: enquiries@batleyselfhelp.org.uk www.batleyselfhelp.org.uk
Section 4 - other supportive services
4.5
Heartline â&#x20AC;&#x201C; Coronary Support Group What is it? Heartline is an established self-support group for cardiac sufferers and their families. Activities include exercise and relaxation classes, indoor and outdoor bowling, home visiting, cardiac resuscitation training, leisure walking and swimming, with monthly social evenings.
Who is it aimed at? People who suffer with cardiac problems and their families.
Where does this group operate? Lindley Liberal Club, 36 Occupation Road, Lindley, Huddersfield, HD3 3EQ The meetings take place on the 1st Tuesday of the month at 7.15pm (for 7.30pm).
How can you refer to this group? No referral is necessary; people are simply invited to join the group and are invited to take someone along for support if they choose to.
Where can I find out more? For more information please contact Peter Bower, 2 Oakdale Crescent, Lindley, Huddersfield, HD3 3WE. Telephone 01484 642664 pnebower@btinternet.com
4.6
Section 4 - other supportive services
Heartbeat â&#x20AC;&#x201C; Coronary Support Group What is it? Heartbeat is a coronary support group, which provides support and information for people with heart disease, and their family and friends. The group has a very informal atmosphere, and everyone is welcome to attend.
Who is it aimed at? People with heart disease, and their family and friends.
Where does this group operate? The meetings take place at the Salvation Army, Bradford Road, Batley on the 1st Tuesday of every month at 7.30pm.
How can you refer to this group? No referral is necessary; people are simply invited to join the group and are invited to take someone along for support if they choose to.
Where can I find out more? For more information please contact Gary Webster, 2 Boundary Terrace, Cresswell Lane, Moorend, Dewsbury, WF13 4PN. Telephone 01924 409519 E-mail enquiries to Ian Riley (Secretary): ianfriley@talktalk.net
Section 4 - other supportive services
4.7
Cardiac Rehabilitation Group What is it? An exercise programme developed for people recovering from a heart attack, open heart surgery or similar. The group promotes two activities: A monthly meeting on the first Tuesday of every month. The meetings start at 7.30pm with a speaker from 8.00-9.00 where the meeting closes. The other activity is the weekly exercise class held every Tuesday afternoon from 1.30 â&#x20AC;&#x201C; 2.30pm at Batley Baths. The support group also organises annual trips and members are also invited to visit other local groups and quizzes.
Who is it aimed at? People recovering from a heart attack, open heart surgery or similar. Other people are welcome.
Where does this programme operate? The monthly meetings are held at the Salvation Army on Bradford Road in Batley. The weekly exercise class is held at Batley Baths on Cambridge Street.
How can you refer to this scheme? No referral is necessary; people are simply invited to join the group and are invited to take someone along for support if they choose to.
Where can I find out more? For more information please contact Ian Riley, 2 Harefield Drive, Batley, WF17 0PQ. Telephone 01924 472137; Mobile 07910053096 E-mail enquiries to Ian Riley (Secretary): ianfriley@talktalk.net
4.8
Section 4 - other supportive services
Diabetes Support Group What is it? A voluntary support group for people with Diabetes and their carers. The Group is run by Diabetics, for Diabetics. In addition to a lot of support from the group, there are talks on various topics in the meetings, and information about diabetes is also provided.
Who is it aimed at? People of all ages with diabetes and carers of people with diabetes.
Where does this programme operate? Huddersfield: The group meets at Huddersfield Methodist Mission, Lord Street Huddersfield. Bi monthly meetings take place on the 4th Tuesday in the month from 6.30pm until 8.30pm.
North Kirklees: The group meets on the last Tuesday of the month, 7 - 9pm at the Oakwell Centre, Dewsbury and District Hospital.
How can you refer to this scheme? No referral is necessary; people are simply invited to join the group and are invited to take someone along for support if they choose to.
Where can I find out more? Huddersfield: For more information please contact a committee member. Chair:
Val Wilson
Tel: 01484 539243.
Treasurer:
Gill Oates
Tel: 01484 718071
North Kirklees: Contact Sandra Watts, Treasurer on 01924 466626.
Section 4 - other supportive services
4.9
The Nerve Centre What is it? The Nerve Centre is a charity which provides support, practical advice, facilities and services not normally provided by the statutory authorities to people living with long-term neurological conditions and their carers. The Nerve Centre offers a wide range of complementary therapies, counselling, relaxation, gentle exercise and support to enhance the lives of people living with long term conditions and their carers. A full programme of social and leisure activities are also offered; including art and craft workshops, coffee mornings and reading groups. The neurological nurse specialists from Calderdale and Huddersfield NHS Foundation Trust provide regular drop-in sessions. Occasional workshops are held which focus on adapting to life with a neurological condition. There is a library with a wide range of resources for reference purposes in various formats. Leaflets are available free of charge and assistance is provided in accessing information via the internet.
Who is it aimed at? People who have long-term neurological conditions or people who care for someone with a long-term neurological condition who live in Kirklees.
Where does this programme operate? The Nerve Centre is located on the 2nd Floor, Standard House Half Moon Street Huddersfield HD1 2JF
How can you access this service? People are encouraged to visit the Nerve Centre if they are having difficulty contacting a support organisation for their neurological condition, or if they are interested in membership. To find out more information about the activities programme and volunteering opportunities use the contact details below.
Where can I find out more?
4.10
Tel:
01484 469853
E-mail:
info@thenervecentrekirklees.org.uk
Website:
www.thenervecentrekirklees.org.uk
Section 4 - other supportive services
Breastfeeding Peer Support Programme What is it? The Breastfeeding Peer Support Programme offers support to women who want to breastfeed or who are currently breastfeeding. Breastfeeding Peer Supporters are mums who are enthusiastic about breastfeeding and feel they can give friendly encouragement to others.
Who is it aimed at? The programme is aimed at new mums, or women who are planning to breastfeed. Trained peer supporters will be able to offer confidential support as one mum to another in a warm friendly environment.
Where is this service available? This support programme is currently developing Baby Bistros - drop-in support groups - across Kirklees and aims to have one in every locality. There are also breastfeeding Baby Cafés in north and south Kirklees:
Where
When
Contact
Batley Baby Café, Staincliffe and Healey Children’s Centre, Chestnut Avenue, Staincliffe
Thursdays 11.30 1.30pm
• The Baby Café on 01924 326920
Huddersfield The Baby Café, Woodhouse Children’s Centre, Chestnut Street, Deighton
Mondays 1 - 3 pm
• Una Crozier - Breastfeeding Champion Health Visitor on 01924 351573 or • Caroline Booth - Infant Feeding Specialist on tel: 07887 993561. • The Baby Café on tel: 01484 234234 • Infant Feeding Specialists/advisors:
Claire Fox & Anita Holroyd. Contact HRI switchboard 01484 342000.
Section 4 - other supportive services
4.11
How can you refer to this programme? You can access Breastfeeding Peer Support through local health visitors, PALS and midwives.
How to become a peer supporter The training lasts for 10 weeks. You will need to have breastfed your own children, live in Kirklees and be able to give friendly encouragement. A certificate of completion will be awarded at the end of the training.
Where can I find out more? Contact: • The Patient Advice & Liaison Service (PALS) for more information on how to get in touch with a breastfeeding supporter in the local area on 01484 466172 or 01484 466214 • The local health visitor • Christine Stephen, Community and Volunteer Engagement Officer, NHS Kirklees - 07534 260943 • Jayne Heley, Baby Friendly Initiative Coordinator, NHS Kirklees - 07903 372643
4.12
Section 4 - other supportive services
Kirklees Drug and Alcohol Action Team What is it? Kirklees Drug and Alcohol Action Team are responsible for developing services to address drug and alcohol misuse in Kirklees. The team work within NHS Kirklees and work closely with Kirklees Council and West Yorkshire Police and Probation Service in order to develop these services.
Who is it aimed at? The service aims to offer effective support and treatment for substance users. Services are also prioritising working with service users, through family, offending, employment and housing support, to enable them to play a full part in the community without drug or alcohol dependence. The main aim of Lifeline is to reduce the harm that substance use may cause to people, their families and communities. The National Strategy seeks to provide a long term approach towards - “creating a healthy and confident society increasingly free from the harm caused by the misuse of drugs”. In order to do this four key areas are targeted: • Young people: to help young people resist drug misuse in order to achieve their full potential in society • Communities: to protect our communities from drug-related, anti-social and criminal behavior • Treatment: to enable people with drug problems to overcome them and live healthy and crime free lives • Availability: to stifle the availability of illegal drugs in our community
Where is the service available? There are many services across Kirklees which offer effective support and treatment for drug and alcohol misuse.
Where can I find out more? For more information on services available across Kirklees, please call 01924 351430 or contact: Kirklees Drug and Alcohol Action Team Beckside Court Bradford Road Batley WF17 5PW
Section 4 - other supportive services
4.13
Lifeline What is it? Lifeline Kirklees provides a wide range of services for people experiencing substance problems, including their family, friends and any others who may be affected. They offer confidential access to services including: • Alcohol, stimulant and opiate services • Open access, walk in provision and telephone support • Holistic assessment focussing on the person’s wider needs as well as substance use • Individual care planned and co-ordinated treatment • Advice, guidance and support (24 hours) • 1-1 and group work • A range of counselling and psychosocial interventions
• Access to clinical prescribing treatment • Outreach provision including mobile outreach van • Harm minimisation including needle exchange • Leisure and recreation activities • Access to GP prescribing in local areas • A safe place to learn new skills and keep occupied • Aftercare support and relapse prevention • Access to inpatient treatment and residential rehabilitation
Who is it aimed at? This service is aimed at: • Individuals wanting to find out more information on substances and their effects
• Individuals wishing to move on from a substance using lifestyle into education or employment
• Drug/alcohol users who wish to give up a substance, or who wish to reduce their substance use and/or reduce harm as a result of their substance using lifestyle
• Anyone else affected by another persons substance use • People wanting to access rehabilitation and detoxification
The service meets the needs of a wide range of people from a variety of different backgrounds. There is access to translation and interpretation services if required.
Where does the programme operate? Lifeline is a diverse organisation working in a wide range of settings across Huddersfield and Dewsbury with both young people, adults, parents and carers. They offer a range of open access and appointments based services and strive to provide services that meet a wide range of diverse needs. Out of hours opening times are also offered.
Where can I find out more? Lifeline Kirklees (North)
Lifeline Kirklees (South)
3 Wellington Street Dewsbury WF13 1LY Tel: 01924 438383
Station Street Buildings, Station Street Huddersfield HD1 1LZ Tel: 01484 353333 (24/7)
4.14
Section 4 - other supportive services
Reading and You Scheme (RAYS) What is it? RAYS is a scheme which promotes the benefits of reading and the use of libraries for people experiencing mild to moderate depression, stress, anxiety or social isolation. The scheme promotes the idea of reading as an alternative to drugs, in order to promote mental and physical well-being. The Reading and You Scheme works by putting the user in touch a bibliotherapist who will either see people individually, or in a group setting. The meetings are very informal and can take place in libraries, community centres, and other venues across Kirklees. Arrangements can also be made for the bibliotherapist to visit the patient in their home if there is mobility or social issues. Bookchat is a book club, which provides the opportunity for people to meet and talk about books and good reads. It is for anyone who enjoys reading and talk about books which they have read.
Who is RAYS aimed at? RAYS is for anyone who would like to share their enthusiasm for reading, who may be suffering from stress, mild depression or is feeling isolated and lonely.
Where does this programme operate? RAYS and Bookchat operate in Batley, Dewsbury, Huddersfield and Slaithwaite libraries, and at other venues across Kirklees.
How can you refer to this scheme? People can introduce themselves to the scheme, or be referred by a health or social worker by calling the numbers below.
Where can I find out more? If you have any questions about RAYS please contact: John Duffy at Batley Library john.duffy@kirklees.gov.uk or Tel: 01924 326021 Jo Haslam at Slaithwaite Library jo.haslam@kirklees.gov.uk or Tel: 01484 226364 Lesley Holl at Huddersfield Library lesley.holl@kirklees.gov.uk or Tel: 01484 222500/502
Section 5 - information and resources
5.1
5.2
Section 5 - information and resources
better health …at the library!
Help yourself to
What is it? The ’Help yourself to better heath’ service is offered by NHS Kirklees in partnership with Kirklees Culture and Leisure Services. It follows an adaptation of the ‘Books on Prescription’ scheme and allows GPs, health professionals and other front line staff to signpost patients on to high quality self help books. By directing people to the right information about their long term conditions, and giving them the confidence to use the information, we can help them to feel more in control of their condition and empower them to live independently. There is a selection of good quality books in local libraries which people can access to find information to help them manage their health condition. All of the resources have been approved by health professionals and have an ‘NHS Recommended’ sticker on them, so you can be sure you are signposting to good quality, accurate material. The service includes books on a range of health conditions and psychological problems. Most of the books on the scheme use structured Cognitive Behavioural Therapy (CBT) approaches to help individuals self care. The collection of self help resources in libraries and mobile libraries include: • Resources for long- term health conditions such as diabetes, heart disease, asthma, depression and anxiety and back pain. Resources range from easy reading to workbooks and structured step-by-step self help. • A small collection of CDs in community languages e.g. Urdu, Punjabi, Gujerati. • Books for carers and parents. • Resources that contain accessible language and information at an appropriate level e.g. with clear print and illustrations. • Interactive CD roms and spoken word CDs containing health information in alternative formats.
• ADHD, Autism, Dyslexia & Dyspraxia • Alcohol & Drinking Problems • Anger & Irritability • Angina • Anxiety • Anorexia Nervosa • Arthritis & Rheumatism • Asthma • Bowels • Cancer • Caring • Chronic Fatigue • Depression Books & CDs • Blood Pressure/Hypertension • Diabetes • Heart Health • Managing Sleeplessness • Managing Stress • Obesity • Overcoming Panic • Obsessions & Compulsions • Relationship Problems • Panic Attacks • Pain - overcoming & management • Relaxation • Self Esteem • Sexual Problems • Smoking • Social Anxiety & Shyness • Stress • Weight Problems • Worrying
Section 5 - information and resources
5.3
Who is it aimed at? Adults who may benefit from additional information to help them manage their health condition, or the health condition of someone they care for.
Where does this service operate? The initiative operates across all libraries and mobile libraries in Kirklees. Resources are also available via the Home Service which deliver books and information to people who are unable to visit their local library.
How can you refer to this programme? Staff working with patients can signpost patients to their local library to access quality resources. The self care team has developed some “Help yourself to better health…” bookmarks which practitioners can use to signpost patients to quality resources supporting self management. The bookmarks contain a list of the longterm conditions for which there are NHS Kirklees recommended resources, can can be obtained by contacting the Self Care Team. The books can be borrowed for 3 weeks with the option of renewal.
Where can I find out more? For more information on the ’Help yourself to better health…’ initiative please contact the Self Care Team on 01924 816207 or e-mail self.care@kirklees.nhs.uk … or contact your local library. To obtain a list of the NHS Kirklees recommended materials please contact the Self Care Project Team using the details above.
5.4
Section 5 - information and resources
General self care websites www.cks.library.nhs.uk/information_for_patients
NHS Clinical Knowledge Summaries
In collaboration with NHS Direct, CKS provides patient information on specific conditions, tests, treatments, operations and services. www.healthtalkonline.org/ www.youthhealthtalk.org/
Database of Patient Experience
This database documents a wide variety of patientsâ&#x20AC;&#x2122; personal experiences of health and illness. It also contains information on treatment choices and where to find support. www.expertpatients.nhs.uk
Expert Patients
The Expert Patients Programme and the courses it runs can help people living with a long-term health condition control their symptoms and lead the life they want. Visit the website to read stories from people who have attended the Expert Patients course and health professionals. www.healthspace.nhs.uk
Health Space
A secure NHS personal health organiser for people. It is part of a national roll out of NHS care records service over the next few years and will contain a Summary Care Record of basic information about patients. It will also give you access to your record. The website is useful for both patients and health professionals. www.livinglifetothefull.com Provides step by step workbooks for anxiety and depression. The course has been written by a psychiatrist who has many years of experience using a Cognitive behaviour therapy (CBT) approach and also in helping people use these skills in everyday life. www.moodjuice.scot.nhs.uk
Mood Juice
Moodjuice is developed by the Adult Clinical Psychology Service and is designed to offer information, advice to those experiencing troublesome thoughts, feelings and actions. From the site you are able to print off various self-help guides covering conditions such as depression, anxiety, stress, panic and sleep problems. www.moodgym.anu.edu.au
Mood GYM
An online interactive programme for dealing with anxiety and depression. The online modules help individuals to identify and overcome emotions by developing good coping skills.
Section 5 - information and resources
5.5
www.nhsdirect.nhs.uk/help/
NHS Direct
Telephone: 0845 4647 The NHS Direct self-help guide covers the most common symptoms, conditions and ailments which people call NHS Direct about for advice. For deaf people and those hard of hearing, a textphone service is available on 0845 6064667. A confidential interpretation service is available in many languages. www.nhs.uk
NHS Choices
Official site of the National Health Service. Get expert information on conditions, treatments, local services and healthy living. www.patient.co.uk Comprehensive, free, up-to-date, quality information about health and diseases. Information is evidence based and written by GPs. www.healthyweight4kirklees.nhs.uk
Healthy Weight 4 Kirklees
Healthy Weight 4 Kirklees is an exciting initiative which aims to inform and engage people in Kirklees about weight management. This website will enable members of the public to access local and national information about weight management. It also forms the foundation for the Kirklees Healthy Weight Network for health professionals and partners, allowing the sharing of best practice, access to current information, and provides support in the delivery of Kirklees Obesity Programme.
Disease specific websites www.alzheimers.org.uk Helpline:
The Alzheimerâ&#x20AC;&#x2122;s Society
0845 300 0336
Provides a wide range of information on coping with dementia. www.arthritiscare.org.uk Helpline:
Arthritis
0808 800 4050
Arthritis Care exists to support people with arthritis. They are the UKâ&#x20AC;&#x2122;s largest organisation working with and for all people who have arthritis. www.asthma.org.uk/ Helpline:
Asthma UK
08457 01 02 03
Asthma UK is the charity dedicated to improving the health and well-being of the people whose lives are affected by asthma.
5.6
Section 5 - information and resources
www.bhf.org.uk
British Heart Foundation
Heart Info Line: 08450 70 80 70 Information about Heart conditions, treatment options, and support for patients, as well as tips for a healthy heart. A huge range of resources and heart information booklets are also available. www.cancerbackup.org.uk Helpline:
Cancer Backup
0808 800 1234
Up-to-date cancer information, practical advice and support for cancer patients, their families and carers. www.diabetes.org.uk
Diabetes UK
Diabetes UK Careline: 0845 120 2960 Provides advice and support on managing diabetes, aimed at parents and their carers, and health care professionals. www.heartuk.org.uk
The Cholesterol Charity
Telephone: 0845 450 5988 Provides information, guidance and support for those suffering from a high cholesterol. The Helpline is manned by specialist nurses and dietitians; www.lunguk.org Help line:
British Lung Foundation
08458 50 50 20
British Lung Foundation supports those who are affected by lung disease and their families. They offer advice and support through their helpline advice service, Nurses, support networks and providing information. www.mind.org.uk/Information
MIND Mental Health Charity
Telephone: 0845 766 0163 Mind produces a wide range of publications, including factsheets, a range of ‘Understanding...’ booklets, covering anxiety, depression, schizophrenia and other mental health problems, and a ‘How to...’ series, promoting ways of coping and strategies for living. The MindinfoLine offers confidential help on a range of mental health issues. www.nos.org.uk Helpline:
National Osteoporosis Society
0845 450 0230
This website provides information about osteoporosis, and the charity produces a range of leaflets. Free information sheets can also be downloaded.
Section 5 - information and resources
5.7
www.painconcern.org.uk
Pain Concern
Telephone: 01620 822572 Provides information and support for pain sufferers, and those who care for them. The Listening Ear helpline gives people the chance to talk to another pain sufferer. www.stroke.org.uk Helpline:
The Stroke Association
0845 3033 100
This website offers support to stroke patients and their families and produces a number of publications including patient leaflets, newsletters and information for health professionals.
For health professionals www.dh.gov.uk/selfcare
Information about self-care
Department of Health website providing information about Department of Health policies and guidance which fit in line with the NHS Plan. www.fiveareas.com
Framework to use with patients
A resource site providing a range of Cognitive Behavioural Therapy (CBT) self help resources. www.selfcareconnect.nhs.uk
Self Care Connect
Online resource providing access to information, resources and support on self care www.wipp.nhs.uk
Working in Partnership
Website supporting GPs with capacity building resources and strategies www.healthyweight4kirklees.nhs.uk
Healthy Weight 4 Kirklees
This website forms the foundation for the Kirklees Healthy Weight Network for health professionals and partners, allowing the sharing of best practice, access to current information, and provides support in the delivery of Kirklees Obesity Programme.
5.8
Section 5 - information and resources
NHS LifeCheck What is it? NHS LifeCheck is an online tool that will help people assess and better manage their health. It will not replace contact with GPs and health professionals but will provide additional information and up to date advice on how and where to find the best help for each individualâ&#x20AC;&#x2122;s concerns. The service will inform, empower and support people, to help them change their lifestyles so that they can be healthier, and live longer.
Who is it aimed at? NHS LifeCheck is for everyone but focuses on the needs of those from the most deprived communities. It provides information and practical advice, supporting people in making small changes that can make a big difference to future health and well-being. There are NHS LifeChecks for people at different life stages:
NHS Early Years LifeCheck - for parents and carers of babies aged between five and eight months
NHS Teen LifeCheck - for young people aged between 12 and 15 years NHS Mid-life LifeCheck â&#x20AC;&#x201C; for people aged between 45 and 75 years
How can you access this service? NHS LifeCheck is available online at www.nhs.uk/lifecheck
How can I find out more? For more information on NHS LifeCheck please visit: www.dh.gov.uk/lifecheck You can also email any queries to: lifecheck@dh.gsi.gov.uk
Section 6 - Coming soon
6.1
Information Prescriptions What is it? The White Paper ‘Our health, our care, our say’ (2006) outlined a commitment from the department of health to ensure access to appropriate information for people with a health or social care need. They proposed that individuals, or their carers, be provided with an ‘information prescription’ from health or social care services which they access, signposting them on to further sources of information or giving advice on self management and self care. Pilots were conducted throughout 2007 and have informed the design and delivery of information prescriptions, and provided evidence of their effectiveness and their impact on the public, professionals and organisations.
Who is it aimed at? Information prescriptions should be available to individuals with a long-term health condition who are registered with one of the participating surgeries in north Kirklees. If the pilot is successful, the scheme will be rolled out across Kirklees in 2010.
How can you access this service? This service is still in the development stages. Look out for information about how to access this service in March/April 2009.
For more information… Please contact the Self Care Project Team at self.care@kirklees.nhs.uk or on 01924 816 207. Self Care Project Team Woodkirk House Dewsbury and District Hospital Halifax Road Dewsbury WF13 4HS
6.2
Section 6 - Coming soon
Staywell What is it? Staywell is a systematic web-based tool which tests patients self care knowledge, focusing on the essential aspects which help stop a condition from worsening. It identifies and records each patient’s gaps in self care knowledge alongside misconceptions and missed check ups. Patients who are most at risk can be recognised and targeted with extra support and/or information.. This data can be kept with the patients’ record and any changes in knowledge can be monitored over time. Staywell also provides the means for willing and able patients to educate themselves in self care. There will be three different types of Staywell questionnaire: • Staywell Diabetes; is for people with both types of diabetes, • Staywell Generic; is for anyone with a long term health condition. • Plus one more which is yet to be confirmed at time of print
Who is it aimed at? They are all aimed at adults with either a long term condition or those who are over the age of 65.
How can you access this service? There will be a number of GP surgeries in north Kirklees piloting the diabetes and generic questionnaires with their patients. The public will also be able to access all three questionnaires online and via various outlets including libraries and Gateway to Care. This pilot is still in the development stages. Look out for information about how to access this service in March/April 2009. If the pilot is successful, the initiative will be rolled out in full across Kirklees in 2010.
For more information… Please contact the Self Care Project Team at self.care@kirklees.nhs.uk or on 01924 816 207. Self Care Project Team Woodkirk House Dewsbury and District Hospital Halifax Road Dewsbury WF13 4HS
Section 6 - Coming soon
6.3
Additional self care information Please use this form to inform the self care programme of any changes or new services that support self care.
Name of service:.......................................................................................................................................
Address:................................................................................................................................................... ................................................................................................................................................................ ................................................................................................................................................................
Telephone number:...................................................................................................................................
Who is the service targeted to:.................................................................................................................. ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ............................................................................................................................................................... ................................................................................................................................................................
Please send the form to: FREE POST Self Care Programme, NHS Kirklees, FREEPOST NEA13086, Batley, WF17 5BR Tel: 01924 816207
6.4
Evaluation Please use this form to provide feedback about the toolkit. Is the information in the toolkit easy to read?
Yes
No
Is the toolkit easy to navigate through?
Yes
No
Is there anything missing?
Yes
No
If so, please use this space to say what is missing ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. .................................................................................................................................................................
Please send the form to: FREE POST Self Care Programme, NHS Kirklees, FREEPOST NEA13086, Batley, WF17 5BR Tel: 01924 816207
6.5
Index Active for Life.............................................. 2.15
Information Prescriptions............................... 6.2
Additional self care information..................... 6.4
Kirklees Drug and Alcohol Action Team........ 4.13
Batley self help depression group................... 4.5
Lifeline......................................................... 4.14
Better health at work................................... 2.23
Long term conditions team.......................... 3.19
Breastfeeding peer support.......................... 4.11
Looking after me course................................ 2.7
Cardiac rehab education programme............. 3.3
MEND.......................................................... 2.17
Cardiac rehab exercise programme (Dewsbury)................................. 3.4
NHS Lifecheck................................................ 6.1
Cardiac rehab programme (Huddersfield)....... 3.5 Cardiac rehab support group......................... 4.8 Cognitive behavioural approaches training..... 1.7 Community rehab........................................ 3.13 Continence service....................................... 3.23 DESMOND..................................................... 3.9
PALS.............................................................. 2.9 Public Health Resource Centre....................... 1.6 Primary prevention (CHD)............................... 3.1 Pulmonary rehab.......................................... 3.25 Secondary prevention (CHD).......................... 3.2 Self care connect........................................... 1.5 Support from libraries:
Diabetes support group................................. 4.9
Self help books......................................... 5.3
EPP education programme............................. 2.1 EPP support group......................................... 2.6 Evaluation...................................................... 6.5 Gateway workers........................................... 4.1
RAYS........................................................ 5.1 Staywell......................................................... 6.3 Stop Smoking Service................................... 2.19 Support 2 Recovery (S2R)............................... 4.3
Get foodwise & exercise programme (EPP)........................................... 2.5
The Nerve Centre . ...................................... 4.10
Health Needs Assessment (HNA).................... 1.1
Young PALS................................................ .2.13
Health trainer programme............................ 2.21
Websites - general self care.......................... 5.5
Heart Failure Service....................................... 3.6
Heartline........................................................ 4.6
Worklink...................................................... 2.25
Heartbeat...................................................... 4.7
6.6
- disease specific............................ 5.6