care navigation for social prescribers, link workers ... · • it recognises that not all patients...
TRANSCRIPT
Welcome to SocialPrescriberPlus™Care Navigation for Social Prescribers, Link
Workers & Community Support Coordinators
Your Facilitator is
Nick Sharples
From
DNA Insight
Media Assets at https://tinyurl.com/vqxl6n3
If you have any questions or need any assets, please call Nick on 0800 978 8323 or email at [email protected]
Please call when you are ready to complete the third Module.
So What’s in Store?
Module 1 – The Role of the Social Prescriber• Background and the future of Social Prescribing• Videos• Working within a Primary Care Network:
– Initial meetings– Referrals from GPs– Patient Information and records
• Working with Patients:– Understanding Behaviour Change– Knowing your patient community– The Crucial first meeting and building trust– Avoiding DNAs– The Health & Well-being Prism– Directories of Services
So What’s in Store?
Module 2 – Case Management Techniques and Approaches
• Techniques and Skills:– Active Listening
– Motivational Interviewing
– Groups 4 Health
– Mind Body Spirit Model
• Evaluation:– For whom?
– Methods
– National Guidance
So What’s in Store?
Module 3 – Looking After the Prescriber
• Supporting you in your work
• Resilience
• Supervision
• Active Learning/Reflective Practice
• Networking
Objectives for Today
• To equip you with the techniques and approaches to assist you in taking on the role of Social Prescriber/Link Worker in a PCN or CVS based Social Prescribing Scheme
• To share and discuss what an effective Link Worker engagement with a patient/service user looks like, from both perspectives
• To provide the tools and templates to allow you to take referrals, record, document, evaluate and report your engagements.
Welcome to SocialPrescriberPlus™Care Navigation for Social Prescribers, Link
Workers & Community Support Coordinators
Module 1
The Role of the Social Prescriber
Personalised Care
Personalised care is the practice of caring for people (and their families) in ways that are meaningful and valuable to the individual person. ”What matters to me!”
It includes listening to, informing and involving people in their own care.
Person-centred care provides care that is respectful of, and responsive to individual preferences, needs and values, and ensures that the person’s values guide all clinical decisions.
Personalised Care
The Social Prescriber Framework
What is a Social Prescriber/Link Worker?
• As a Social Prescriber you proactively work with, and help your patients on a case management basis, to navigate the complexities of the health and social care system.
• You give them time and co-create a shared plan that will encourage them to move from a condition of dependence on the GP and Practice to one of independence where they can take greater control of their conditions and live a healthy and fulfilled life.
• You partner with council and voluntary groups to ensure they can access the most appropriate service or community group for their needs, helping them to do so where needed.
• You use a ‘strengths-based approach’ - different elements that help or enable the individual to deal with challenges in life in general. These elements include:
– Their personal resources, abilities, skills, knowledge, potential, etc.
– Their social network and its resources, abilities, skills, etc.
– community resources – groups, clubs, etc.
• It is all about “What matters to me!”
The Power of Social Media
Key Attributes of a Link Worker
Someone who:
• Is paid to give their time
• Uses a strength based approach to increase people’s confidence to take control of their health and wellbeing
• Builds trust and relationships with people
• Gives people time to talk about what matters to them
• Actively listens to understand what matters to people from a holistic perspective
• Co-creates solutions with people
• Enables and supports access to solutions
• Facilitates joined up care and social inclusiveness
• Is knowledgeable about the range of local support available to help with people’s wellbeing issues
Social Prescribing Schemes
• A variety of models have evolved to suit local conditions and funding constraints:– CCG driven– Council driven– Collaboration between both Council and CCG– PCN driven
• Inherent challenges:– Short term funding– Allocation of funding between prescriber and service– Evaluation/Value for Money– Tension between Council/CCG/PCN – funding, boundaries, agendas
• The Way Forward:– Restructuring GP Practices into PCNs – 30–50,000 patients– 1,000 Social Prescribers recruited, one to each PCN– Close liaison with voluntary and community sector
Setting yourself up for Success
Tracking Patient
Engagements
Understanding
Behaviour Change
Your Patient Community
Building Rapport and
Trust
Reducing DNAs
Working within a PCN
Primary Care Social Prescribing Flow Chart
Patient presents in GP Practice with non-medical needs
GP/Practice staff identify non-medical needs and make/suggest referral to Social Prescriber/Link Worker using Referral Form
Link Worker contacts patient to arrange appointment for initial assessment –at Practice/patient home/public space, or by phone during COVID
Initial Assessment Meeting
Confirm patient’s needs match criteria for
accepting patient onto SP scheme (if not refer back)
Assess patient’s readiness for
change (Stages of Change Cycle).
Co produce initial Star/Prism to determine ‘What Matters?’ to the
patient
Agree action plan with patient, book next appointment (assess
likelihood of DNA and measures to mitigate)
Document meeting/actions in patient notes (SNOMED referral code) and complete initial patient information form – assign scheme specific patient
reference number
Challenges facing new Social Prescribing Link Workers
• Unfamiliarity with Primary Care
• Every Practice is unique – culture driven by the GPs
• Building relationships and becoming part of the team at each Practice you support
• Discovering and building relationships with community groups, services and existing Link Worker schemes
• Encouraging GPs to refer patients to you
• Accessing and learning the Practice EMIS/SystmOne IT system
• Navigating and rising above the PCN/Practice politics
Setting yourself up for Success
Tracking Patient
Engagements
Understanding
Behaviour Change
Your Patient Community
Building Rapport and
Trust
Reducing DNAs
Working within a PCN
Initial Meeting with PCN Management
• Request a formal induction meeting with Clinical Director or Senior GP Lead on SP.
• Provide a proposed agenda in advance, to cover:– Operational Aspects:
• Do you work for the PCN or for the Practices?
• Practice priorities for patient referral
• Working days/time at each Practice (politics)
• Referral process and forms/EMIS summary if any
• Caseload (250) and duration of support for individuals, flexibility allowed
• Objectives and measures of success, reporting & evaluation
• Management of volunteers
• Link Workers running groups
Link Workers can Manage Groups
• Where no voluntary groups are available, Link Workers can run their own groups from the Practice.
• Group topics are as wide as the interests of the patient community, but include:– Singing groups
– Gardening groups
– Walking groups - https://poly.google.com/view/3GuP-XttM8M
• Many online resources being developed to help patients who are shielding/vulnerable during coronavirus
Initial Meeting with PCN Management
• Request a formal induction meeting with Clinical Director or Senior GP Lead on SP.
• Provide a proposed agenda in advance, to cover:– Operational Aspects:
• Do you work for the PCN or for the Practices?• Practice priorities for patient referral• Working days/time at each Practice (politics)• Referral process and forms/EMIS summary if any• Caseload (250) and duration of support for individuals, flexibility allowed• Objectives and measures of success, reporting & evaluation • Management of volunteers• Link Workers running/managing groups• Clinical supervision
– Administration/Logistics:• Consultation space• Access to Practice IT/Patient records, Directories of local Services• Access to work mobile phone and laptop (essential to do your job)• How to be ‘part of the team’ – team meeting dates/times, sharing role at staff
meetings, Practice SP Champion (like Carer Champion)• Managerial supervision• Promotional material
Initial Meeting with PCN Management
• Request a formal induction meeting with Clinical Director or Senior GP Lead on SP.
• Provide a proposed agenda in advance, to cover:– Operational Aspects:
• Do you work for the PCN or for the Practices?
• Practice priorities for patient referral
• Working days/time at each Practice (politics)
• Referral process and forms/EMIS summary if any
• Caseload (250) and duration of support for individuals, flexibility allowed
• Objectives and measures of success, reporting & evaluation
• Clinical supervision
– Administration/Logistics:• Consultation space
• Access to Practice IT/Patient records, Directories of local Services
• How to be ‘part of the team’ – team meeting dates/times, sharing role at staff meetings, Practice SP Champion (like Carer Champion)
• Managerial supervision
• Promotional material
• Once all agreed with CD, repeat meeting with Practice GP/PM in each Practice to be supported
Setting yourself up for Success
Tracking Patient
Engagements
Understanding
Behaviour Change
Your Patient Community
Building Rapport and
Trust
Reducing DNAs
Working within a PCN
The GP Referral Form
Patient Information for Social Prescribing (1)
Patient Information for Social Prescribing (2)
Setting yourself up for Success
Tracking Patient
Engagements
Understanding
Behaviour Change
Your Patient Community
Building Rapport and
Trust
Reducing DNAs
Working within a PCN
Understanding Behaviour Change
The ‘Cycle of Change’
• The ‘Cycle of Change’ is a model for understanding the stages of behaviour change.
• It recognises that not all patients are yet ready, committed or able to take advantage of your Social Prescribing offering
• It is a tool for the Social Prescriber to use to guide the type and nature of the patient engagement – NOT shared with the patient
• Used in conjunction with the Health & Wellbeing Prism to judge progress and suitable next steps
• Informs the content and pace of motivational interviewing.
The Cycle of Change
The COM-B model: Behaviour occurs as an interaction between
three necessary conditions
Psychological or physical
ability to enact the behaviour
Reflective and automatic mechanisms
that activate or inhibit behaviour
Physical and social environment
that enables the behaviour
Behaviour Change
The Cycle of Change
Setting yourself up for Success
Tracking Patient
Engagements
Understanding
Behaviour Change
Your Patient Community
Building Rapport and
Trust
Reducing DNAs
Working within a PCN
Understanding the Nature of your Patient Community
Demography and Health & Wellbeing
The Demography of Handsworth (2011 Census)
• GP Registration data indicates that people from 170 different countries moved to Handsworth in the period 2007-2010
• It has a younger profile than the city average, with nearly two-thirds of the population (63%) aged between 16 and 64 and 29% of the population aged between 0 and 15
• It is the fifth most deprived ward in Birmingham (out of 40)• Worklessness rate (those of working age not employed) in 2013 of
24.6%, compared to a citywide average of 16.7%• The proportion of ethnic minority residents is well above the city
average amounting to 88% of the population in total (42% Birmingham).
• The Asian ethnic group constitutes 60% of the total population. The next largest ethnic minority group is Black (22%), followed by the White population (12%)
• Of the Asian ethic group, the Pakistani and Indian population are particularly evident constituting 24% and 22% of the total ward population
• In nearly 20% of households (19.3% - 1838 households), no individuals over the age of 16 have English as a main language.
Setting yourself up for Success
Tracking Patient
Engagements
Understanding
Behaviour Change
Your Patient Community
Building Rapport and
Trust
Reducing DNAs
Working within a PCN
The Crucial First Meeting (Preparation)
• Trust in GP or health professional who referred patient to you is a key driver in uptake – refer to the GP/health professional in introductions
The Hierarchy of Building Trust
Trusting
Building Rapport
Liking
Knowing
The Components of Trust
The Crucial First Meeting/Call (Preparation)
• Trust in GP or health professional who referred patient to you is a key driver in uptake – refer to the GP/health professional in introductions
• Preparation is vital (you never get a second chance to make a first impression):
• Get patient history from GP and how the GP would like you to help the patient
• Full name and preferred style of address• Who is coming along/will be present/on the call with patient –
role and names• Tea, coffee ready and kettle boiled if in Practice • Environment:
– Private– Undisturbed– Comfortable
Creating an Inviting Environment
• The chairs or seating are at a right angle to each other, maybe a small coffee table just in front. Allow sufficient space between chairs so that there is no sense of intrusion on personal space, no confrontation or threat.
• Try for natural light, make it comfortable and a soothing place to be.
• Consider framed prints, rugs to throw over sofas, cushions, bean bags, art materials, plants and lamps to soften the room.
Building Rapport and Trust on the Phone during COVID
• In the current coronavirus crisis, what has changed?– Most if not all consultations and check-ins are now made on the phone.
– Operating model has evolved from reactive to proactive
– Likely to be a part of the ‘new normal’ post COVID
– Video consultations/Facetime being introduced – but not suitable for all.
• With no visual cues, patients will make judgements about your attitude, your willingness to help and even your personality based on the way you speak:– Friendly, Calm, Sincere and Professional
– Smile – your patients can hear you smile.
– Welcome them by their name, and introduce yourself with your first name and role.
– Ask how they would like you to address them?
– Use their name back to them several times.
The Crucial First Telephone Call (Introductions)
• Introductions (Establishing a rapport with your patient):– Decide on your tone, pitch, volume and pace, and and practice it out
loud before you call - nerves can affect all of the above.
– Smile.
– Introduce yourself and your role/organisation
– Confirm who you are speaking to
– Explain the nature of your call (avoid implying they are vulnerable or at risk)
– Ask if now is a good time and share how long you have for the call
– Ask how they would like you to address them?
– Explain confidentiality (using organisation’s guidelines/requirements)
A Telephone Call to ‘Check-in’
• “Good Morning (Mrs Williams), my name is Hilda and l am a Link Worker with Dr Langridge’s surgery. We are ringing all of our patients to see how they are managing during the lockdown and if there’s any additional help you might need to let you stay healthy and well. Would it be okay to have a short chat about that? Would now be a convenient time – if not we can reschedule it.”
• “How would you like me to address you during our chat?...... Is Mrs Williams OK?”
• Establish whether patient is on the shielding list or is self isolating, and if so for how long.
• “Thank you. Can you tell me how’s it been for you during the lockdown? How are things going at the moment?”
• Use open questions to encourage the patient to share their concerns. If patient doesn’t know where to start, you can ask about specific aspects, such as getting exercise, feeling good about themselves, practical issues such as shopping and staying in touch with friends .
Telephone Techniques Q & A
Q: What do I do if a patient is very distressed or anxious on the phone, telling me about a lot of upsetting or traumatic experiences they have had?
A: Use your active listening skills to acknowledge their distress, summarise what you have heard, and move them back to the purpose of the call. If someone is at risk of
harm, for example if they are suicidal and unable to keep themselves safe, then follow your organisation’s safeguarding procedure. Make sure to raise any safeguarding
concerns with your line manager or supervisor.
Q: What if the patient seems at risk of immediate harm or they are frightened of another person?
A: Please ensure you have read and understand your organisation's safeguarding procedure, as this should be followed when there is a concern for someone’s safety.
You should also make your line manager or supervisor aware of your concerns.
Q: Can we reassure a patient that what they tell us is completely confidential and that their information/details won't be passed on to anyone else?
A: We should never agree to keep secrets on behalf of a patient, but you can reassure them that information will only be shared with other organisations with the
patient’s consent, unless you have concerns for their or another person’s safety or become aware of a crime being committed. Check your organisation's confidentiality
statement for the exact wording.
Q: What do I do if a patient needs extra support beyond what I can offer in my role?
A: You can explain to the patient that this is outside of what you are able to offer, but you can arrange a time to call back with more information about organisations who
may be able to help. You should discuss these cases with colleagues and/or your supervisor so you can provide the patient with information about alternatives to ensure
they get the help they need. If, after looking into alternative options, the patient’s request is unable to be fulfilled, you should be upfront with them about this and help
them to think about what else might help.
Q: What do I say if I can’t think of a service that can help the patient?
A: You can arrange a time to call back so you can go away and research the options available. There is nothing wrong with saying that you need to look into things - we
are not expected to know all the answers all the time!
Q: How can I keep my conversation solution-focused and moving forwards?
A: Being prepared before making the call will help - gather any resources that you use frequently (for example, information and contact details for a few services), and
review any information you already have about a patient. When speaking to the patient, listen to what they are saying and check that you have understood correctly. You
can then make suggestions based on what you have heard, and this will help move the conversation forward. If a patient seems unsure about what they would like, or
about an option you have given them, explain more about what a certain service may be able to provide. If the conversation moves off-track, acknowledge what the
patient is saying and gently remind them of the purpose of the call before resuming the questions.
Q: I am feeling overwhelmed or upset because some of these conversations have been quite emotional, who can I talk to about this?
A: Arrange a time to check in with your line manager or supervisor. Step away from the phone for a few minutes and do something relaxing, like stretching or mindful
breathing. It can be very challenging to speak to people who are vulnerable and upset, and you should make sure to look after yourself as well. Taking frequent short
breaks and making sure to step away for a longer break in the middle of your day will help prevent things from becoming too overwhelming, but if you are struggling then
please let someone know.
South Warwickshire Healthy Connections – SP Guidelines
2.5 First F2F Appointment – (30 mins to 1 hour)
Introduction:
• Introduce yourself and your role
• My role is to work with you to explore what is important for your life and wellbeing,
identify local activities and services you can benefit from and support you to start using
services that can help you.
• Explain format of the session:
• The session will last [insert as appropriate]
• We will explore what’s affecting your health and wellbeing
• I’ll ask you some questions so I can find out about you and to check we’ve thought of
everything
• If you need any information I will provide this or let you know where you can get it from
• I will help you to identify local activities and services you can benefit from
• I will support you to access any support you need
• We will come up with an action plan for you to take away
• We’ll arrange to catch up again to see how you are getting on
• Check the patient is happy to proceed. If not, wish the person well and give them your
details in case they change their mind.
The Crucial First Meeting (Preparation)
• Trust in GP or health professional who referred patient to you is a key driver in uptake – refer to the GP/health professional in introductions
• Preparation is vital (you never get a second chance to make a first impression):
• Get patient history from GP and how the GP would like you to help the patient
• Full name and preferred style of address
• Who is coming along/will be present with patient – role and names
• Tea, coffee ready and kettle boiled if in Practice
• Environment:– Private
– Undisturbed
– Comfortable
• Introductions (Establishing a rapport with your patient):
• Eye Contact (where appropriate) and smile
The Crucial First Meeting (Eye Contact)
EYE CONTACT• Western Cultures
– Eye contact is expected in Western culture, it is a basic essential to a social interaction which shows a person’s interest and engagement with your conversation.
– If somebody doesn’t give any eye contact during a conversation, it may be considered insulting. – In an interview situation, strong eye contact by the interviewee is seen as a sign of self-belief, whereas a lack of eye
contact is seen as a lack of confidence.
• Middle Eastern Cultures– Eye contact is less common, and considered less appropriate than in Western cultures.– Women should not make too much eye contact with men as it could be misconstrued as a romantic interest.– Intense eye contact is often a method used to show sincerity. Long, strong eye contact can mean ‘believe me, I’m
telling you the truth’.
• Slavic Cultures– Direct eye contact is expected. It translates honesty and trustworthiness. Avoiding another’s gaze can seem
suspicious and disrespectful.
• Asian Cultures– Asian cultures place great importance on respect. Hierarchies are much more visible in their society than in Western
cultures, and their social behaviours mirror this.– In countries such as China and Japan, eye contact is often considered inappropriate. In such an authoritarian culture,
it is believed that subordinates shouldn’t make steady eye contact with their superiors.
• Indian and Pakistani Cultures– It is rude to look someone directly in the eye while talking to them. It signifies arrogance and also can be perceived as
seeking validation. Lowering one’s gaze is respectful and shows that one is not yearning for attention.– Sustained eye contact is not common and many Indians will keep eye contact minimal or avert their eyes from the
opposite gender. Some women may avoid eye contact altogether. Direct eye contact is generally appropriate so long as you divert your gaze every so often.
https://culturalatlas.sbs.com.au/
Setting yourself up for Success
Tracking Patient
Engagements
Understanding
Behaviour Change
Your Patient Community
Building Rapport and
Trust
Reducing DNAs
Working within a PCN
Encouraging Patients to Attend and Stick with SP
• DNA rates for Social Prescribing are particularly high:– 10% - 20% for initial meeting
– 20% - 30% for second meeting
• Re-engaging following a DNA is incredibly difficult, so vulnerable people fall through the net
• Such a high DNA rate is inefficient and bad for Link Worker morale
Insights from other Social Prescribing Schemes
Why Patients sign up to and stick with SP
Why Patients agree to meet with a Link Worker
• Patient has trust in the GP or Clinician who recommends an SP consultation
• Patient recognises need for help with non-clinical problems and that GP cannot provide
• Navigators contact patients by phone to arrange initial appointment - phone call clarifies the nature of SP if confused by the GP introduction
• Friendly, non-prescriptive approach reassures patients
• Patient given choice of location for initial meeting (Home or Practice) – ‘What Matters to Me?’
• Initial patient call made by the Link Worker, not by a manager or administrator.
Why Patients Continue with the Programme
• Link Worker’s person-centred approach facilitated feelings of trust, control, and readiness to reflect on their current circumstances and their non-medical needs. ‘What matters to me?’
• Patients valued the strength-based approach• Patients felt listened to and valued. • Patients reported that appointments with Link Workers felt less
rushed and, unlike with GPs, they felt able to discuss their non-clinical needs without being pointed to a medical solution to deal with the consequences of the non-medical problems:
• Feeling in control and freedom to decide in which service to participate, promotes patients’ adherence
• Link Workers who accompany patients to first sessions help them to build confidence, self-reliance, and eventually independence. Crucial steps in determining the adherence of some patients.
The Health & Wellbeing Prism
A Framework to guide your discussions with the Patient
The Health & Well-being Prism
• A tool to determine and understand the general well-being of your patient/patient and act as a framework for your discussions.
• You build an overall picture by viewing your conversation with the patient through the prism of a number of relevant viewpoints based on the social determinants of health:
The Social Determinants of Health
The Health & Well-being Prism
• A tool to determine and understand the general well-being of your patient/client and act as a framework for your discussions.
• You build an overall picture by viewing your conversation with the client through the prism of a number of relevant viewpoints based on the social determinants of health:– Looking after myself/Taking exercise/Getting out
– Practicalities of life - Money/Housing/Benefits/Transport
– My work/Hobbies/Volunteering
– Happiness with Lifestyle/Desired social activity
– Overall mental well-being/Feeling good about myself
– Supported by Family/Friends/Groups
– Thinking positively/Feeling optimistic
– Managing symptoms & unhealthy behaviours/taking medication
• Shared with the patient, co-completed and used to gauge progress of your engagement with the service user.
The Health and Well-being Prism
Happiness with LifestyleDesired social activitySupported by Family/
Friends/Groups
Thinking positivelyFeeling optimistic
Managing symptoms &unhealthy behaviours
Taking medication
My workHobbies/Volunteering
Looking after myselfTaking exercise/Getting out
Overall mental well-beingFeeling good about myself
Practicalities of life -Money/Housing/Benefits/Transport
Patient Ref _______ ___ of ___ Date __________ 136542 1 1 11 Jan 2020
Framework to chart Patient progress through Social Prescribing
Directories of Service
Different Approaches to Consider
The Directory of Services
• A directory of names, organisations and contact details of referable services appropriate to your team and your service users
• Internal only or available to service users and others?
Providers of Public Facing Directories
• http://www.simplyconnectsolutions.co.uk/
• www.InformationNOW.org.uk
• https://www.wellaware.org.uk/
• https://hull.connecttosupport.org/s4s/WhereILive/Council?pageId=3226&lockLA=True
Nettleham Patient Directory
The Isle of Wight Directory of Services
Example Directory for Eastern Vale
The Directory of Services
• A directory of names, organisations and contact details of referable services and community groups appropriate to your team and your service users
• Internal only or available to service users and others?
• Includes GP criteria/caveats/exclusions – make sure the Social Prescribing criteria are included
The Service Directory
The Directory of Services
• A directory of names, organisations and contact details of referable services and community groups appropriate to your team and your service users
• Internal only or available to service users and others?
• Includes GP/PCN criteria/caveats/exclusions – make sure the Social Prescribing criteria are included
• How will you grow the Directory to include services not currently included?
The Directory of Services
• A directory of names, organisations and contact details of referable services and community groups appropriate to your team and your service users
• Internal only or available to service users and others?• Includes GP criteria/caveats/exclusions – make sure the
Social Prescribing criteria are included• How will you grow the Directory to include services not
currently included?• How will you share it with colleagues? How can they
update it?• How will you build a collection of free or discounted
services for your patients?