OxFed Social Prescribing Service · EAST OXFORD Mark Williams PCN [email protected] 10 St...
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Lan Jenner Social Prescribing Project Manager OxFed Social Prescribing Service
Transcript of OxFed Social Prescribing Service · EAST OXFORD Mark Williams PCN [email protected] 10 St...
Lan Jenner
Social Prescribing Project Manager
OxFed Social Prescribing Service
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• Genes
• Physical Environment
• Clinical Care
• Social and Economic Factors
• Health Behaviours
What determines how healthy we are?
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The need for social prescribing
http://healthandlearning.org/community-health/
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What percentage?
27% of GP attendances are avoidable(NHS England – Making Time in General Practice)
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•Healthier
•Happier
•More self reliant
•Reduced dependency on health services
What are we trying to achieve?
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OxFed Social Prescribing Service
•Service established in 2015: target frail elderly and housebound population
•Received over 4000 referrals
•Signposted and referred people to over 170 different community based services
•Expanded in Oct 2017 to target other vulnerable groups
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•Assess needs
•Agree patient goals
•Advice and Signpost, Active Referrals
•Support engagement and advocacy
•Build links with partners in the community
NORTH OXFORD Mark Williams PCN
1 Banbury Road Medical Centre 172 Banbury Rd, Oxford OX2 7BT
2 Summertown Health Centre 160 Banbury Rd, Oxford OX2
4Jericho Kearley/Chivers Jericho Health Centre, New Radcliffe House,
Walton St, Oxford OX2 6NW
5Jericho Leaver Jericho Health Centre, New Radcliffe House,
Walton St, Oxford OX2 6NW
Joanna SzymorKara PCN
Joanna.szymorkara.nhs.net
619 Beaumont Street 19 Beaumont Street Surgery, Oxford, OX1 2NA
7 27 Beaumont Street 27 Beaumont Street Surgery, Oxford, OX1 2NR
8 28 Beaumont Street 28 Beaumont Street Surgery, Oxford, OX1 2NP
9 King Edward Street 9 King Edward Street, Oxford, OX1 4JA
EAST OXFORD Mark Williams PCN
10St Clements St Clements Surgery, 39 Temple Street, Oxford,
OX4 1JS
11 Cowley Road Medical Centre 1 Manzil Way, Cowley, Oxford OX4 1XD
12 Bartlemas 1 Manzil Way, Cowley, Oxford OX4 1XD
13 St Bartholomews Manzil Way, Oxford OX4 1XB
Elaine Barclay PCN and Audrey Parris PCN
14Hollow Way Medical Centre 18 Ivy Close, Cowley, Oxford, OX4 2NB
15Temple Cowley Health Centre Temple Cowley Health Centre, Temple Road,
Cowley, Oxford, OX4 2HL
16Donnington Medical Practice 1 Henley Avenue, Oxford, OX4 4DH
17The Leys Health Centre The Leys Health Centre, Dunnock Way, Oxford,
OX4 7EX
Frances Hamilton-Johnson PCN
18 Kennington Health Centre 200 Kennington Rd, Kennington, Oxford OX1 5PY
19South Oxford Health Centre South Oxford Health Centre, Lake St, Oxford OX1
4RP
20Botley Medical Centre Elms Rd, Oxford OX2 9JS
Ursula Nicholls PCN
21 Manor Surgery Osler Road, Headington,Oxford OX3 9BP
3 Marston Medical Centre 24 Cherwell Drive, Marston, Oxford OX3 0LY
22Bury Knowle Health Centre Bury Knowle Health Centre , 207 London Road,
Headington, Oxford, OX3 9JA
GP Clusters & designated Practice care navigator (V10 February 2017)
CENTRAL OXFORD
HEADINGTON
SOUTH AND WEST OXFORD
SOUTH EAST OXFORD
07710095324
0771 563 4777
0771009532
07415402011
07715665683
07415400106
07710095313
Practice Care Navigators
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Referral Criteria
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Referrals routes and methods
•GPs•Other members of the practice team including reception staff•Other members of the community health team such as district nurses and occupational therapists•Hospital discharge teams including HART•Self-referral by patient or carer
•Practice tasks on EMIS•Face to face at practice meetings•Telephone or e-mail directly to PCN
•currently unable to book directly into social prescribing clinics
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• Patient: Elderly female patient with dementia, lives alone, referred by friend
• Assessment by PCN: No known support, falling, concerns regarding adequate nutritional intake and also
compliance with medication, has personal care needs, not receiving benefits and no working smoke
alarm
• Support and Active Referrals: Joint visit with Age UK benefits adviser - advised re acquiring mobility
scooter; referral to Dementia service; Referral to adult social care for needs assessment; Referral to fire
safety team for house safety assessment and OCC small repairs for key safe; referral to Community Voice
re pendant alarm
• Outcomes: home support carers – daily visits to support medication compliance and nutritional intake.
Attending Daybreak club 2x weekly, Dementia UK involved - Attendance Application in hand, pendant
alarm and fire safety visit pending; Patient’s son more involved
Case Study
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➢ Volunteer Involvement: Health Champions to “buddy” with patients accessing service to support and motivate
➢ Greater awareness of SP: New patient leaflets and posters and Practice Update Reports
➢ Monitoring Outcomes - Patient outcomes and service outcomes
Introduction of Elemental - new EMIS integrated software platform allowing us to track referrals and monitor outcomes
➢ Strengthening our Social Prescribing Network Growing interest in Social Prescribing – creation of local social prescribing network
Formalize links with other Neighbourhood Teams and Link Workers : City Locality Officers, Health & Well-Being Partnerships, MIND, CAB, AGE UK, Community Centres, Dementia Service, Carers, HART
Working with Partners to develop fun/creative services to refer into: green prescription service, arts
Improve Referral Pathway - Introduction of MIND wellbeing workers into neighbourhood clusters
Social Prescribing training : Work with partners to identify training for navigators (Oxfordshire Training Network)
Directory of Services: potential for sharing directory?
Service Development
Contact
T +44 (0)1865 223 900E [email protected]
oxfed.uk
OxFed, Northway Community Centre (2nd Floor), Dora Carr Close, Oxford, OX3 9RF
OxFed Health & Care Ltd. is a company registered in England and Wales and is the trading company of the Oxford Federation for Gener al Practice and Primary Care.
Company Number: 09368553. Registered Address: Northway Community Centre (2nd Floor), Dora Carr Close, Oxford, OX3 9RF. © 2017 OxFed Health & Care Ltd.
Thank you
for your time
