Adult Demand Programme

- Wellbeing Co-ordination Project

14th March 2014

What is Wellbeing Co-ordination?

A new approach to help people:

• Take control of their situation

• Manage their health & wellbeing more effectively

• Build their personal resilience & ability to cope

• Build their personal independence

• Engage the help they need early in order to avoid reaching crisis points

People are often able to cope far better if their needs can be met in a holistic, joined-up way – this approach is about how we can help them achieve that

Why Do We Need It?

Recent studies & surveys have highlighted a number of reasons people in Swindon often don’t engage help until they reach crisis point:

•Lack of knowledge about the services available

•Difficulty in engaging services

•Weariness at having to “tell their story” repeatedly

•Lack of co-ordination between services & organisations

•Carers not being able to leave loved-ones for long enough to get help

•People get lost in “grey areas” between services

We also know that people need additional help when they reach certain key points in their lives – bereavement, job loss, changes in health, etc.

Wellbeing Co-ordination Approach

The approach was developed to:

• Build on current best practices

• Develop use of person-centred planning

• Ensure people own plans about themselves

• Help people to find support for themselves

• Enable people to be as independent as possible

• Improve joined-up working between organisations

• Build support within local communities

The approach & processes are based around Solution Focus - complements Children’s Services work

The intention is that this new way of working will be introduced across all relevant organisations involved in health, wellbeing and social care in Swindon

Wellbeing Continuum Perspectives…

Primary Care(GP)

SecondaryCare

General PublicGP involved, but need additional

support“Stuck” between Primary

and Secondary Care

In Secondary CareDischarged & recovering – may be under

GP care

Piloting The Approach

• Commissioners agreed to pilot wellbeing co-ordination approach with Service Users being stepped-down from secondary mental health services

• Much of the focus within the “system” is currently on meeting clinical needs, but the reasons people struggle to cope are far wider (financial issues, social isolation, loss of benefits, etc.)

• Wellbeing co-ordination gives us a way to change this and be more joined-up - it is about working differently, not creating new roles

• The approach is supported by:

­ GP leads for mental health

­ Mental Health Care Forum

­ Mental Health Providers Forum

• Pilot started using staff and organisations who understood the concepts and already worked in similar ways, now starting to broaden out to involve others

How Does The Pilot Work?

PhasedTransition

AWP CareCo-ordination

WellbeingCo-ordination

Care plan Step-down & wellbeing plans

developed together

Ongoingreview of wellbeing plans

Secondary Care Primary Care (GP)

Step-down(Discharge)

The wellbeing co-ordination approach is designed to support the person’s journey of recovery & independence:

•The person is involved at all stages of the process

•The person identifies their priorities, needs and strengths

•The person owns their plan and is key to its delivery

•The Wellbeing Co-ordinator acts as a coach/mentor, but does not replace the role of the statutory Mental Health Care Co-ordinator

•Plans are developed around the needs of the person, which may well need services from several organisations

•The person is supported at each stage of their journey, so don’t get “lost” in the system

•The plan establishes a baseline on which the person can build & measure success

Principles of Wellbeing Co-ordination Plans

Supporting People’s Journey to Recovery & Independence

Community BasedGroups & Activities

Supported ActivitiesIn Wider Social Setting

Specialist SupportGroups & Activities

Wellbeing Co-ordination Support

Progress So Far…

• Pilot launched in November 2013

• Aim was to work with 12 individuals - currently working with 28 to allow for setbacks in recovery and some not wishing / being able to become part of the pilot

• Strong engagement from both statutory and third sector staff

• Feedback from staff is that pilot is progressing far more smoothly and effectively than they had hoped given the nature of the target client group

• Additional benefits being realised in terms of working relationships and shared learning

• Feedback from users around significant reductions in step-down anxiety and that a “hole in services” is being addressed

• Governance & supervision through Case Analysis Workshops – reflective team approach used to highlight learning and develop approach

• Links being identified into other areas of need

Learning So Far…

• Having a phased transition is a major step forward in managing people’s anxiety levels

• The coaching / mentoring approach helps people look at their needs & requirements differently

• People know themselves well – most already have goals in mind

• People don’t ask for the earth – plans are realistic

• The areas of help people need are very diverse

• One fairly common theme is around wanting a regular “check-up” to reflect on things every few months before they become overwhelming and trigger points are reached

• Building in capability for Wellbeing Co-ordinators to link to GPs and Primary Care Liaison Service is welcomed by users, but hasn’t been needed yet

• Cross-sector approach is working well – discussions build richer plans and address disconnects

Monitoring Progress

• Each person’s wellbeing during the pilot is tracked using the Warwick-Edinburgh Wellness Scale

• In addition, each person’s identified outcomes are also tracked on a regular basis and clustered into key groups:

­ Coping at home

­ Welfare rights, benefits & debt

­ Support networks & social isolation

­ Employment, training & volunteering

­ Supportive activities

­ Relationships & social integration

• Other tools, such as the Recovery Star model, are used for more in-depth support work dependant on individual needs

Three Questions For The Group

• How do we collectively design our services to bring together the best that the statutory and third sector can offer at each stage so that we best meet the needs of the individual?

• How do we support our teams to build better cross-sector and cross-organisational working relationships?

• How do we design our services so that we ensure that people don’t get lost at transition points – concept of “passing the baton”?

Many thanks for listening.

Dave Potts

pottsdg@btinternet.com

dpotts2@swindon.gov.uk

07704 472600