Age UK Oxfordshire Circles of Support; supporting the elderly health care journey and getting them safely home from hospital
Every service user has unique care co-ordination needs and concerns that can only be met by understanding their individual lifestyles and circumstances. Older people are particularly vulnerable to social isolation and loneliness, and there is much evidence of the negative impact this has on their general health. Age UK Oxfordshire, the regional fraction of the largest charity supporting older people in the country, run a service called Circles of Support, that through effective integrated service provision, aims to counter this to a degree, improving care co-ordination for this population group, and in turn their quality of life. Ann Nursey; Head of Circles of Support for Age UK Oxfordshire, shares more about exactly how this is achieved.
What is it?
Circles of Support started in October 2014, and is one of seven pilot projects funded by the Cabinet Office and National Tripartite Group, focused on testing the impact of bringing Voluntary and Community Services to the heart of the health and social care system. Not only are older people (aged 60+) widely known to experience issues relating to social isolation and loneliness, but as you age, your immune system naturally changes. This effectively means that some of the people with the poorest health are the most isolated.
The project is based on the belief that older people who have, or are supported to have a strong social network, may have a lower likelihood of hospital admission, and ultimately be healthier than more isolated individuals. The premise being that having someone to talk you through your options, help and encourage you to stay fit and simply have fun on a regular basis, gives an individual a sense of purpose and a motivation to stay active, well and generally take care of themselves.
“The project is based on the belief that older people who have or are supported to have a strong social network may have a lower likelihood of hospital admission, and ultimately be healthier than more isolated individuals. The premise being that having someone to talk you through your options, help and encourage you to stay fit and simply have fun on a regular basis, gives an individual a sense of purpose and a motivation to stay active, well and generally take care of themselves.”
How does it work?
Six Community Networkers, and a small team of volunteers, from Age UK Oxfordshire are helping to develop Circles of Support around people at risk of admission to hospital, and who need help to establish activities and relationships in their local community. The Community Networkers and volunteers are embedded in 6 Integrated Locality Teams, with health and social care staff, and aim to provide a holistic and person-centred response to a person’s needs.
Age UK Oxfordshire also has three Care Navigators, supported by volunteers, working as part of the multi-disciplinary team on certain wards at the acute hospitals. They support people and their families with information and advice, to understand their options if they have care and support needs, and to put in place the help they need so that they can go home from hospital safely as soon as they are well enough.
The community networkers and care navigators are employed and managed by Age UK Oxfordshire, but have honorary contracts with the health trusts, sit in the Integrated Team office, and have access to their IT systems and client records as well as the Age UK database. They participate in multi-disciplinary team meetings and work with their health and social care colleagues on an equal footing.
Since we started the work, the response from service users and health and social care workers has been very positive. We really haven’t had any colleagues saying that they don’t understand what we are trying to do. In fact, if anything, we are being asked to do more and more. When the pressure is on in the hospital system, being able to draw from an initiative that is trying to effectively make life easier and lighten the load is a good thing! Staff are grateful, receptive and keen to work with us. People have very much embraced us and we try to be flexible and offer support wherever we can.
“When the pressure is on in the hospital system, being able to draw from an initiative that is trying to effectively make life easier and lighten the load is a good thing! Staff are grateful, receptive and keen to work with us. People have very much embraced us and we try to be flexible and offer support wherever we can.”
In terms of commissioners their response has also been very positive and supportive, but ultimately funding has to come from somewhere, and they are waiting to see evidence from the forthcoming Nuffield Trust report, evaluating the seven pilots running across the country, which will show if what we are doing is reducing costs in the system e.g. fewer readmissions, faster discharge rates before committing to supporting the project long term.
The initiative has also been really great for staff dynamics. The team have found that being located together with health and social care colleagues has helped everyone to get to know each other, and made communication easier. Referrals within the team can be quickly sorted out on a daily basis as well as at weekly team meetings. Joint visits and shared case management mean that the knowledge and expertise of different practitioners can be brought together and discussed with the service user in a way that recognises the interacting elements of a person’s life, and makes life easier for them – not harder.
Health and social care practitioners have fed back that they value having community networkers, care navigators, and volunteers, as part of their teams:
“The NHS is focused on medical help. They know social activities are important for people but they can’t invest time in this.”
“The healing process is benefited by [Age UK’s] work. With this support you can achieve more than just discharging without support.”
“Saves us doing referrals and phone calls – the Community Networker knows all the right contacts. She is part of the team because she is physically here.”
“Makes a huge difference working on the same [hospital] site.”
“Without the Care Navigator we wouldn’t have the whole information and the right guidance for patients – for example she is able to advise on benefits.”
“The networkers are a huge asset to us.”
“I have no concerns about referring clients to Care Navigators – they do a professional job and respond appropriately and sympathetically. Skill is needed as people and families can be distressed.”
Service user impact
There are sadly a lot of lonely, older people in the community, and they have become increasingly isolated. A lot of older people have recurring health concerns, but do not have the social networks needed to access the care they need on a regular basis. Circles of Support is trying to counter that and the responses given from service users in their feedback surveys, speak for themselves:
“I appreciate having her to talk to and she was very helpful and caring to me”
“Revived my mental faculty by joining me up to a group of German conversation”
“She gave me support and made me realise help was available”
“Very helpful in referring to services and local groups to meet people.”
“I left hospital very recently and I already have a laundry service in place and solemates are coming next week.”
“It is amazing that everyone is working together to sort this out, this has not happened before to me’ – patient supported by the local Integrated Locality Team.
Over the last 10 months, the way the community networkers and care navigators work with their colleagues has evolved, with a growing trust, understanding and respect for each other’s contribution. Community networkers now provide lots of informal information and advice to colleagues about community resources they can link their clients into; they carry out joint visits; and they can remain alongside a colleague, in the background until a person is ready for them to become involved.
Challenges so far?
With a service so socially focused there is a need to recruit and train the right kind of volunteers and staff; committed, compassionate people that can stay the course. Thankfully we have been really successful in building a great, capable network of people including retired nurses, and other people with vocational direction. However service user interest in the scheme is constantly growing, so we always, always need more people, so recruitment is definitely up there in terms of challenges.
And of course the nature of non-profit programmes being supported by stop-start funding, is always an issue, but one we are well aware of and trying to work around regardless.
Currently we have funding until the end of April 2016, and the pilot evaluation data will close at the end of September, with the final report set for publication in December 2015.
As well as looking at readmission services and the speed of service user discharge exchanges, the report will also include qualitative interviews with both staff and service users, to really track a patient’s health journey. The only drawback to trying to show the scheme’s preventative impact is that even if something is benefiting someone’s life it won’t necessarily be reflected in the core data for perhaps two or three years. Circles of Support has been running for just half that time, and while the positive preventative impact is being felt it may not necessarily show at this stage. But we are hopeful that this won’t be the case!
Finally there is an issue around companionship and linking service users to low level contact services. Circles of Support exists to link people to other people and groups in the community, rather than providing ongoing support from the team itself. There are a lot of groups out there for like-minded people that want to connect over an activity, but not everyone wants to go out to group activities. We are trying to fill the gaps between people who just want someone to have a cup of tea with, knit with, or to come with them to a hospital appointment. It’s hard to stimulate that kind of development, but we are working to support the setting up of good neighbour schemes and friendship drives, but they take time to evolve and we are of course a short term pilot. There is a great expression “small steps have big impact” – and whilst we have lots of personal stories to show this, it is harder to measure in objective terms.
It is early days for this project, and for the Integrated Locality Teams in Oxfordshire. The impact of the seven pilot schemes on preventing admission to hospital will be evaluated by the Nuffield Trust report this autumn, due to be published in December 2015.
Approaches to integrated working are evolving across the country, and undoubtedly there is much more for us to learn. However, the feedback from case studies, health and social care colleagues, and the people we have worked with, has been overwhelmingly positive and supports our belief that integrated service delivery is a crucial element in establishing efficient and person centred support.
For further details on the difference Circles of Support is making to service users download the Interim Report here
To learn more about Age UK and Circles of Support visit: www.ageuk.org.uk/oxfordshire