Transcript Social Prescribing - Bexley Voluntary Service Council

Social Prescribing
The Rotherham model
Patients in Control of their Care
Clinical Commissioning Group
Background
The 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.
LTC Social Worker
It’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 Matron
One-stop shop –
there are numerous
possible agencies to
refer to so makes it
easier referring to
one
Rotherham Social Prescribing Model
Integrated LTC Case
Management Team
Feedback
 Patient is on risk tool
 Patient has non-medical
needs
Voluntary and Community Sector Advisor
(VCSA)
Assessment
Feedback
Menu of
options
Funded VCS Service
Community Activity
(non-funded)
Social Prescribing Patient Journey
Month 0
Month 1
Month 2
Month 3
Month 4
Maintaining Independence
Towards Independence
Patient Outcome
X weeks
VCSA
Referral Out
GP
SPS Referral in
SPS
Funded
VCS
provider
Service 2
X hours
SPS
Funded
VCS
provider
Service 3
X sessions
VCSA FOLLOW UP
VCS
provider
Service 1
Patient continues
to access service
(patient self funds)
Patient
continues to
access service
(external funding
sustains service)
Patient referred
on to sustainable
activities /
service
Patient attends
peer-led group
SPS funded
Provider
Service
No sustainable
outcome for
patient
SPS funding
Sustainable funding
TheStory So Far………
Key Statistics
1974
3200
700
65%
42%
37%
5%
referrals in to SPS since Sep 2012
referrals on to VCS Services
referrals on to non-VCS Services
referrals aged 75+
live alone
have an informal carer
BME
GP Quote:
Gives them a focus/purpose
and goal to achieve.
Integrates back into the
community, especially the
socially isolated. Supports
and educates patients
Outcomes
55% - fewer outpatients appointments
48% - fewer hospital admissions
43% - fewer A&E Attendances
83% - progress on at least one outcome area
76% - financial benefits (£275,000 in additional benefits since Sep 2012)
69% - less isolated
54% - more active
Social prescribing - Success factors
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VCS is integral to case management in primary care
CCG champion / streamlined and effective Steering Group
Simple referral processes for GPs
Patient Quote:
I was on my own, I was
GP ‘buy in’ to social prescribing
totally on my own…
Each day I’m getting
Adequate resourcing of VCS services
better and
VAR’s ability to support groups
better….before I could
• Social prescribing funded services as
pathways to independence
• Robust (and secure) patient data
management to demonstrate impact
hardly walk…I’m
feeling very positive,
each day I get up and I
just can’t believe how
much I’ve come on
NHS National Award for Social Prescribing
Case Study
Patient V
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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 married
Outcome: patient is more confident, more independent, much happier and less isolated
Outcome: patients rarely rings 999, more satisfied with support package and will be reducing the
hours of support needed
Outcome: patients value SENSE group so much they are to continue it themselves by self-funding
and applying for grants
Patient feedback
Thank You
Questions?
• 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.