March 2019

During late 2018, Dudley CVS appointed an external consultant, David Waterfall, to work alongside the team to collate and analyse data regarding the Integrated Plus social prescribing service, and to use this information to produce an evidence-led evaluation report.

Dudley CVS has been delivering a social prescribing service for the nearly 5 years. In early 2014, Dudley CVS with support from Dudley Clinical Commissioning Group (Dudley CCG), identified an opportunity to develop and deliver an innovative, flexible and complementary service called ‘Integrated Plus’.

The service was set up to trial a different approach to supporting people in their own homes to ensure the non-clinical needs of patients are taken into account at the GP-led Multi-Disciplinary Team meetings (MDTs) established in 2014. Integrated Plus offers 1-2-1 social prescribing support to patients aged 16 and over who are:

At high risk of hospital admission;
Frequently visiting their GP;
Vulnerable and in need on non-clinical, social support.

Key findings from the report:

2,720 out of 3,756 clients have connected with the service during September 2014 – August 2018.
In terms of a typical patient referral to Integrated Plus; 60% are aged 64 and over, 37% are aged between 24 – 63, 58% are female, 71% have no caring responsibility, 25% are referred due to feeling isolated, 17% because of a long term health condition and 16% due to feeling that they have mild to moderate depression. There is a high correlation between clients feeling isolated and feeling that they have mild to moderate depression.
94% of clients rate the service as 4 or 5 stars (out of 5), 96% consider Integrated Plus has had an impact on them (of which 28% consider this to be significant), and 79% feel that Integrated Plus has helped connect them to services and activities suitable to their needs.

Performance

Following Integrated Plus, client change for each of the seven core outcomes was:

Finance; an 81% reduction in those patients that were not managing, and also an increase of 48% for those who were managing. The greatest enhancement in an indicator was “I have enough money to meet basic needs”
Physical Health; an 82% reduction in those patients that were not managing, and also an increase of 29% for those who were managing. The greatest enhancement in an indicator was “I am managing long term conditions well”.
Mental Health; an 76% reduction in those patients that were not managing, and also an increase of 58% for those who were managing. The greatest enhancement in an indicator was “Feeling optimistic about the future”
Social Contact; an 80% reduction in those patients that were not managing, and also an increase of 35% for those who were managing. The greatest enhancement in an indicator was ““I regularly have face to face social contact with people who are not family members”
Housing; an 82% reduction in patients that were not managing, and also an increase of 24% for those who were managing. The greatest enhancement in an indicator was “I feel able to keep up with my rent”
Safety; an 83% reduction in those patients that were not managing, and also an increase of 24% for those who were managing. The greatest enhancement in an indicator was “I feel I have people I can contact”.
Learning; an 72% reduction in those patients that were not managing, and also an increase of 10% for those who were managing. The greatest enhancement in an indicator was “I feel happy in my retirement”

In broader terms, following the intervention 46% fewer clients report poor quality of life, and 45% fewer clients report poor wellbeing.
For hospital data, there are significant reductions in A&E attendance after Integrated Plus with a 14% reduction after 6 months, increasing to a 17% reduction after 12 months. Regarding inpatient admissions, after Integrated Plus there is a 14% reduction after 6 months, increasing to a 15% reduction after 12 months. In terms of hospital cost avoidance, data shows £751,400 for reductions in Inpatients, and £58,305 in reduced A&E admissions; totaling £809,705
For GP data, of the 43 surgeries engaged; 34 had a decrease in surgery consultations, 21 had a decrease in telephone consultations, and 26 had a decrease in home visits. In terms of GP cost avoidance, data shows £73,115 in fewer GP Consultations, and £16,400 for fewer GP Home Visits; totaling £89,915. The surgery with the greatest extent of cost avoidance was Wychbury Medical Centre/Cradley Road Medical Practice, with a cost avoidance of £11,135 (from 306 referrals, of which 189 supported)
Through surveying of GPs, 100% of surgeries rated Integrated Plus as good or excellent, and 89% felt that the Link Officers added value to the current Multi-Disciplinary Team meetings. All surgeries agreed that Integrated Plus had helped to reduce inappropriate GP consultations, and most surgeries felt that “Reduces isolation and loneliness” was a key benefit for patients. Wider benefits included, “Our main Link Officer has an excellent rapport with our patients, nothing is too much trouble for him and he is literally only a phone call away. He attends all MTD meetings and has good input from the patients he sees.”

For more information you can read the full report here:

https://issuu.com/dcvs/docs/ip_final-evaluation_26-03-19

For more information, please contact Kate Green. Tel: 01384 573381.

Email: buildingblocks@dudleycvs.org.uk

At high risk of hospital admission
Frequently visiting their GP
Vulnerable and in need on non-clinical, social support

Our support is about enabling and facilitating connections with others, nurturing new friendships and helping people to find purpose in their lives. We focus on the whole person’s needs whatever they might be to jointly find solutions to challenges faced. Our approach is about spending quality time with people, actively listening to their needs, goals and aspirations. We explore what is important to the person and help them to identify, amplify and reflect on their strengths, passions and skills. 99% of people we have connected with stated that spending quality time with them actively listening and exploring what they want to achieve as the most valuable component of our service.

Other key facts and stats

4,326 referrals from GPs and at the MDT meetings. Of 4,326 we have connected with 3,132 people.
81% reduction change in people that were not managing in the areas of finances but who are now getting appropriate support or now managing ok
82% reduction change in people that were not managing their physical health but who are now getting support or now managing ok
80% reduction change in people that were isolated and lonely but who are now accessing services/activities or no longer feel isolated or lonely
8,719 outward referrals to organisations, 60% to the voluntary sector
Avoidable A&E attendances have reduced by 17% over a 12 month period after Integrated Plus interventions, cost avoidance totalling £58,305
Avoidable hospital admissions have reduced by 15% over a 12 month period after Integrated Plus interventions, cost avoidance totalling £751,400
Overall GP consultations have reduced by 15%, cost avoidance totalling £73,115

Karen supported to find time for herself and regain her confidence

Karen was referred to Integrated Plus by her GP. She was diagnosed with depression and finding life difficult to cope with. Karen is selfless and spends most of her time caring for others. She has caring responsibilities for her mother, an aunt and a son who is disabled. Despite her busy schedule, Karen is regarded as being positive and upbeat about herself and her life but while looking after everybody else her own mental health was deteriorating and she became unwell.

When Karen met the Locality Link Officer for Stourbridge, Wollescote and Lye she said she felt “Lost and exhausted and didn’t know what to do.” The Link Officer listened to Karen and discussed options for her to have some time concentrating on herself, regaining her confidence and doing something she would find helpful and worthwhile. The Link Officer asked Karen what hobbies and interests she had and if she would like to do some activities and Karen said yes and the Link Officer agreed to accompany her to her first activity until she felt comfortable with her surroundings. They went to The University of the 3^rd Age in Stourbridge and Karen enjoyed it and settled in a lot quicker than she thought she would.

Karen now has the confidence to attend on her own and has been to the U3A several times and is going to join the group as a member, she is looking forward to enrolling on a diverse programme of classes in the New Year, including, lace making, walking and tap dancing. She was surprised and pleased to find that the lace making course is taught by a neighbour and this has rekindled their friendship.

The Link Support Worker met Karen a couple of months later to do a follow up review and she said her mental health has significantly improved and that she is feeling much better. Karen has also grown in confidence and has attended some Carers Coffee Mornings and said this has been important in reducing the isolation and loneliness felt by many carers.

Karen has reconnected with neighbours and her wider community and has made new friends since being referred to Integrated Plus. She said she was very grateful for the “…impartial support from Integrated Plus.” And without this support she said she would probably be “sat at home rocking back and forth in her chair not knowing what to do next.” With support from Integrated Plus and Karen’s desire to make changes she is looking forward to the future with renewed confidence and hope.

For more information contact: Kate Green. Email: buildingblocks@dudleycvs.org.uk