Reimagining Care: Developing the CHIN Model for Self-Care and Social Prescribing

1. Reimagining Care Closer to Home @SocialEnt_UK @IVAR_UK #BHPselfcare

2. Welcome Katie Coleman & Helen Garforth • @SocialEnt_UK • @IVAR_UK • #BHPselfcare

3. Design tangible actions or projects to develop the CHIN model that will: Support people to self-care Connect social prescribing and community initiatives across North London Re-imagine how the system could work best for patients and residents Establish the roles local voluntary sector organisations, commissioners and others can play Aims for today:

4. A common Outcomes Framework for social prescribing across NL Expert patient programmes in each Borough A social prescribing link role in each CHIN and a mechanism for connecting togheter A central person/ organisation/ system to make opportunities/ services/ providers visible Where are we at? Focus on four areas: @SocialEnt_UK @IVAR_UK #BHPselfcare

5. Research and conversations about what’s happening in NL around self care Core group formed Partnership Session 1 in Sept Volunteers coming together to take forward ideas and bring them today… How we got here? @SocialEnt_UK @IVAR_UK #BHPselfcare

6. What helps us feel good and look after our health? What helps us recover and stay well? • Relationships, social networks, family, friends – ‘depend on us and support us’ • Holidays, travel • Hobbies • Work • Success • Exercise • Having fun – social activities • Walking, fresh air, pets • ‘Feeling better on the journey’ • ‘Seeing others doing the same’ • ‘me time’ • Self-belief • ‘doing things we love and enjoy’ • Giving back, sharing • Nature, outdoors • Shopping • Eating, healthy eating • Belonging • Socialising, interaction • Relaxing, time/prioritisation @SocialEnt_UK @IVAR_UK #BHPselfcare

7. …what gets in the way? • Time pressures • Stress • Family • Work • Life • Perfectionism • Drugs and alcohol • Children • Services that don’t meet needs • Over thinking • Fast food • Lack of information/confusion • London life – traffic, hectic life • Technology, phones 24/7, social media • Too much socialising • Conflicting public health messages – ‘fads’, one size fits all @SocialEnt_UK @IVAR_UK #BHPselfcare

8. Local priorities Looking at how the new Care and Health Integration Networks (CHINS) can make the most of what’s working well such as social prescribing, expert patient programmes etc, and discuss how we can all collaborate to support better health and wellbeing: • Exploring what self-care means in North London, and how it is supported • Sharing stories of what is working well and what’s not , and what might • Working together to prioritise and plan for further action and further sessions • Developing action plans that will make a difference when it comes to looking after ourselves in North London- both quick wins and longer term changes in the system @SocialEnt_UK @IVAR_UK #BHPselfcare

9. Examples of what’s already happening in North London? @SocialEnt_UK @IVAR_UK #BHPselfcare

10. 4 possible areas for joint action Access to Information, building awareness (of social prescribing??) Compiling resources and information in a database/platform. Carry out communications and engagement activities to raise awareness. Actions • Review what’s already been done • Explore potential for sharing the platform • Research/consultation on what people want to know • Carry out a cost benefit analysis/create a business case • Involve CVS Workforce development Carry out training with the whole workforce drawing on the skills and knowledge of the voluntary sector. Create an online database. Change contracts. Actions • Mapping of training and services • Engage the workforce • Develop an memorandum of understanding with GPs and other services • Collect feedback from service users and the workforce @SocialEnt_UK @IVAR_UK #BHPselfcare

11. 4 possible areas for joint action System-wide coordination Build knowledge and understanding of social prescribing. Make sure opportunities are consistently available and known (i.e. on the same platform). Ensure all GPs have a link worker. Support volunteers and use codesign Actions: • Share data, good practice, outcomes measures • Create a business case • Standardised protocol – operational framework • Share vision statement EPP in place across NCL Make sure EEP is in place in every CCG to reduce usage of hospital services for patients with long-term conditions Actions: • Business case for export PAT programme • Standard specifications for Care Nav and LAC etc @SocialEnt_UK @IVAR_UK #BHPselfcare

12. A common Outcomes Framework for social prescribing across NL Expert patient programmes in each Borough A social prescribing link role in each CHIN and a mechanism for connecting together A central person/ organisation/ system to make opportunities/ services/ providers visible Recap our focus – reimagining the system arriving at tangible projects @SocialEnt_UK @IVAR_UK #BHPselfcare

13. What’s happening elsewhere in BHP Some definitions – SP, CHIN Inspiration – what works well around NL? Re-imagining roles within the system Action planning Interrogating plans Next steps What we’ll do today @SocialEnt_UK @IVAR_UK #BHPselfcare

14. Herefordshire and Worcestershire - ‘Think Carer’ • BNSSG - ‘A Good Life in Old Age’ • Greater Manchester - ‘Borough of Rochdale, Building & Connecting Communities’ • North East STPs - ‘Keeping Well in Communities’ • Humber, Coast and Vale - ‘What makes us feel good – our health in our hands’ • Mid and South Essex – ‘Breathing well: pathways for respiratory health’ • Hampshire and the Isle of Wight - ‘Pathway to engagement & co-production: mental health crisis care’ What’s happening elsewhere? @SocialEnt_UK @IVAR_UK #BHPselfcare

15. Presentations • Working definition of social prescribing in London – Jason Tong and Claire Davidson • Social prescribing practically from a VCSE perspective – Andy Murphy (Age UK Islington) • What is CHIN and how do they work? – Katie Coleman Establishing definitions: @SocialEnt_UK @IVAR_UK #BHPselfcare

16. Social prescribing and self-care models and definitions Claire Davidson and Jason Tong @SocialEnt_UK @IVAR_UK #BHPselfcare

18. Definition of Self-Management for Long Term Conditions • “The individual’s ability to manage the symptoms, treatment, physical and psychological consequences and lifestyle changes inherent in living with a long-term condition.” DH 2005 • Knowledge, Skills, Confidence • Medical management, Role management, and Emotional management

19. Social Prescribing Definition: New relationship/model of care Self-referral Traditional practice in health settings - Signposting New Model of Care in health settings – Social Prescribing

20. Social Prescriptions: Statutory and Community Assets

21. Example of a whole system self-care and social prescribing model

22. What does social prescribing look like practically from a VCSE perspective? Andy Murphy AgeUK Islington @SocialEnt_UK @IVAR_UK #BHPselfcare

23. Social Prescribing – WHAT DOES IT LOOK LIKE PRACTICALLYFROM A VCSE PERSPECTIVE? Age UK Islington – In OUR View Practically – Social Prescribing is a means, not an end in itself Practically – Social Prescribing exists on a continuum from ‘Information’ to ‘Navigation/Link Work’ Practically – Social Prescribing has to fit within a wider range of ‘Wellbeing’ service inputs and processes Practically – Social Prescribing is like other forms of Prescribing You want to prescribe the right thing … in the right dose … in the right way … as part of a wider ‘treatment’ … being mindful of interactions … minimising negative side effects … avoiding dependency … assuming the person can take them ... assuming the person will take them And then you want to … Check its working … Review and increase/decrease/change/stop as needed ……. towards some goal….. Doing {prevention] Properly

24. Conceptual Model – Goal/Value Proposition for Social Prescribing within ‘Wellbeing’ (There’s got to be a reason for buying it…) +veChange for individual Primary Care Acute +veChange for individual POS WHATS GOING ON NEG WELLBEING Social Care POS COPING ABILITY NEG Age UK Islington ‘What’s Going On and How Coping’ Matrix (Situation Gauging) Year of Care Model

25. Practical Model - Operationalising (internally and externally) (There’s got to be a way of organising it, managing it and measuring it…) Situation Situation Highly negative Highly Positive 0 1 2 3 4 5 Situation Situation Highly negative Highly Positive 0 1 2 3 4 5 ONE supported Age UK Statutory Service Self Managing ‘All Ages All Stages’ continuing contact Self managing Self Managing Nil ability confident 0 1 2 3 4 5 Self managing Self Managing Nil ability confident 0 1 2 3 4 5 Navigation Enablement Advice Information Carers Hub Activities • Wellbeing Screening • Targeted • Regular • Wellbeing Promotion • Get Help • Keeping Active • Get Together Escalation Case work needed? (Common goal for individual and system) Early/Self identification +veChange for individual Activities Attendance

26. CommsModel – Visualising it for People and Practitioners (There’s got to be a way of explaining it…)

27. Practical Model – Delivery Process Route to Team > Gauge/Co Produce Plan > Coproduce Delivery > Gauge Outcome and Impact > Set Follow On> Quality Assure (There’s got to be a way of delivering consistently … )

28. Opening Stages (There’s got to be a way of working out- with the service user/patient- what to prescribe, and how it will be delivered…) Route to Team > Gauge/Co Produce Plan > Coproduce Delivery > Gauge Outcome and Impact > Set Follow On

29. Tracking Inputs – Why? Service Activity & Inputs Opening Closing (There’s got to be a way of working out what works …)

30. Workforce Set the ‘Actions Completed’ field to ‘Yes’ when Actions are completed as part of Check Outcomes/Impact/Quality stage (There’s got to be a way of aligning your staff and volunteers on ‘the way’….) Set the ‘Actions for Plan Set’ field to ‘Yes’ when Actions are set as part of Finalising the Service to Deliver

31. Workforce & ‘Directories’ (There’s got to be a way of ensuring consistent/correct ‘prescribing’ – even by less experienced staff and volunteers….)

32. Sustaining Outcomes (There’s got to be a way of gauging follow up/follow on, stepup/down progress towards overall goals, and what works at population and sub group levels - so you can do more of it … ) Common Outcome Framework and Wellbeing Gauge – across services. Targeted Prevention Input Follow up/ follow on set based on GAUGED future self managing capabilities

33. (There’s got to be a way of tracking and responding to trends for an individual over time, integrating with the rest of the system – and continually improving ...) Wellbeing in 1 – Over Time • Keeping Active • Get Together Age UK continuing contact supported Wellbeing Promotion Wellbeing Screening ONE Self Managing 2027 2017 2020 < < < < < < < < --------------------------------------------------------------------------------------------- Case Records ONE Age UK

34. What is CHIN and how do they currently work? Katie Coleman @SocialEnt_UK @IVAR_UK #BHPselfcare

35. Care Closer to Home Integrated Network (CHIN) Team CHIN OUTCOMES • STP, CCG, CHIN QOF + targets: • CHIN shared registers with templates to deliver QOF + • Shared management/ input to delivery of targets annually • Contracts aligned CHIN TEAM Pharmacist working across the practices within the CHIN. Working with registers, proactively reviewing patients. Specific service lines working in primary care, alongside the CHIN practice teams to improve population health outcomes. Practice based pharmacist Community Services staff (Specialist nurses, Physio etc.) Acute (specialist advice and guidance) 5 x General Practice team (GPs, PNs, HCAs) & QIST Mental Health Mental Health input in to the team via a link worker or primary care mental health support through clinics within the CHI. Proactive population support. Consultant/ specialist advice and guidance to GPs/ other CHIN staff in managing patients in primary care and avoiding unnecessary referrals. Voluntary Sector link worker/ navigator Social Care Voluntary sector care navigator linked to CHIN and able to proactively social prescribe. Social care linked to CHIN to support and link to local authority support for proactive support.

36. What is the most exciting aspect of this emerging model from your perspective? • What are the things that worry you? Group feedback & reflection: @SocialEnt_UK @IVAR_UK #BHPselfcare

37. Local case studies to inspire: • Presentations • Bridge Renewal Trust, Haringey – Geoffrey Ocen • Age UK Islington – Andy Murphy • Expert Patient Programme, working within the CHIN – Claire Davidson @SocialEnt_UK @IVAR_UK #BHPselfcare

38. Bridge Renewal Trust, Haringey Geoffrey Ocen @SocialEnt_UK @IVAR_UK #BHPselfcare

39. ‘Re-imagining Care Closer to Home’ – 2nd Partnership Session CHINS and Social Prescribing in Haringey - A Voluntary and Community Sector (VCS) Perspective 7 December 2017 Prepared by Geoffrey Ocen Chief Executive Bridge Renewal Trust

40. Content • About The Bridge Renewal Trust • CHINs in Haringey – what’s happening? • Social Prescribing in Haringey – what’s happening? • Way forward and how the VCS can work collaboratively to deliver CHINs and Social Prescribing services in Haringey

41. About The Bridge Renewal Trust • Our mission: To deliver practical ways that people can live healthier, long and fulfilling lives – thus playing our part in working towards reducing health inequalities and building stronger communities. • Haringey Council’s Strategic Partner for the Voluntary and Community Sector – supporting capacity building, fundraising, partnership development, volunteering, VCS forums and networking. • Haringey CCG’s partnership engagement provider (with Public Voice) – promoting engagement, public meetings, co-production and raising awareness.

42. CHINs – what’s happening? • We have been working with Haringey CCG and GPs to develop closer working relationship with Haringey VCS organisations to ensure effective co-production of CHIN services across Haringey. • 3 x CHIN design workshops attended by Haringey CCG, GPs, Partners over April – June 2017 including VCS CHIN meetings. • CHIN business cases developed and approved for: • West Haringey (frail and older people in care homes) • Central Haringey (frail and older people) • East Haringey (North and South)(Diabetes and Hypertension) • Approval for 4 x Care Navigators and VCS participation in governance

43. Social Prescribing in Haringey – what’s happening? • Social Prescribing is being developed as a VCS-led service in partnership with Haringey Public Health, CCG, CHINs and other partners. • Proposed model, in support of Haringey’s Community Wellbeing Framework has the following components: • Asset mapping of all community and voluntary sector initiatives; • Co-ordination role to link residents to opportunities and have asset based conversation that will identify their opportunities; • Training of all frontline staff on asset based/strength based approach in health and care; • A range of interventions in the community for social prescribing / community involvement. • Online asset map http://bridges.force.com/directory/. • Established Local Area Co-ordination (LAC) in two most deprived wards. • Developing CHIN links and applied for funding from Department of Health

45. East Haringey (North and South) • Diabetes and Hypertension • Engaging and educating BMEs (specifically Afro-Carribbean, Turkish and Asian) in managing their conditions – including translators in specific clinics. • Identifying and working with non-compliant patients to improve their self-management and health outcomes.

46. Central Haringey • Home Visiting Service for older people, and “GP Gym” exercise classes. • Improved care plans and appropriate interventions. • Care navigation and development of new VCS opportunities. West Haringey • Older people living in residential care homes and extra care housing schemes. • Integrated model of care which enables residents to be healthier and have a better quality of life, and more positive experience of care. • Care navigation and development of new VCS opportunities.

47. Way forward and how the VCS can work collaboratively to deliver CHINs and Social Prescribing services • Ongoing mapping to identify existing and develop new VCS services to meet CHIN and emerging priorities. • Identifying and providing support to VCS to maximise engagement and service provision including: • True partnership – governance and co-production • Funding - particularly for small grassroot VCS organisations; how CCG and other commissioners can make it easier for small groups to compete. • Infrastructure support and training – eg. asset mapping, social prescribing, safeguarding, volunteering / time credits • Co-location, co-ordination and processes – closer working, link workers/care navigators, referral pathways, information governance etc • Business case development - outcome measurements and demonstration of value for money.

48. Thank you

49. Age UK Islington Andy Murphy @SocialEnt_UK @IVAR_UK #BHPselfcare

50. Age UK Islington – Inspiration (and some Perspiration) What’s Inspired our Journey with Wellbeing Services, Social Prescribing, CHINs, Personalised Care and Prevention Doing {prevention] Properly