5 Ways Wellbeing Teams and Community Circles can help people get home and stay at home

Yesterday I met with colleagues from Macmillann, to share how Wellbeing Teams are working, and what could be possible in relation to people experiencing cancer. I am excited that the next two Wellbeing Teams are getting started within GP practices. We think there are five ways that Community Circles and Wellbeing Teams can support people to come home from hospital or to avoid hospital admission. Here is a summary of the approaches, and what we have tried so far.

1) Home from Hospital Support

What could it look like?

When people arrive in hospital, as part of their welcome pack they are given a leaflet about Community Circles, and a mini-profile and contact details of the Community Circle Connector, and when she will be on the ward. This is a role that Helen Smith did for a year in Preston.

The Community Circle Connector would then meet the person and explain about circles and how they work. The Community Circles Connector and Wellbeing Leader would be part of the Multidisciplinary Discharge Team.  When someone is getting ready to go home, the Wellbeing Leader would support them to choose their Link Wellbeing Worker, and together, with other relevant people (for example the O.T) they would co-design the discharge and initial support at home. This takes into account what matters to the person and their priorities, as well as what is needed to keep them safe and well, and linking with their family if they are involved. The Community Circles Connector also explores with the person whether they want to start their circle straight away or later when the person is re-established at home.

The Link Wellbeing Worker co-ordinates the person leaving hospital, and actually brings them home if necessary. They ensure that there are welcomed home with fresh sheets, milk in the fridge, etc. The Link Wellbeing Worker is part of the person’s team, and brings in other team members as required. They work using reablement principles, including and the Support Sequence to focus on self-care, using technology, involving family, friends and the Community Circle (if this has started) as well as community resources and services (for example Falls clinics, local gym). At 6 – 8 weeks there is a person-centred review with the team, the circle, the social worker and any health professionals who are involved. The social worker will have done an assessment to identify the person’s outcomes and whether they are eligible for a personal budget. The Link Wellbeing Worker and the person then co-design their service, within their budget, to achieve their outcomes, and the person now chooses their team (from the Wellbeing Workers who have been supporting them so far).

This approach:

·     Provides continuity for the person, from hospital to home, and without having a separate reablement team and home care team.

·     Integrates the support that is provided by family, friends and voluntary sector, through the role of the Community Circle Connector.

·     Reablement and community navigation is built into the way that the Wellbeing Team and Community Circle Connector work.

Our experience so far

Age UK Doncaster has a Community Circle Connector linked to their Home from Hospital Service, who offers people a Community Circle at the 25 day or 90 day review. A Community Circle Connector worked for a year linked to the discharge team at a hospital ward in Preston.

The Wellbeing Team in Devon has demonstrated how peoples support can be reduced over time. One person started with 42 hours support and six weeks later this had been reduced to 24 hours.

2) G.P Practice

What could this look like?

The Community Circle Connector and Wellbeing Leader are part of the Multidisciplinary Team at the GP surgery. If the GP is concerned about someone being lonely, they may suggest that the person talks to the Community Circles Connector to support this. If someone needs more support at home, and a personalised care and support plan, this could be instigated by the GP. There are 5 stages of personalised care and support planning:

Preparation: The Community Circle Connector could help the person prepare, by exploring what matters to the person, and what is working and not working for them and their priorities. Preparation includes an assessment by social worker to see if they are eligible for a personal health budget and their broad outcomes.

The Conversation: A health professional may have the conversation with the person to support them to identify their specific outcomes, and ideas about how to achieve these.

Record: The outcomes and actions are recorded in the patient’s notes.

Implementation: A Community Circle or support from the Wellbeing Team may be part of the implementation, if the person needs support at home, or to implement social prescribing, have health coaching, or to help navigate what is available locally and connect the person.

Person-centred review: The Community Circle Connector or health/social care professional would facilitate the review to look at what has worked and not worked, the person’s outcomes and actions to move forwards. The Community Circle and/or Wellbeing Team would be involved in delivering these actions with the person.

This approach:

·     Delivers best practice care and support planning, and integrates health, social care and community support at an individual level.

Our plans to explore this

We are starting to work with two GP practices, one in London and one in Brighton to develop this approach. There could be possibilities within the Integrated Personal Commissioning programme to explore this as well.

3) Virtual Ward

What could this look like?

The Community Circle Connector and Wellbeing Leader could be part of the Virtual Ward MD Team.  When people are referred, the initial MDT meeting would consider who needs to support the person, and who would lead the assessment and planning process (initial conversation and designing the support). The Community Circle Connector, Wellbeing Leader and appropriate health professional could meet the person and together identify the person’s needs and priorities, and co-design the best ways to deliver this. As well as health professional’s treatment and support this could include support at home from the Wellbeing Team, and getting started with a Community Circle.

The support would be provided as the person requires it, alongside the treatment programme. The circle would meet as often as the person wanted – for example every 2 – 4 weeks, and would work together on the purpose of the circle and keep looking at what was working and not working from the person’s perspective, and connecting with the health professionals and Wellbeing Team as needed. The person-centred review would include the person, their circle, the Wellbeing Team members and relevant people from the MDT, to ensure that the support was co-ordinated around what matters to the person and their health.

This approach:

·     Integrates health, social care and community support at an individual level.

·     Enables a single person-centred review to cover the requirements of health and social care statutory reviews, and includes community support as well through the circle.

·     Proactively raises any issues or tensions, through the Community Circle, before they become bigger issues or risks

·     Builds reablement and community navigation into the way that the Wellbeing Team and Community Circle Connector work.

Our experience so far

A Community Circle Connector was based with a Virtual Ward MDT in Liverpool for 6 months.

4) Hospice at Home

What could it look like?

The Community Circle Connector and Wellbeing Leader would be part of the Hospice at Home Team.  When people are referred, the initial MDT meeting would consider who needs to support the person, and who would lead the assessment and planning process, including the end of life discussions and advanced care planning conversations. The Community Circle Connector, Wellbeing Leader and appropriate health professional would meet the person and together identify the person’s needs and priorities, and co-design the best ways to deliver this.  This could include support at home from the Wellbeing Team, and getting started with a Community Circle.

The circle would meet as often as the person wanted and could be a place for discussions about end of life wishes. The circle could also continue after the person had died to support family and friends.

The person-centred review could include the person, their circle, the Wellbeing Team members and relevant people from the MDT, to ensure that the support was co-ordinated around what matters to the person and their end of life wishes and plans.

This approach:

·     Integrates health, social care and community support at an individual level.

·     Ensures that the person is supported to have the end of life discussions that they want, either with the family and the circle, or with health professionals.

5) Community Team

What could it look like?

This Community Team is a proactive team working from the GP surgery.

The team would include a Community Matron, Community Circle Connector, Wellbeing Leader and a social worker.

They would work with the 2% of people on the GP’s register who are at risk of admission to hospital. The Community Circle Connector meets with the person first, at their home, and supports them to prepare for the conversation, by looking at what matters to the person, what is working and not working, and their priorities. The corresponds with the first step of personalised care and support planning.

The Community Matron, Wellbeing Leader, social worker and Connector then meet the person as their home and look at the person’s priorities. If it relates to housing, the social worker would take this forward; if they needed more support at home, this could be co-developed with the Wellbeing Team, if it related to social prescribing, a Community Circle could support this.

This proactive approach would enable solutions to be put into place, that reflected the person’s priorities, to support the person to stay at home. The Community Team would agree with the person when to review this, and whether this would just be the Community Circle Connector or the whole team.

This approach:

·     Delivers best practice care and support planning, and integrates health, social care and community support at an individual level.

·     Supports people around their priorities, not just health concerns.

·     Goes to the person, instead of expecting them to come to clinic sessions.

Our plans to explore this

We are working with Dr Rod Kersh, a consultant for older people in Doncaster, and a GP practice who will be testing out this approach.

Some of this may look similar to work you are seeing other people doing, and we hope to keep building on existing best practice as well as testing new approaches. Please share work that you think this connects with so that I can follow this up and learn more. Two of these approaches (GP practice and Community Teams) will be starting over the next few months, and we are looking for more opportunities to test and learn.

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