Improving later life for the people of Cheshire East

Age UK Cheshire East

Dominic AndersonDeputy Chief Executive

Cheshire EastWellbeing

Coordinators

Age UK Cheshire East Local charity providing services around health and

wellbeing, knowledge and practical support

Work with people aged 50+

Won the IMPACT Award from King’s Fund in 2012

Objective to develop the role of the voluntary and community sector in implementation of Caring Together

Cheshire East Cheshire East has the fastest growing ageing population in the

North West - by 2033 more than 45% of the population will be over 50 years of age. *

Life expectancy for males and females in Cheshire East is the highest in the North West and higher than the England average.*

The number of people over 65 classified as being obese in Cheshire East is set to rise from 18,300 in 2010 to 26,900 in 2030.*

The number of people aged over 50 with dementia living in Cheshire East is set to almost double by 2030, from 5,300 in 2009 to 9,100 in 2030.*

* Ageing Well in Cheshire East Programme; A plan for people aged 50 and over 2012-17 (CECPCT2012)

‘Ageing Well in Cheshire East’

making Cheshire East a place where, independence , wellbeing and participation of older people is supported and developed, *

expanding the range of low-level prevention and early intervention services through partnerships with third sector organisations, (including volunteer and befriending services), *

improving links between health and social care integrated teams, GPs and hospital services - integrating services and to coordinate better care. *

The Ageing Well Programme aims to ensure that services are planned in such away that they will continue to meet the needs of the population. Priorities include :

* Ageing Well in Cheshire East Programme; A plan for people aged 50 and over 2012-17 (CECPCT2012)

Wellbeing Coordinators

Background to development with East Cheshire NHS Trust

Funding

5 Wellbeing Coordinators based with Caring Together Integrated Neighbourhood teams

Role redesign project with Skills for Health

Wellbeing Coordinators

to complement the Community Nursing Workforce Review and to develop a more prevention-oriented service

to create a focus for health improvement within the newly established integrated neighbourhood teams

to create pathways into voluntary and community sector services and support

to enable people with long-term conditions to access brief interventions to support them to manage those conditions and reduce their reliance on health and social care services in the future

A partnership between Age UK Cheshire East, East Cheshire NHS Trust, Eastern Cheshire, South & Vale Royal CCGs has developed the role of the Wellbeing Coordinators, in response to a number of priorities:

Wellbeing Coordinators

to support self-care for people with long term conditions

build personal resilience in self managing their health and wellbeing

assessment and review of individual needs

development of individual wellbeing plans

motivating behavioural change

The role of the Wellbeing Coordinator:

Wellbeing Coordinators

Wellbeing Coordinators

Wellbeing parameters – this captures a range of health related data such as; weight, BMI, blood pressure, cholesterol, whether the client has diabetes, smokes, drinks alcohol, eats fruit and vegetables, has any allergies and medicine adherence.

Wellbeing measures – this short questionnaire captures information relating to the client’s feelings and thoughts, their satisfaction and happiness with their life currently as well as a question relating to social trust

Evaluation – establishing a baseline

Wellbeing Coordinators

Reduction in GP visits for emotional issues

Improvement in measures of wellbeing using patient questionnaires

Improvements in LTC parameters including things like reduction in BMI, reduction in insulin dependence etc.

Reduction in unplanned hospital admissions

More effective discharge/reducing re-admissions

Evaluation – additional measures

Successes

The increasing development of local service integration

WBCs seen as ‘equal partners’ – input and work is valued and respected

Numerous client achievements to date

Flexibility to manage change

Transferable role template

Additional funding secured through Big Lottery

Challenges

Organisational change (community nursing review)

Different levels of engagement

Information Governance

IT – access/non-compatible systems

‘Short term-ism’

Hints and Tips in Role Design

Learn from other projects

Take risks/action

Review and make changes

Communication is key

It can be slow – a step at a time

Focus on the outcomes

Case Study

Mr P, 80 year old gentleman who lives alone.

Long-term conditions - heart failure and osteoarthritis.

Referred from Community Heart Failure Nurse as he showed an interest in losing weight, but was finding it difficult due to his long term conditions. He did, however, understand that losing weight would greatly improve his symptoms.

Case Study

On the initial visit, the WBC spent time getting to know Mr P, and discussing his needs, goals, and his past attempts at losing weight

Mr P told the WBC that he had had dealings with dieticians in the past, but that he did not find them particularly helpful. He said he would “dearly love to lose weight” but wasn’t sure how to go about it, short of “starving” himself. The WBC advised Mr P on the importance of eating a healthy, balanced diet, and taking part in regular physical activity, as evidenced in NICE Clinical Guidance (43) on Obesity, 2006.

Case Study

Interventions – food diary, seated exercise plan

Mr P identified two short term wellbeing goals:

To complete exercise plan three times per week, for four weeks

To learn how to use the internet, particularly Skype, in order to keep in touch with family across the country

Case Study

Outcomes

Increased physical activity – does home exercise programme every other day, swims twice a week, attends Tai Chi

Increased fruit and vegetable consumption and lost 7 pounds

Attended IT classes and bought a tablet to communicate with family

Case Study

Outcomes

Reports improved mobility, general wellbeing and reduced breathlessness

Feels part of the community

Wider impacts on partner agencies

Questions/Discussion