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W .H.AT – SUSTAINABLE COMMUNITY CARE SHARON MOAT INT PROJECT LEAD.WHA T I’LL COVERTODA Y • INTs • Why • How • The story so far • Why is it relevantMUL TIAWARDWINNING SERVICE W.H.A.T August 34INT VALUES – FLEXIBLE, UNITED AND INCLUSIVE • To be an integrated workforce. • To have one agenda and open communication. • To enable everyone to contribute to a clear outcome. • To recruit together. • To work flexibly and create new opportunities. • To be innovative and adaptive. Connect Group Adult & Community Service (ACS) Suffolk Health & Wellbeing Board Social Care Service Development & Connect for Health Contracts (SCC) Community Connectors Public Health Children & Young People Connect Co-ordinator (CYP) INT Schools Geriatrician (GLINT) Care Homes Community Domiciliary Transport INT Core Leadership Team Care Providers Libraries Integrated Neighbourhood Team Manager District Councils Safeguarding Community PCN Clinical Directors Development, Norfolk & Housing, Social Prescribing Lead Suffolk Environment, Foundation etc. District Council Trust (NSFT) Ipswich & East How the INT Clinical Norfolk and Suffolk Foundation Trust (NSFT) Primary Care Network (PCN) Commissioning fits in with Group (IESCCG) Dementia St. Elizabeth’s Services Hospice other services. Dentists Compassionate Partnerships Programme SCC & IESCCG Communities Manager Transformation Community Health & Team Faith Groups Therapy Emergency Services LD & MH Services (SCC) Ambulance / Fire / Local Pharmacy Committee Police Voluntary Community Sector (VCSE) Home First Community Action Suffolk, RVS, First Responders, GNSWOODBRIDGE INT REGIONINTEGRA TED NEIGHBOURHOOD TEAM • Woodbridge INT manager is Nikki Pemberton • To work with all members of the community to promote mental and physical health and wellbeing and promote independence.VISION OF IPSWICH AND EAST SUFFOLK • a “place of strong communities in which everyone is able to stay well, take control over their mental and physical well-being and support when it is needed, and receive joined up health and care”. HOW IT BEGAN Within the INT Core Leadership Team We had been looking at our Population Health Management data (PHM) We knew within Woodbridge the data confirmed our thoughts. We had very high rates of frailty within a high elderly population. Looking closely, we could see that we had a higher rate of people having falls. PRESENTATION TITLE August 2024 10WHY LOOK A T FALLS ? • Falls and fractures, are both high volume and costly for health services. Local Population Health Management (PHM) data highlights that falls are the second most powerful predictor of acute emergency admission spend throughout Ipswich and East Suffolk (IES) and North East Essex (NEE). • Falls and fractures in older people are often preventable. ONS POPULATION PROJECTIONS SUGGESTTHAT POPULATION OF SUFFOLKWILL INCREASE BY NEARLY 7% OVER THE NEXT 20YEARS,BUTTHE INCREASE INTHE OLDER POPULATIONWILL BE MUCH GREATER.THE OVER 65 POPULATION IN SUFFOLK IS PROJECTEDTO INCREASE BY 21% BY 2030 AND 38% BY 2040.ALLTHINGS BEING EQUAL,WE COULD CRUDELY ESTIMATETHATTHE NUMBER OF PEOPLE EXPERIENCINGA FALL MAY INCREASE BYTHE SAME PERCENTAGE…. Suffolk Residents aged 65 years and older population Percentage change in Suffolk Residents aged 65 years 300,000 projections by age group and older population by age group from 2020 baseline 90% 250,000 47,588 54,493 80% 42,467 26,603 70% 200,000 46,912 21,765 28,540 60% n 38,570 38,967 i t 15,979 18,120 38,661 35,365 l 50% l 150,000 29,709 p p 25,159 45,175 52,543 P 40% P 45,868 41,468 i 30% 100,000 35,399 g 56,126 58,150 a 20% 49,947 44,823 48,486 C 50,000 10% 0% 45,984 49,478 57,122 59,034 54,490 2020 2025 2030 2035 2040 -10% - 2020 2025 2030 2035 2040 -20% Year Year 65-69 70-74 75-79 80-84 85-89 90+ 65-69 70-74 75-79 80-84 85-89 90+ …however,the number is likely to be much higher because the change in population for the very elderly, who are most likely to experience a fall,is proportionally greater. 2/11/20XX 12 WHA T WE KNEW  There were already pathways for frequent fallers, such as the FAB and GLINT clinics.  We had services like Active Lives conducting Strength and Balance classes within the local community.  We continued to see many patients on our therapy lists who had experienced falls but were too well to meet the criteria for the existing pathways.  We lacked early intervention for individuals who had their first fall, experienced a change in balance, or were becoming anxious about falling. W.H.A.TONE TEAM  We took our ideas to our ONE TEAM group.  We developed our ideas further and gained interest from our peers.  We built amazing relationships with our group. We had the right people in the right room! We showcased our project and gained an audienceTHE IDEA OF A ONE STOP SHOP WAS CREATED. We wanted to create an event, where people could come and speak with all the professionals, they needed all under one roof. To create a space where people could gain advice, be supported and get the guidance they needed to prevent further falls. Professionals we chose were: Physiotherapy/Occupational Therapy Nursing Mental Health Support Social Prescribing/Social Care Pharmacy Foot HealthWHA T HAPPENED NEXT…. We arranged further We kept in touch with our meetings to continue our We believed in it’s worth One Team cohort project We proposed theidea to our Nikki took the idea to our INT INT CLT and gained funding CLT meeting and ensuredour We made a proposal for for 12 months= £10K. We INT Sponsor was aware and funding. were hoping ot achieve at on board . least 1 event a month. W.H.A.TCHALLENGES We faced many challenges! - Foot care- seeking someone independent who could offer a treatment and show the importance of foot care. It wasn’t that easy. - Finding a pharmacist available for regular sessions. We wanted someone who could prescribe and most importantly de-prescribe! - Venues- we are a large area, we wanted to reach different communities - Securing funding. - Avoiding RED TAPE. Designed by Lexamer / Freepik - Being as resource efficient as possible . W.H.A.TFOOT HEALTH • Foot health review is an integral part of the clinic • Neuropathy • Poor circulation • Painful joints • Poor fitting shoes/ slippers WHO ARE WE SEEKING ? • The sessions are aimed at people who: • have had a fall. • are noticing a change in their balance. • are getting less confident in getting out and about. • are worried about falling.REFERRALS • People can self refer or refer a family member • Advertised in GP waiting rooms • Parish newsletters / churches/ hairdressers • Strength and balance classes • Yoga classes • Other HCPsWHA T HAPPENS ON CLINIC DAY • Have six 30 min sessions with HCPs present • Complete a Falls Efficacy Scale • BP recorded seated and standing • Refreshments • Taught how to get up from the floor. • Feedback form • Relaxed and friendly environment WE MADE IT HAPPEN • Since May 2023 we have held 15 in sessions in 4 different village hall locations • We have seen 148 people ( often with spouse, family member or friend) • 94 female 54 male • Ages range from 61yrs to 93yrs • Average age is 79yrs • Medications are reviewed stopped / changed • Onward referrals / recommendations for adaptations/ aids are made • More than 140 follow up calls/ contactsWHICH AREAS ? Woodbridge postcodes (IP12), 66% Other postcodes (IP5,IP13,IP15,IP16, IP17),34%FEEDBACK • Feedback regarding the sessions has been overwhelmingly positive. • People have valued the opportunity to see a multidisciplinary team in one venue. • People have valued the opportunity to be heard without time pressures in a relaxed environment.FEEDBACK W.H.A.TVery impressed by the whole thing. The wellbeing ladies were lovely and really helped my wife. Overall, it gave me more confidence and made me feel like I wasn’t the only one with these problems. Difficult to explain. Good to have someone to listen. I was able to talk without feeling judged or unimportant. People had time to listen. Very conscious that a GP is time limited so you don’t want to burden them WHY DOES IT MATTER ? • 166 miles saved each session • Medication review prevents wastage and ensures appropriate adherence • Falls prevented • Confidence regained PRESENTATION TITLE 2/11/20XXWHY IS IT GREEN OR SUST AINABLE ? PRESENTATION TITLEGUIDANCEAND RECOMMENDA TIONS -AND FINALL Y • Good for ageing population • Good for staff • Good value • AND GOOD FOR THE PLANET “My husband was lucky enough to attend the above session yesterday morning, to which I accompanied him. We would both like to say a massive ‘thank you’ to all concerned. From entering the hall until leaving, everyone was most welcoming, helpful and informative. My husband was a different man walking out, from the one who walked in. His whole personality had changed back from the old, bent, shuffling shell, to the man he had always been……..” PRESENTATION TITLE 2/11/20XX THANK YOU • ANY QUESTIONS ? • Nikki.Pemberton@suffolk.gov.uk • Sharon.moat@suffolk.gov.uk