Making ConnectionsInterim Findings

PRESENTERS

• Andrew Liles, Wessex AHSN

• Caroline Winchcurch, CEO, Hart Voluntary Action

• Di Cheeseman, Age UK Surrey

• Julie Benson, Team Leader, Making Connections, Age UK Surrey

AGENDA

• What we are evaluating

• The Making Connections model explained

• Referral information

• Patient Reported Outcomes

• Qualitative Evaluation

• Impact on A&E and emergency admissions

• Active Ingredients

Making Connections Evaluation

Increase in sense of well-being reported by clients.Clients realising desired goals

Reductions in A&E attendances, admissions to hospital, GP appointments, referrals to mental health and social care

Increased use of voluntary and community based services.

Social Prescribing

“A means of enabling GPs and other frontline healthcare professionals to refer clients to a link worker – to provide them with a face to face conversation during which they can learn about the possibilities and design their own personalised solutions ie ‘co-produce’ the ‘social prescription’ – so that people with social, emotional or practical needs are empowered to find solutions which will improve their health and wellbeing, often using services provided by the voluntary and community sector”.(Social Prescribing Network Conference Report: January 2016

Making Connections Delivery

• Using the Age UK Surrey model already in place in Farnham, the project has been replicated and extended to include anyone over 18 years of age who would benefit from short term support to improve their sense of wellbeing living in North East Hants and Farnham.

• “Guided conversations” in home over a number of visits to inform a person-centred plan with goals set by the client.

• Client has up to 3 months’ support from a team of co-ordinators (and volunteers). Target to reach 350 patients.

• Support to link patients in with services run in the community, especially voluntary groups and with volunteers.

• Wider dissemination of information to raise awareness and encourage self-help or self-referral.

• Evaluation of outcomes to date by end of March 2017.

Referrals

• 48 referrals received in the Farnham project (July 15 to June 16)

• 188 referrals received from 1st July – 6th Jan• 81 active clients• 33 clients have completed and achieved their goals• 23 clients triaged and referred on to appropriate

support• 19 clients on the waiting list• Remainder withdrew due to worsening health or

declined service

Referral examples• Nepalese woman in her 50s living in inappropriate housing for

her disability• Man in his 90s with reduced mobility wants his wife

recognised as his carer and linked to carers’ support• Young man in his 30s (ex-army) – trouble with holding down

work and socialisation with others• 26 year old man who is autistic and has mental health issues

who has low self esteem• 3 women in their 20s with post natal depression• Woman in her 50s with MS who needs motivation to regain

her independence• 2 young Central European men who have suffered

trauma and are isolated due to ethnic background

Goals

• Volunteering• Wellbeing• Independence• Life skills• Money matters• Carers’ Issues• Practical support

Patient Reported Outcomes – Health Confidence

I know enough about my health (N before = 80 / N after = 35)

I can look after my health (N before = 80 / N after = 35)

I can get the right help if I need it (N before = 80 / N after = 34)

I am involved in decisions about me (N before = 80 / N after = 35)

Health Confidence Score aggregate score (N before = 80 / N after = 34)

Heal

th C

onfid

ence

0 10 20 30 40 50 60 70 80 90 100

68

56

59

69

63

72

69

71

68

70

On follow up On referral

Patient Reported Outcomes – Personal wellbeing

I am satisfied with my life (N before = 80 / N after = 35)

What I do in my life is worthwhile (N before = 80 / N after = 34)

I was happy yesterday (N before = 79 / N after = 35)

I was NOT anxious yesterday (N before = 79 / N after = 35)

Personal Wellbeing Score aggregate score (N before = 78 / N after = 34)

Pers

onal

Wel

lbei

ng

0 10 20 30 40 50 60 70 80 90 100

42

44

49

37

43

56

52

61

45

54

On follow up On referral

Qualitative Evaluation

Interviews with 8 people identified four themes:

1. Strength of the relationship

“We just chatted about everyday things and we thoroughly enjoyed each other’s company”

“ I keep thinking that it’s a privilege them sharing with me what their lives have been and are, to allow me to come in and assist them”

“I’ve loved her coming”

2. Practical assistance

“She comes and takes me out occasionally, which is wonderful.

Qualitative Evaluation

Interviews with 8 people identified four themes:

3. Match between client and service

“ I’m only a youngster at 72 and quite active”

4. Service infrastructure

“(attending the MDT meetings has) raised the profile of the voluntary sector with the health professionals and social services”

“They’ve been absolute gold dust to us, they come every week”

Impact on A&E and Emergency Admissions

• The Commissioning Support Unit have analysed the emergency activity records of 206 clients referred to Making Connections between August 2015 and November 2016.

• Their analysis compares clients use of A&E and emergency admissions to hospital for the 120 days before referral with the 120 days that follow.

• The majority of patients are still within 120 days of their referral date so haven’t been included yet – so the findings are very early and come with a health warning.

Impact on A&E and Emergency Admissions

• The very early and caveated findings are showing:– A reduction in the rate of A&E attendance of 18%

– A reduction in the rate of emergency admission of 19%

• These are encouraging and comparable with other social prescribing services evaluated by the AHSN.

• We will continue this analysis to firm up the rates of change and use these to undertake an economic evaluation of the service.

Active ingredients that support this model

• Co-design of project with CCG.• Time to develop the relationship with the client – guided

conversations• Practice buy-in and support.• Being part of the MDT is essential. When it works best, the

Coordinator is an equal player at the table - this takes time to build.

• Good local knowledge and connections• The benefits of the Coordinators being hosted by an

organisation that is focused on community development and partnership.

QUESTIONS

ContactNorth East Hampshire and Farnham CCG

Making Connectionsc/o Hart Voluntary Action

Civic OfficesHarlington Way

FleetGU51 4AE

Tel: 01252 815652E-mail: NEHFCCG.MakingConnections@nhs.net

www.makingconnections.org.uk