Using Community to Address Frailty

Dr Mohan Sekeram GP in Merton and Clinical lead Social Prescribing for

Merton CCG

Lauren Walker Fire, Safe and Well Regional Manager, HLP

Jason Tong Change Manager and lead on social prescribing, HLP

01

Transforming London’s health and care together

Understanding the Opportunity of

Social Prescribing

2

Case Study – Mr Jones

3

85 years old

Scores severely frail on Emis tool

Registered blind

Independent with Activities of Daily Living

(ADL)

Mobile

Lives alone

Attends lunch club once a

week

Social prescribing means different things to different people, however, the Social Prescribing Network’s co-produced definition is:

“Enabling healthcare professionals to refer patients to a link worker, to co-design a nonclinical social prescription to improve their health and wellbeing.”

Definition of Social Prescribing

Social Prescribing Benefits

5

“There is emerging evidence that social

prescribing can lead to a range of positive health

and well-being outcomes. Studies have pointed to

improvements in areas such as quality of life and

emotional wellbeing, mental and general

wellbeing, and levels of depression and anxiety.”

Kings Fund

There was a social return on investment of

£2.90 for every £1 invested. Getting a broader

perspective on value is vital to developing the

business case to encourage commissioners to

invest in social prescribing

University of the West of England

“A Social Return on Investment (SROI)

analysis demonstrated that every £1 of

Creative Alternatives expenditure resulted in

£6.95 worth of benefits to clients or savings

to other services.”

Sefton Public Health Team

“One review of studies on social prescribing

showed that, on average, it was associated

with a 28% fall in GP visits and a 24% drop in

attendance at emergency wards.”

Social Prescribing Network

“The well-being benefits experienced by service users

equate to a social return on investment of £2.19 for

every £1 invested in the Rotherham Social Prescribing

Pilot.”

Sheffield Hallam University

Social Prescribing – London Shared Vision

• Significantly reduces health inequalities

Framework for social prescribing

• Create vibrant and diverse third sector supplier market

• Strengthen community capacity

Strong Local Partnerships • Role of the care and

support workforce evolves

• Holistic assessment and personalised care planning widely available

From medical to social model

• Public can access and see the benefits

• GPs & public drive demand

Greater public

awareness

• Health champions increase workforce capacity

• People stay independent with improved understanding of opportunities available

• New care navigation roles

• Link workers track and evaluate social prescribing

• Improved job satisfaction

• Reduced workload

• Improved referrals

Greater public

awareness

New roles and ways

of working

General Practice can

become a hub for wider

community activity

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Social Prescribing Strategy for London

7

HLP working with GLA, NHS England, Social Prescribing

Network and local councils to develop a pan London Social

Prescribing Strategy.

Cross organisational work streams developing to deliver 5

key themes to spread and scale Social Prescribing across

London.

Digital platforms to support delivery

Supporting Voluntary Community and Social

Enterprise Sector

Integrated Working Between Sectors

Sustainable Models – Including sustainable funding

Evaluation – Building the evidence base

Click to edit Master title style

8

Local and National Agenda

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Social prescribing is key strategy in

• Five Year Forward View

• GP Forward View

• Health Inequalities Strategy, GLA

• All 5 London STP plans

DH, Health and Wellbeing Fund (Social Prescribing

theme)

HLP supporting the spread and scale of Social

Prescribing and Fire Safe and Well across London.

Operating model for social prescribing &

access to community based resources

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Referrers Connectors Prescriptions

Local Social Prescribing Connector

Schemes:

Commissioned at CCG/ local

authority level

Mainly hosted in the VCSE sector,

either through a single project

or consortium

Employ link workers, often based in

GP surgeries

Provide holistic coaching support

based on what matters to the

person and co-produce support

plans

Actively connect people to

community groups

Support community groups to

receive referrals

All General Practice primary care

teams refer. Some practices have

Care Navigators who do active

signposting to other agencies

including social prescribing

connector schemes

Police and Fire services

Hospital discharge teams,

paramedics, 111

Social Workers

Allied Health Professionals

Mutli-disciplinary teams (MDTs)

Social prescribing link worker meet patient to co-produce on a wide

range of statutory and community assets

Signposting to small range of statutory or community asset or

referral to social prescribing services for more complex requirements

Patient search online for self-care , statutory or community assets

Complex

Social and community care needs

Less complex

Low

Patient Activation

High

Self Care Holistic Operating Model

Understanding the Opportunities for Each

CCG/STP

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Support

Infrastructure

Suite of support tools to commissioners

• Case for Change [https://www.myhealth.london.nhs.uk/healthy-

london/programmes/personalisation]

• Commissioners’ guidance to support the

implementation of social prescribing [https://www.myhealth.london.nhs.uk/healthy-london/latest/publications/steps-

towards-implementing-self-care]

• Social Prescribing and Wiki [https://wiki.healthylondon.org/Social_Prescribing_and_Self_Care_Wiki]

• Financial and population modelling and Secondary

care utilisation report [http://www.i5health.com/SPDashboard.html]

• Common Outcome Framework for social prescribing

Understanding the Opportunity

Overview of Dashboard

13 https://wiki.healthylondon.org/Social_Prescribing_and_Self_Care_Wiki

Common Outcome Framework for Social

Prescribing

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Common Outcomes Framework for Social

Prescribing

Impact on the person, their

carers and families

Impact on the Health and

Care system

Impact on Community

groups

DEPRESSION • BEREAVEMENT

• HEART PROBLEMS • FINANCIAL

CONCERNS

• RECURRE

NT

INFECTIO

NS

• HOUSING

ISSUES

Merton Social Prescribing Services

OTHER CAUSE OF SYMPTOMS

TOTAL: 316

ETHNICITY: 58% white, 20% black, 11% asian

REASON FOR REFERRAL: - 55% Mental Health

- 25% Social needs

- 10% Social isolation

- 5% Other

- 4% Frequent attender

- 1% Weight management

(26 month)

Progress (Feb 17 – Feb 18)

- Patient stories

- Wellbeing Star (used at baseline and

follow up)

- 75 patients had completed two stars,

with an average increase in overall

wellbeing score of 0.7; Increase from

2.8 to 3.5. Statistically significant

(t = 1.99; p = 0.00 )

1. Not thinking about it

2. Finding out

3. Making changes

4. Getting there

5. As good as it can be

Evaluation - Qualitative

- 138 visited the GP within 3

months of SP.

- They took up 1,641 appointments

before SP and 1,098 afterwards

(reduction of 543).

- The average number of

appointments per patient reduced

from 11.9 to 8.

- T-test analysis shows that this is a

highly significant reduction in the

number of appointments

(p value = 0.00).

This box chart shows the number of GP appointments patients attended three before

and after their first Social Prescribing appointment.

APPOINTMENTS 3 MONTHS BEFORE SP APPOINTMENTS 3 MONTHS AFTER SP

AVERAGE APPS: 12

AVERAGE APPS: 8

GP Appointments at 3 months

- 36 patients visited their GP within

6 months of SP.

- They visited A&E 60 times before

SP and 31 times afterwards

(reduction of 29 visits).

- The average number of

appointments per patient reduced

from 1.4 to 0.7.

- T-test analysis shows that this is

a significant reduction in the

number of appointments (p value

= 0.04).

This box chart shows the number of A&E appointments patents attended six months

before and after their first Social Prescribing appointment.

A&E APPOINTMENTS 6 MONTHS BEFORE FIRST SP

A&E APPOINTMENTS 6 MONTHS AFTER FIRST SP

AVERAGE VISITS: 1.4

AVERAGE VISITS: 0.7

A&E appointments at 6 months

- Patient B seen before Christmas for Depression and medical certificates. Seen monthly for 4 months

- Saw Ray- Identified he work as chef and other benefits.

- Job at community center

- Currently working and off medication and no more medical certificates.

- Self esteem

- Resilience

- Supporting community

- Reduced use primary care

Social Prescribing in Action

02

Transforming London’s health and care together 21

Understanding the Opportunity

of Fire Safe and Well

National background to Safe and Well

Fire Safe and Well video

Background to London pilot project

A safe and well visit will be a person-centred visit in the home to identify and

reduce risk to the resident or residents. It will expand on the advice and

intervention already provided as part of a home fire safety visit to identify

opportunities to improve health and wellbeing. The range of risks addressed

will be tailored to meet local needs and capacity. We will identify the key

interventions where we can reduce risk by delivering advice, provide

services and/or refer to partners.

Healthier Futures – LFB Community Health Strategy, September 2016

Supporting vulnerable and hard to reach people

• 86,000 Home Fire Safety Visits p.a.

• Wide range of referral sources

• Trusted organisation

• Full access to people’s homes

Priority People – links to frailty

A person may be more vulnerable to fire if:

• There is an increased fire risk in their property

e.g. smoking materials; health equipment (O2, air-flow mattress, incontinence pads);

hoarded materials; risk-taking behaviour

• They have a reduced ability to react to a fire

e.g. sensory impairment; cognitive difficulties; learning disability; substance misuse

• They have a reduced ability to escape from a fire

e.g. reduced mobility; reduced decision making ability; blocked escape route

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Support

Infrastructure

Fire Safe and Well pilot boroughs

Health and wellbeing interventions

• Core priorities

o Falls prevention

o Smoking cessation

o Winter wellness

• Local priorities

o Social isolation & loneliness

o Atrial fibrillation

o Alcohol misuse

Harnessing the value of the wider workforce

03

Transforming London’s health and care together

Case Study

29

Case Study – Mr Jones

30

85 years old

Scores severely frail on Emis tool

Registered blind

Independent with ADL

Mobile

Lives alone

Attends lunch club once a

week

GP Intervention

31

• Severely frail

• Visually impaired

• Osteoarthritis

• Asthma

• Ischaemic heart disease

• Charles Bonnet syndrome

• Feeling low

• Feeling isolated

Social Prescribing Intervention

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• Identified befriender

• Supported to claim

attendance allowance

• AA paid for cleaner (who

found dentures)

• Linked with blind veterans

• Volunteering with Macular

Society

• Referred for Fire Safe

and Well visit

Fire Safe and Well Intervention

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• Installed heat alarm in

kitchen

• Ensured escape route

clear

• Provided advice

regarding safe cooking

and heating

• Referral to Merton Falls

Prevention service

• Referral for energy check

• Signed up to UK Power

Network priority register

• Registered white goods

with product recall service

Benefits

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• Holistic support

• Reduced isolation

• Improved mood

• Improved nutrition

• Safer living environment

• Reduced falls risk

• Reduced fire risk

• Increased resilience

• Living well with frailty

• Reduction in risk factors that

could impact upon use of

primary and secondary care

• Reduction in risk factors that

could impact upon use of the

fire and rescue service

04

Transforming London’s health and care together

Social Prescribing Animation

(1)

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Social Prescribing Animation

(2)

05

Open Forum for Discussion

36