social prescribing the rotherham model patients in control of their care
TRANSCRIPT
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 [email protected] • Linda Jarrold on 01709 834449 or [email protected]
• 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.