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Living Well Team

Living Well Team. Operational since October 2015 I nvestment from Public Health Grant 24 FTE Living Well Coordinators plus 4 Managers Community based in 4 localities covering whole County 2500 referrals to end May 84% of all people have not returned to social care within 12 months.

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Living Well Team

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  1. Living Well Team • Operational since October 2015 • Investment from Public Health Grant • 24 FTE Living Well Coordinators plus 4 Managers • Community based in 4 localities covering whole County • 2500 referrals to end May • 84% of all people have not returned to social care within 12 months

  2. Who do Living Well work with? • People who need some help to prevent them from needing more intensive care and support • Those at risk of some of the key triggers into long-term health and social care • Adults who are currently not eligible for on-going social care and support. • Adults over the age of 18 • Older people • Adults with physical, learning disabilities, sensory impairment, autism or low level mental health needs

  3. Living Well Partners Health and Adult Services (HAS) Customer Service Centre • Key indicators • Lonely and/or socially isolated • Recently bereaved or loss of a support network/person • Recent loss of confidence • Face to face Information, Advice and Guidance Referral to Living Well Team • Work with individual • (identify other key issues) • Risk of falls • Seasonal health • Fuel poverty • Environment • Lifestyles • Sensory issues • Important for... • Motivational Interviewing • Making Every Contact Count • Important to… • PC tools • Good day/bad day Identify existing networks Behaviour change techniques Building confidence Lifestyle Services Personal and community assets Connecting people

  4. Living Well Team – a new approach • Key to success is how we support the person • Person centred approaches • Strength based support • Excellent knowledge of local community • Avoid unnecessary onward referrals • Manage health and stay well • Behaviour Change and Motivational Interviewing • Making Every Contact Count • Mental Health First Aid • Alcohol Identification and Brief Advice (IBA) • Stop smoking and brief advice • Fuel poverty • Falls prevention

  5. Living Well Partners – priorities • Priority referrer groups were identified using defined criteria • Used evidence from NYCC Customer Services Centre - high volume of calls from partners requesting help with ‘social needs’ and practical support. • Many do not meet criteria for social care assessment at this stage. • Primary Care: frequent repeat visitors to GP practices for non-health/social issues. • Secondary Care: particularly emergency departments and hospital discharge teams. • Identified early adopters and possible champions within each locality. • Trading Standards • Job Centres • Children and Young People’s Services • Housing Associations • Data shows that the number and proportion of referrals from these health partners are increasing.

  6. Partnership - Health and Living Well • Working with health partners to introduce Living Well and encourage appropriate referrals for their patients; • GP Practices – included practice nurses and frailty nurses • District Nurses • Community Response Team • Physiotherapists and Occupational Therapists • Discharge Liaison Teams • Vanguard • Multi-disciplinary meetings • Follow up information was provided – poster, information pack • Referral documents are provided via the CCG Referral Support Service (on-line) • Positive local relationships

  7. Living Well – Evaluation Framework

  8. Working with Communities • Living Well Coordinators are extra eyes and ears in the community. • Provide feedback on the availability of low level support in the community to health and care commissioners. • Support the Community Directory • Signposting to VCSE • Receive referrals from VCSE (increase) • Link with Stronger Communities

  9. Living Well and Stronger Communities • Clear communication pathways between both teams via regular meetings and the exchange of intelligence. This has resulted in a greater understanding of the community and its assets and areas of development. • Living Well have been involved with various models of the World Café approach facilitated by Stronger Communities. This has enabled the Living Team to gather and disseminate information whilst connecting and working creatively with communities • Both teams have a clear goal of sustainable outcomes and when gaps are identified we work creatively with partners and colleagues to find solutions i.e. supported volunteering and befriending.

  10. Living Well Intelligence • Countywide themes • Befriending – face to face, online, telephone • Mental Health (thresholds for services high) • Hoarding • Support for younger people – autistic spectrum, learning disabilities • Transport • Local knowledge • Practical support – e.g paperwork • Peer groups for men • Supported shopping – some positive approaches in some areas • Young onset dementia • Peer group sensory impairments

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