Social Prescribing &

Care Navigation

Tom O’Gorman, Project

Manager - Camden CCG

& Monica Riveros,

Services Manager -Age

UK Camden

Care Navigation and Social Prescribing

June PPG Forum

Camden Local Care Strategy

What is Social PrescribingSocial prescribing enables all local agencies to refer people to a ‘social prescribing link worker’ to connect them into community-based support, building on what matters to the person as identified through shared decision making, personalised care and support planning, and making the most of community and informal support. Social prescribing is part of a comprehensive modelof personalised care.

The Camden Care Navigation and Social Prescribing Service was launched on the 1st October 2108 and it is delivered by 3 linked services:• Care Navigation - Age UK Camden• Community Links – Voluntary Action Camden and• Wish Plus

This integrated Social Prescribing model enables Camden residents to access care and support in the right place, at the right time.

It aims to help and enable Camden residents to:• Identify their support needs at an earlier stage to prevent escalation• Access support services within their local community • Improve their experience of care

Camden Local Care Strategy

NHS Long-Term PlanThe NHS Long-Term Plan and the Five Year Framework for GP contract reform set out commitments to social prescribing. NHS England will provide funding directly to primary care networks for a new, additional social prescribing link worker to be embedded within every primary care network. Practices must sign up to the new network contract DES to benefit. In years 2 -5, the funding will be allocated on a population basis.

Social prescribing link workers will give time to people who lack the confidence or knowledge to get involved in community groups or to approach agencies on their own. The role will include:• providing personalised support to individuals, their families and carers to take control of

their wellbeing, live independently, and improve their health outcomes• taking a holistic approach, based on the person’s priorities, and the wider determinants of

health• co-producing a simple personalised care and support plan to improve health and wellbeing,

potentially using other tools including the patient activation measure• introducing or reconnecting people to community groups and services• supporting the delivery of a comprehensive model of personalised care • drawing on and increasing the strengths and capacities of local communities, enabling local

VCSE organisations and community groups to receive social prescribing referrals

1000 trained social prescribing link workers in place nationally by 20/21, rising further by 23/24.

Model for Social Prescribing

Camden Local Care Strategy

What do Care Navigators do?Care Navigators in Camden provide (up to) 6 weeks personalised case management support for Camden residents. • The service users receive personalised support and assessment (often in their own home) from a named Care Navigator in order

to help identify needs and to support navigation through the local care systems and community services.

Eligibility:• 18+• Camden resident• Registered with a Camden GP• Living with one or more long term health conditions

The Care Navigators are covering 33 GP surgeries across Camden and based in GP surgeries covering each GP neighbourhood

GPs can refer via EMIS using the Camden Care Navigation and Social Prescribing Service Referral Form.

Residents can self-refer

The Care Navigator will contact the patient referred within 3 working days of receiving the referral and arranges a time and place to meet (patient’s own home, community location, GP surgery).

Camden Local Care Strategy

What does Community Links do?Community Links accepts referrals from GPs, other clinicians, social workers, volunteers, self-referral, relatives.

Community Links Volunteers provide outreach and signposting from GP practices, libraries and other community settings and help with referrals.

They use a database of thousands of local community organisations and groups to find people the right activity. The range is from traditional services right through to self help and volunteering opportunities.

Elligibilty:

• Camden residents.

GPs can refer by:• Completing the referral form, which is on the GP website Camden Care Navigation and Social Prescribing page:• Freephone – 0800 193 6067 • NHS secure email – Camccg.socialprescribingreferral@nhs.net.

Residents can self-refer

As long as they have permission from the resident and their contact details they can call them and match them up with appropriate activity.

Community Links feeds back to GPs and checks with patients to see if their social referral was successful and / or offer other opportunities.

Camden Local Care Strategy

Case Study 1 – Care Navigators71 year old female

• Referred by Camden Adult Social Care (ASC)• History of long-term depression, anxiety and poor mobility• Had become housebound • Moving from an independent flat to sheltered accommodation.• Did not have a family or friendship network

• ASC Access & Support Officer was helping the client with practical aspects of her move:• registering with utilities providers• setting up a landline phone and direct debits etc

• Care Navigator visited to client’s new home and referred her to:• A home-visiting optician• The community podiatry service• A local dentist.

She was also supported/referred to: • Get a Taxicard to start to access her local community• CNWL physiotherapy team for strength and balance exercises• A benefit check with Age UK Camden Information and Advice Team• Kentish town Community Centre activity classes• Community Connectors to help rebuild her confidence in going out and attending activity classes• Scottscare for friendship and support

Camden Local Care Strategy

Case Study 2 – Community Links

A GP contacted Community Links concerning a patient who they felt was becoming socially isolated. The patient was:

• Recently retired

• Managing her physical health condition but getting more and more socially isolated.

• Resistant to the idea of visiting a ‘Day centre’.

Community Links staff explained to the GP that there were different activities in the neighbourhood to choose from and if

the patient visited the health advocate volunteer in the GP practice they could talk through some options.

Staff made sure that the patient was expecting the volunteer visit.

The patient talked to the volunteer and realised her professional skills could be brought out of retirement and be very

useful in certain volunteering positions.

The patient was also interested in getting involved in advising on commissioning of services through Camden Council’s

scheme to include residents in the process. The patient and the volunteer are currently exploring some options.

Camden Local Care Strategy

Social Prescribing ReferralsOrganisations that Care Navigators have signposted residents to:

Adult Social Care OT services (adaptations, physio)Befriending ServicesInformation and Advice Counselling servicesHandy person serviceOpticians PodiatryCommunity CentresBetter GymShopping ServiceWill writingGood Neighbour Scheme Blue badge applicationBritish Red CrossCommunity Connectors

Community LinksCamden Council RepairsCamden CarersCamden Memory ServiceCamden Mental Health Team,Dial a RideDistrict nurse teamDWPGreen CamdenIcopeLondon Irish CentreMary Ward Legal CentrePeer MentoringPlus bus door to doorWish+Voluntary Action CamdenBritish Computer Association for the Blind

Overview of types of community based support that Community Links volunteers have signposted residents to:

Camden Local Care Strategy

Next Steps

What is happening next:

• Liaison between PCNs and current social prescribing provision to develop proposals for new Social Prescribing Link Workers

• Greater utilisation of Care Navigators• More practices with a named community links worker• Greater alignment to mental health social prescribing services

Other actions:

• Update the Care Navigation and Social Prescribing communications and find more ways to promote the service to residents

GIVE US YOUR VIEWS ON HOW TO IMPROVE