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British Red Cross
The role of the third sector in delivering
seamless care
Kate Griffiths
Director for Wales, British Red Cross
The third sector’s role in seamless care
A Healthier Wales:
“Co-ordinating health and social care services seamlessly, wrapped around the needs and preferences of the individual, so that it makes no difference who is providing individual services.”
Home to the Unknown report (2019)
➢ People are returning home without adequate consideration of their non-clinical needs
➢ Often they are not eligible for statutory support at home
➢ There is variation in discharge practices
➢ Communication is often a challenge
➢ People don’t understand the ‘system’
What our research tells us
British Red Cross’ role in health
and social care
An example: Winter Pressures 2018/19
Since December 17th the British Red Cross has been delivering a winter pressures programme in 7 NHS
hospitals in Wales.
25,000 people have been supported by Red Cross staff and volunteers in EDs – bereavement support,
emotional support, collecting meds/results/equipment/accompanying patients, transport home and
resettlement/signposting and follow up support
471 people have been taken home and resettled from hospital
People resettled have received shopping, home environment checks and emotional support
293 people received a follow up support phone call or visit
Jon had recently moved home where his social networks shrunk. After an extended period of unemployment he finally found a job but
soon after fractured his ankle and was admitted to hospital for treatment. After a short-stay in hospital Jon was discharged and within days
was visited at home by the hospital’s Supported Discharge team. They discovered him at home alone with no food, no electricity, no
heating, and no money to resolve these issues. Jon was therefore re-admitted as a failed discharge.
What We Did
▪ We were asked to help transport Jon home and facilitate his JSA for his second discharge home
▪ Pre-discharge our team contacted the local foodbank to arrange some provision of food, and money to finance electricity
▪ Once agreed we sent volunteers to collect 2 weeks’ worth of food parcels, in addition to £40 for electricity and transport
▪ Our volunteers took Jon home, settled him in, demonstrated what meals he could prepare with the food parcels, assisted him in
placing money onto an electricity key and arranged community transport so he could reach his first appointment at the fracture clinic
The Difference We Made
▪ This demonstrated, combined with a number of factors, a single accident can have significant complications to how an individual lives
their life.
▪ We enabled the core issues to be addressed as Jon, and some others, saw them
▪ Assistance from the volunteers allowed Jon to have access to food, to be comfortable living in his own home, and to continue his
recovery by reaching his follow up appointments.
▪ This intervention helped Jon in a critical moment whilst alleviating pressures on health care services that dealt with the re-admission
and delayed transfer of care.
Case Study 1
Graham had been admitted to hospital after falling down the stairs. As he fell, he injured himself and his wife in the process. The wrist
injury to his wife meant she was more restricted in the care she could provide to him along with the needs of caring for his dementia.
Graham was now medically fit to go home but had nowhere to sleep in his home because negotiating stairs presented a risk.
Graham and his wife planned to live downstairs for the short term but they were keen to get a stairlift eventually, to regain full
independence. Hospital staff deemed it not safe to discharge Graham until his living arrangements had been adjusted.
What We Did
British Red Cross put in place low level support to facilitate Graham’s discharge.
Two Red Cross support workers met Graham and his wife at home that same afternoon. They worked together to make improvements
and low level adjustments to the living room. A temporary bed was installed with a suitable bedrail for Graham. Furniture in the room was
repositioned in order to allow for space and safe transfer to the bathroom and living area.
The team also discussed the activities that Graham and his wife enjoyed doing and talked about how they could continue with these and
what extra considerations they would need to take into account to help get their independent lives back. We continued to support the
couple at home and helped them to obtain quotes for the installation of a stairlift and provided information and support for their decision
over the telephone.
The Difference We Made
• We freed up a bed and nursing/OT time earlier than would otherwise have happened
• We got Graham out of hospital and improved his chances of recovery to independence
• We supported Graham’s carer and helped him to avoid unplanned readmission
• We looked at the couple’s non-medical needs to help with their quality of life
Case Study 2
Thank youFor more information please contact:
Kate GriffithsDirector for Wales, Independent Living and Crisis Response
“SIM
BETTER @ HOMEElisa Faulkner – Operations Manager”
Age Connects Morgannwg is an older persons charity operating in Bridgend, Rhondda Cynon Taf and Merthyr Tydfil.
Established in 1972, we provide a range of services including:
• Support
• Information & Advice
• Independent Advocacy
• Nail cutting
• Befriending
• Products including funeral plans and will writing services
➢We listen
➢We learn
➢We care
We are about older people getting the help they want, when they want it. We work to ensure that those who are vulnerable and at risk are kept safe. We empower older people to be heard, to have choice and control, so they don’t feel isolated or discriminated against and that they receive the support and services they need. Our work is driven by what older people say matters most to them and their voices are at the heart of all that we do.
Hospital to Home➢Princess of Wales - Bridgend
➢Royal Glamorgan - Llantrisant
➢Prince Charles – Merthyr Tydfil
• An essential partner to the NHS, we ensure safe discharge of people to their homes and provide immediate support, including settling them in at home and ensuring they are safe and warm.
Better @ Home• Ongoing support including shopping,
assistance with sorting out bills, making and accompanying to appointments, companionship and signposting to other services.
• Filling the gap where social services may once have stepped in, our work assists in reducing readmission rates and ensuring older people feel safe at home, following a hospital stay.
The role of the third sector in delivering seamless care.Supporting people living with arthritis
Mary Cowern – Wales DirectorGofod3 2019
01.
Our Role - Addressing the gaps
FearpaindoctorsMedicationIsolationChallengesMisconception
Approx. 29.2% of the adult population
of Wales live with the pain of arthritis
• Most frequently reported chronic condition
in Wales & leading cause of disability
• 1 in 5 consult a GP every year with MSK
problems
• MSK problems are addressed in one in
eight (12%) GP appointments
• MSK conditions cause 20% of all sickness
absence and 30.6 million working days to
be lost in the UK every year.
• Aging and overweight population
• Many myths and misconceptions about
arthritis
Delivering seamless care
understanding support needs• We know our client base
• We can be innovative and agile in delivering community focused, value for money solutions across boundaries
• We can build on our specialist knowledge and strengths, including our research intelligence
• We are outcome driven and value driven
• Self care, co-production and shared decision are making central to our services
“The people who
say arthritis has
the most impact
on their quality of
life are 3 times
less likely to adopt
self management
strategies Arthritis Care OA Nation, 2012 Report
We don’t work in isolation –partnerships are key to our success
02.Seamless care in action
Get Active with Arthritis ProgrammeSupporting people living with arthritis to overcome the barriers to becoming more active and to lead a healthier lifestyle
• 3 Year Project funded by Big Lottery
• Delivered in Mid & North Wales
• Addresses gaps in statutory service delivery
• Unique to Versus Arthritis and the wider MSK community in Wales
• Co-produced in partnership with people living with arthritis and health professionals
Plugging the gaps• Myths, fears and lack of confidence to remain or become active
• Lack of access to physio sessions & NERS
• Cost barriers
• Our solution
• 1-1 mentoring sessions, taster activities, self-management sessions, continuity activity sessions within the community and activity support groups
• Outcome - beneficiaries adopt and maintain newly learnt skills and enjoy activities with renewed confidence
Working with the statutory sector
• Working alongside primary care to support
condition management
• Promoting shared decision making
• Cross referral from physiotherapy teams and
NERS
• Self-management toolkit
I’m very impressed with the content and presentation of the resource for arthritis patients and look forward to working in collaboration with you all at Arthritis care to promote it to the working population seen by CMATS.
It will be refreshing to be working with arthritis patients (who do not require surgery) to promote such a positive message of how they can improve their lifestyle and live well with arthritis.
Congratulations on producing this life improving and excellent resource!
Physiotherapy Clinical Specialist, Newtown
03.The difference we make
FlintshireGet ActiveFunConfidenceCompanionshipGardening
Thinking outside the box
04.The challenges
Barriers & Pitfalls• Building relationships where
there isn’t a direct contact via
commissioning
• Reliance on grant funding or
short term funding
• Managing demand vs capacity
05.Why its important
“I was diagnosed with Rheumatoid Arthritis when I was 10 years old. I
missed so much school and spent most of my time in hospital. The
Biologic drugs changed my life and my future. I felt totally unrestricted
and independent for the first time ever.
I was determined to take on new challenges and prove that my RA
was no barrier. In 2011 I was awarded a Flying Scholarship and after
6 weeks in the USA I gained my PPL!”
Helen Saxon-Jones. Get Active Project Coordinator.
Thank you!
Gofod3
www.versusarthritis.org
PIVOTPembrokeshire Integrated Voluntary
Organisations Team
Debbie JohnsonPembrokeshire Association of Community Transport Organisations
What is PIVOT?
A Pembrokeshire third sector collaboration:
to
• Support at home after a hospital stay
• Prevent inappropriate hospital admissions
• Build confidence and self esteem to enable people to
live independently within their own homes.
Funded through Welsh Government Integrated Care Fund
• Transport from hospital and settling at
home for people with no means of
transport and/or support.
• Signposting and referrals for information
and advice and to additional help and
support, including other third sector,
health and statutory services.
• Access to rapid response service for
small adaptations within the home and
home safety checks.
• Practical and emotional support,
including shopping, light housework and
laundry.
The PIVOT Service
3.5 Case Workers.
Small team of home
help volunteers.
25 volunteer drivers
on a rota basis.
7 days a week
365 days a year
until 8 p.m.
Single telephone
number to access
any part of the
service
Seamless Care: a pivotal link
PIVOT
Referrals from …
Acute health professionals
(A&E and Wards)
Social Services
Emergency services, Paramedics
GPs
Community health and social care
Community Connectors
Third sector support & advice
Community support
Statutory services
Benefits checks
Home safety advice
& adaptations
Community transport
Linking to …
Person-centred Support and follow-up
Seamless Process – a coordinated
chain of support
(More than a)
Transportservice
Rapid response adaption
Case Worker
Visit (within
24h)
Practical Help and Support
Sign-posting
and Advice
Follow up / Follow through
Referral in …
Single point of contact
Referral on ….
Impact
(2018/19 to date)
• Supported 721 service users
• 60% prevented hospital admissions
• 40% supported discharge
• Saving over 4,000 bed days per year (valued at £1million).
• £5.6 benefit per £1 invested
• Keeping people out of hospital and helping them to get the support they need
PIVOTPembrokeshire Integrated Voluntary
Organisations Team
Debbie JohnsonPembrokeshire Association of Community Transport Organisations