social prescribing the rotherham model patients in control of their care

Social Prescribing

The Rotherham modelPatients in Control of their Care

Clinical Commissioning Group

BackgroundThe NHS Challenge• Increasing numbers with long term conditions• Above average unplanned hospital admissions• Unable to fund prevention without freeing up money from the acute

sector• How can VCS help?

Development of Rotherham Social Prescribing• Co-production workshops – agreement of model linked to integrated

case management pilot• Business case submitted to Rotherham CCG• Initial pilot proposal – 10 GP practices, but 26 signed up!• 6 months to recruit staff team, set up systems and join first GP

meetings

What is Social Prescribing?Strengthening individuals, strengthening communities

Social prescribing (sometimes called community referral) is a framework for linking patients with non-medical needs affecting their health, well-being and ability to self-manage to sources of support within the community.

PRESCRIPTIONExercise / healthy lifestylesSelf-management programmes

Social and leisureArts and craftsBefriending/mentoringConfidence buildingLearning/trainingMoney – benefits, debt, fuel povertyHousing/adaptationsCarers supportDementia supportTransport/mobilityAdvocacy

LTC Social WorkerIt’s been excellent for the patients, in having access

to such a medley of support services where

you can interlink

Rotherham Social Prescribing Model Key Features

• Social prescribing integral to integrated case management teams

• Patient selection by GPs - using risk stratification

• Single infrastructure organisation (VAR) manages contract ( 26 partners)

• VAR employs and manages 5 link workers• Co-produced action plan and menu

of support activities• Funding to expand VCS capacity

and fill gaps in provision

LTC MatronOne-stop shop –

there are numerous possible agencies to refer to so makes it easier referring to

one

Integrated LTC Case Management Team

Voluntary and Community Sector Advisor (VCSA)

Funded VCS Service Community Activity(non-funded)

Assessment

Patient is on risk tool Patient has non-medical

needs

Menu of options

Feedback

Feedback

Rotherham Social Prescribing Model

Month 0 Month 1 Month 2 Month 3 Month 4

X weeks

X hours

X sessions

Patient Outcome

GP VCSA

VCS provider Service 1

VCS provider Service 3

VCS provider Service 2

SPS Funded

SPS Funded

Patient attends peer-led group

Patient continues to access service (external funding sustains service)

Patient referred on to sustainable

activities / service

No sustainable outcome for

patient

SPS funded Provider Service

SPS

Refe

rral

in

Refe

rral

Out

VCSA

FO

LLO

W U

P

Social Prescribing Patient Journey

SPS funding

Patient continues to access service (patient self funds)

Towards Independence Maintaining Independence

Sustainable funding

The Story So Far………Key Statistics

1974 referrals in to SPS since Sep 20123200 referrals on to VCS Services 700 referrals on to non-VCS Services 65% referrals aged 75+42% live alone37% have an informal carer5% BME

Outcomes

55% - fewer outpatients appointments48% - fewer hospital admissions43% - fewer A&E Attendances83% - progress on at least one outcome area76% - financial benefits (£275,000 in additional benefits since Sep 2012)69% - less isolated54% - more active

GP Quote:Gives them a focus/purpose

and goal to achieve. Integrates back into the

community, especially the socially isolated. Supports

and educates patients

Social prescribing - Success factors

• VCS is integral to case management in primary care • CCG champion / streamlined and effective Steering Group• Simple referral processes for GPs• GP ‘buy in’ to social prescribing • Adequate resourcing of VCS services• VAR’s ability to support groups

Patient Quote:I was on my own, I was

totally on my own… Each day I’m getting

better and better….before I could

hardly walk…I’m feeling very positive,

each day I get up and I just can’t believe how

much I’ve come on

• Social prescribing funded services as pathways to independence

• Robust (and secure) patient data management to demonstrate impact

NHS National Award for Social Prescribing

Case StudyPatient V• Patient is registered blind and has angina• High anxiety levels – rings 999 frequently when support workers aren’t there• Limited friends and rarely goes anywhere independently, no confidence• Referred to SENSE art and craft group, disabled swimming session and befriending services.• Re-arranged his support worker hours to cover weekends by doing other activities in the week.• He has now met lady that attends the same group, they have fallen in love, are moving in

together and getting marriedOutcome: patient is more confident, more independent, much happier and less isolatedOutcome: patients rarely rings 999, more satisfied with support package and will be reducing the hours of support neededOutcome: patients value SENSE group so much they are to continue it themselves by self-funding and applying for grants

Patient feedback

Thank YouQuestions?

• Janet Wheatley on 01709 829821 or janet.wheatley@varotherham.org.uk • Linda Jarrold on 01709 834449 or linda.jarrold@varotherham.org.uk

• External evaluation interim report (December 2013) http://www.shu.ac.uk/research/cresr/reports

Voluntary Action Rotherham, The Spectrum, Coke Hill,Rotherham, S60 2HX; Tel: 01709 829821, Fax: 01709 829822.

VAR is a company limited by guarantee, Registered Charity Number: 1075995, Registered Company Number: 2222190.