Integrated Plus supports people aged 16 and over who frequently visit their GP and who are at high risk of hospital admission. The aim of the service is to look at the whole needs of a person, regardless of what those needs might be and jointly find solutions to problems faced and identify opportunities for people to become more involved and active in their community. We help ensure people are accessing services and activities appropriate to their needs. Integrated Plus is funded by Dudley CCG. During 2017/18, there were 12 staff, one manager, 5 Link Officers and 5 Link Support Workers.
Mary helped to access social networks and services to help her maintain her independence
A link officer met with Mary in June 2017. Mary had lost her husband in March and was finding it hard to adjust without him, they were very close. Her daughter lives in Hampshire and her son lives in Gloucester so she had no close family who lived local to look after her. Mary’s daughter had suggested she moves to Hampshire to be closer to her and Mary was considering this. In the meantime, Mary wanted to get more active in her community to keep her occupied and busy.
During the initial home visit, the Link Officer and Mary together explored some things that may be of benefit to Mary. Mary was introduced to the COPD group in Dudley called Airtime, which is a social peer network for people who suffer with chronic obstructive pulmonary disease and other respiratory conditions. Air Time brings people together to collaborate, make new friends, offer peer support, and help people to help each other to better self-manage their condition and generally have some fun. As Mary had some anxiety about going to Airtime, the Link Support Worker supported Mary to attend and helped to connect her with others there. Mary said “the group is very good, I have made friends and we have a great laugh – they are a cheerful lot”. As Mary had enjoyed the first visit so much, she has been back to Airtime via taxi and looks forward to going every Thursday.
Mary was also connected to the Assisted Living Centre in Coseley as Mary identified that she was afraid of falling in the house, especially when getting in and out of the bath. The assisted living centre has a range of equipment to assist daily living. It is located in an adapted house which enables demonstrations and trial use of equipment within every day settings such as the kitchen, bedroom or bathroom. The link officer chaperoned Mary to this appointment and Mary was able to get an electronic bath seat for no additional cost. This was installed a week or so later and Mary says that “the bath seat helps me every day. I am not afraid of falling when getting out of the bath because the chair is great support”. Overall, the bath seat enables Mary to get in and out of the bath with ease and by a press of a button!
We had also noticed that Mary was not seeing very many people on a day to day basis and as a result was getting extremely lonely and confused when problems arose, such as issues with the telephone, television and heating. To help her in this situation, a referral was made to the Enabling Community Support Service, who provide a range of practical help, advice and support to older people, aged 60 plus, in their homes. It is intended for people who live at home but who need a little extra support on a short term basis, to live independently, happily and successfully.
Mary now gets a visit from a member of the team, Andy, every Wednesday and they chat about anything and everything!
Mary was also given information on a number of services that could help, such as the Driving Miss Daisy taxi service, Cruse Bereavement Care, a calendar of events from Dudley Stroke Association and the Townswomen’s guild in Sedgley, all of which Mary is considering accessing whilst she is still in Dudley.
Throughout the months we helped Mary, we built a rapport with Mary’s daughter which enabled her to rely on us. Mary’s daughter communicated with both the link officer and link support worker through phone calls, e-mail and texts when she was concerned about her mother and we were able to feedback to her daughter about these concerns by visiting or calling Mary to make sure she was okay. Ideas that her daughter had about the care that her mother needed were also taken into account and we were able to inform her about the groups and services available in the Dudley area, which she was impressed by.
Mary has now sold her house in order for her to move to Hampshire to be closer to her daughter. Although she is excited to move on in her life, Mary is extremely grateful for the work that ourselves at Integrated Plus, Enabling Community Support and friends/staff at Airtime have done for her:
“I feel happier now I have support from Andy at Enabling Community Support, he is a lovely man and he is very kind. As a matter of fact, I have found everyone very kind and most helpful. I would give Integrated Plus 11/10 if I could for sorting all of this out for me, I don’t feel so lonely now that I know I have all this support around me and a lovely group Air Time to go to every Thursday”.