Changing Lives in Cornwall: Briefing for Cornwall Clinical Commissioning Groups

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1 Changing Lives in Cornwall: Briefing for Cornwall Clinical Commissioning Groups Summary This briefing paper provides Cornwall s Clinical Commissioning Groups with the context for Changing Lives, an outline of health and well-being services delivered through this approach and the impact it has on individual lives. Changing Lives is an approach pioneered by Volunteer Cornwall and Age UK Cornwall with support from our statuary and voluntary partners. The focus is to create local solutions by joining up what already exists and demonstrating the positive impact of community-based activity on reducing health inequalities, tackling social exclusion, improving cohesion and enhancing the health and wellbeing of our population. The Changing Lives framework: * Place individuals at the centre of locality commissioning and service delivery * Develop services based on evidence of multiple outcomes and impact * Build on what people can do through self management and self care. * Create access points which make sense to people * Don t layer solutions, connect local services and people together * Provide individual navigation, brokerage and signposting * Mainstream prevention throughout * Add value to specialist interventions * Create a shift towards mutual aid and reciprocity * Create new communities of practice across disciplines and in collaboration with members of local communities What can this approach offer Commissioning Groups? Using this approach, Volunteer Cornwall and Age UK Cornwall has developed a menu of services which enable people to live healthy independent lives and help prevent unnecessary hospital admission and readmission through good social integration, the delivery of flexible and progressive services and partnership working with volunteers and communities. These services offer: * an opportunity for personalised care planning and ongoing case management * flexible delivery to complement and support primary care functions and delivered against QIPP priorities * a call and/or visit by a trained and supported team member in the community who will provide a gateway to a range of practical and emotional support * individual navigation, brokerage and signposting to agencies; including specialist teams * help to identify local gaps that needs addressing and assist in shaping where priorities and resources should be targeted * opportunities for those receiving services to increase their participation in community activities * access to a simple portal which will access a range of community support services Page 1

2 What can we provide? The response will differ according to individual circumstances and need and is delivered flexibly. It may range from answering an enquiry or well being visit, to more in-depth, complex assistance and the level of support depends entirely on the needs of the individual. Where required, a holistic assessment will be offered through a trained Promoting Independence Team which operates countywide. The response often falls into the following categories but tailored to local and individual needs: Improving Hospital Discharge/Preventing Hospital Admissions (Get Well, Stay Well) This service is aimed at individuals who have been discharged from hospital and who may be at risk of readmission or declining health; perhaps due to a lack of social networks or poor mobility. Trained volunteers will visit to identify potential risk factors and assist in signposting or navigating individuals to the most appropriate assistance; this might include support to access specialist teams, help with housing, practical support and benefits advice Following a NHS/Cornwall Council funded pilot project in Camborne and Redruth in March, of the 7 individuals supported through the project and who were considered to be at high risk of hospital admission, none returned to hospital within a three month period. Preventing Falls (Steady-On) Through a nationally accredited programme, volunteers are trained to identify and support individuals who may be at risk of falling or who have fallen already and require ongoing support. This service offers access to a trained Postural Stability Instructor who is able to develop one to one or group activity to encourage exercise and improve balance. Page 2

3 Mrs. G is an older lady with balance problems. She falls regularly often resulting in a call to and a visit from the GP. In the last 6 months, she has also called out the ambulance service and had an emergency admission to hospital. She started attending a balance course run by Age UK Cornwall s trained postural stability instructor. She pays 3 a week for a class and attends weekly with nine other people identified as at risk of falling by her GP; the individual contribution pays for the instructor s time. The GP recently reported that the lady had fallen again, but rather than resulting in a call out, had rung to say that she had used all the techniques provided to her, managed to get back on her feet and continued with her day. None of the other 9 individuals attending have reported a fall since undertaking the course. Memory Support (GP Practice based worker) Working as part of Age UK Cornwall s Promoting Independence Team, the memory support worker forms part of the practice team. The role offers low level intervention for individuals with memory loss and/or dementia together with ongoing support for the carer and family. The role is flexible and can be tailored to meet the needs of the practice and population, but might include case management, home visits, signposting, practical support, befriending, cognitive stimulation and connections with the local community. It enables early identification of physical health concerns and provides an enhanced secondary care function whilst increasing capacity in primary care. In the Pool GP practice, Rosie has been employed by Age UK Cornwall and supported jointly with the practice for the last 12 months. Funded by the practice and the NHS, in that time she has: * increased the dementia register by 33% * provided 100% of individuals on the register with a health check, personalised care plan and information pack * supported all carers to receive a carers assessment * helped avoid inappropriate hospital admissions * supported two people to remain at home; saving 30K in the first 6 months * supported access to memory cafes and cognitive stimulation groups * increased referrals to respite/day services Maintenance Cognitive Stimulation Therapy Cognitive Stimulation Therapy (CST) is an evidence based form of treatment for people with mild to moderate symptoms of dementia. CST has been proven to improve memory and cognition and is the only non-pharmacological intervention for cognitive symptoms recommended by NICE (National Institute of Health and Clinical Excellence). Although it must follow a structured programme it offers a simple, flexible and fun support group for people with dementia and their carers. Currently, Cornwall Partnership NHS Foundation Trust (CFT) run several CST groups attached to a Memory Assessment Service. The Maintenance Cognitive Stimulation Programme was commissioned by Cornwall and the Isles of Scilly NHS, tasking Age UK Cornwall with the delivery of a 14 week maintenance programme to 10 groups across the County offering an ongoing maintenance programme to that provided by CFT; these 10 groups are funded until 2013 and mostly full to capacity although demand continues to grow. Page 3

4 Volunteer Cornwall has developed a national accredited training programme for the recruitment and training of more MCST trainers across the county to underpin the growth of this much needed service. All participants undertake a mini-mental state examination (MMSE) and Quality of Life assessment near the beginning, in the middle and at the end of every 14 weeks they attend. Of the participants in the current 210 groups, 73% have scored the same or increased their MMSE and Quality of Life. Using the Changing Lives approach, many participants in the classes have been supported to develop their skills with some taking an active part in running classes. The groups have also fostered a spirit of cooperation and mutual support with several going on to provide ongoing help outside the group structure. A regular attendee at the Truro group, Mr K waited behind to talk about his experience of living with dementia. His previous occupation meant that he was used to presenting and teaching and he wanted to help people through the initial stages following diagnosis. Mr K is now a seasoned presenter at sessions and training and was the first volunteer for our mentor for dementia scheme in Pool and is helping with a training video. Viva Viva is an initiative being run by Volunteer Cornwall, supported by Cornwall Council Adult Care & Support. It focuses on people with a physical, mental, learning or sensory disability and people with long term illness. We find welcoming, fun and meaningful volunteering opportunities for people who may never have volunteered before, but have an incredible amount to give. The aim is to make volunteering accessible to anyone who wishes to give their time freely to a host organisation. The project provides support, encouragement and training to enable a person to get started and thereafter maintain their volunteering. Viva works with a person s existing key worker, Community Psychiatric Nurse, Occupational Therapist, Physiotherapist and others, offering support during initial meetings with a host organisation and provides ongoing advice and assistance until a placement is firmly established. It allows people to go from being passive recipients of service to becoming actively involved in, and contributing towards the community in which they live. Time Banking In 2009, Volunteer Cornwall opened the first Cornish Time Bank in St Austell. Time Banking is a skill exchange scheme which enables members to swap their skills with other people. Whatever time a person gives to help someone, they get back from someone else. Time Banks work on the basis that everyone s time is worth the same so for every hour you give, you get a one hour time credit which you can then use to have someone help you for an hour. Time credits don t have an expiry date and any time banking activity can be fitted around an individual s other commitments. Time Banking is particularly popular amongst people on lower income who are less likely to engage in formal volunteering. It is also particularly good for providing low level support which is not covered by statutory provision. Working with partners, Volunteer Cornwall will be rolling out a further 6 Time Banks this year and is also exploring a plan to extend Time Banks across the entire county. Page 4

5 Truro Well Being Centre A range of partners who support the health and well being of people and communities in and around the Truro area, led by Volunteer Cornwall and Age UK, have come together to open the Truro Well Being Centre situated in the old Tourist Information office on Boscawen Street in the Municipal Buildings. The idea behind this exciting new initiative is to provide information on community health and well being projects and activities in and around the Truro area. We aim to find the right support for an individual s needs by bringing together health professionals, statutory, voluntary and community sector organisations and individuals to help improve health and wellbeing within the local community. Both staff and trained volunteers will signpost people to relevant services and if we don t know the answer we ll try to find out. As the Centre develops we hope to build on the excellent services that already exist by listening to suggestions and ideas from users and partner organisations. We want to develop more well being centres across Cornwall in places that local people connect to; including GP practices. They are vital places where people can connect and access a range of services and support through one portal. Assisting Patients To Travel To Health Appointments Between them, TAP, hosted by Age UK in Cornwall and the transport division of Volunteer Cornwall provide over 200,000 journeys a year with over 500 volunteer drivers. One centralized booking system brings together 12 local voluntary car schemes through a single telephone portal Through this number, callers will be given information on a range of transport options, including eligibility for subsidised transport, public transport and parking with their journey booked for them with a community car if needed. By matching individual needs to appropriate types of transport, we can even help to find taxis with disabled access if a volunteer driver is not suitable. The service provides a vital link to transport for people in more remote locations when other options are not easily available reducing the sense of isolation and increasing independence. We currently run several dial a ride and community car services in GP locality areas, to and from community and acute hospitals, providing safe and secure transport for individuals needing to reach health related appointments. Both organisations have experience in developing transport solutions at a local level. Changing Lives works! Far too often, we concentrate on a specific condition, a specific intervention or a specific service. Using the Changing Lives principles, Volunteer Cornwall and Age UK Cornwall has developed services which offer multiple outcomes and it flexible enough to be delivered against local priorities and needs. Our services are subject to ongoing evaluation to ensure that we are providing services to the individuals who really need our help and support and to ensure that the services we do provide have a real and lasting impact on their ability to remain living independently in their own homes. Page 5

6 Here are a few interesting facts about our current services: * 80 people a day ring our advice line for help and assistance or come into our offices * 1,000 people a year are supported through our promoting Independent Team * 5,000 people are registered with us for volunteering * We delivery practical shopping, cleaning and home care services paid for by the individual, to 500 people a year * 400 people have taken part in one of our exercise classes * 500 people with learning disabilities are supported through our service * Together, our organisations provide 516 volunteers who drive over 4.5 million miles every year How can we help deliver Changing Lives to Clinical Commissioning Groups? Some of the services mentioned require a level of additional investment to increase capacity and respond to local need whilst others require a blended approach to funding; mixing contributions from individuals with commissioned services. However, we believe that all the services identified will result in cost savings to NHS and social care through a mix of low level interventions and carefully targeted preventative work. We want to help develop a radical and innovative approach in Cornwall where commissioners and local providers work together, using the Changing Lives framework, to have a positive and lasting impact on the health and well being of our population and we welcome further dialogue with Cornwall s Clinical Commissioning Groups to take this forward. For further information contact either Ian Jones, Scott Bennett or Tracey Roose. Ian Jones Scott Bennett Tracey Roose Page 6

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