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.

opzioni binarie demo prova 1) Home from Hospital Support

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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).

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·     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.

bonus forex no deposit 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.

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