Spring 2014 Issue 4 Welcome to the fourth edition of the My Life a Full Life quarterly newsletter. Hard to believe that a little over a year ago, the framework and vision for the My Life, a Full Life programme was being discussed. What a difference a year makes! As this issue demonstrates, right across the Island we are collectively making this change happen; voluntary and community support groups have been coming together to network and improve their links, new initiatives such as the care navigators helping people to understand the different services they can access, whole communities looking to support people living with dementia, GPs and others based in the community trialling new ways of working together, those who commission services looking to do so in an integrated way. Real change is taking place and it’s already making a difference to people’s lives – like Tony whose story we share in this issue about the support he has received from the respiratory team and Bob who has already felt the benefits of the crisis response pilot which started in February. We’re also flying the flag high for the Isle of Wight, with significant interest in the programme being expressed by other local authorities and Clinical Commissioning Groups including Cornwall, Surrey and Wiltshire and even the Department of Health in Barcelona, all keen to find out more. At a national level, we continue to feature prominently in relation to work around integrating care – check out http://www.nationalhealthexecutive.com/Health-Service-Focus/making-the-case-for-integrated-care We all recognise that there is still much more to do but at the same time, progress is being made and as we spring into 2014 – there is much to celebrate and plenty to inspire everyone involved in the programme. Changing people’s lives for the better Crisis Response team – Bob’s story Bob is a 92 year old gentleman who suffers with dementia. He lived with his wife Flo who was very ill and she had a stroke at home and suffered a cardiac arrest, witnessed by a neighbour who was a healthcare professional. Flo was taken to the Emergency Department where she sadly died. Bob has no family on the Island and, worried how he would manage at home, the healthcare professional asked the ambulance crew to seek help from the crisis response team to support Bob. The events that had occurred were at 3.30pm on a Friday afternoon and the team knew, from the little history given, that Flo was Bob’s main carer and that he would not manage on his own at home and could not be left. Apart from his dementia Bob also suffered from shortness of breath and had a history of falls. The role of the crisis response team started at 4pm where they assessed Bob and how severely his dementia would affect his day-day living. Being bereaved and a little confused by what he had witnessed and his understanding that his wife of many years had just passed away, it became apparent that, for his own safety, Bob would require some immediate care. The team spoke to the duty social worker for the crisis response team who arranged for a duty social worker to meet Bob and the team and discuss the best way of caring for him in the short term. In Bob’s best interest a period of respite care in a residential home would be provided over the weekend and subsequently this allowed the team to look at ways of managing Bob’s care within his own home in the future. A joint meeting was held between the crisis team and social services and a plan was set up for him to return home. This included Bob having assistive technology provided in his own home that would connect with Wightcare if he was to wander out of the house at night (this being a main concern of the teams hence admission for intermediate residential care). A care package was also set up to support Bob to remain living independently at home. Bob was referred to the dementia liaison team and nurse specialist for follow up when he returned home and also, as an active member of the Masonic lodge, Bob was referred to his local lodge so that he could be supported by the Almoner in his future care decisions. If the crisis response team had not existed, Bob would have had no choice to be taken from his home in the ambulance with his wife, bought into the Emergency department and then most likely be admitted to hospital as a social care admission until a care package could be set up for him. Instead, he remains at home and is by all accounts doing well with a care package set up to support him. The Silent service – Tony’s story (in his own words) “I joined the Royal Naval Volunteer Reserve, known as the Silent Service, just before my 18th birthday in 1945. I learnt how to and then cleared mines in a naval minesweeper, learnt to smoke (at 5p for 20 – who wouldn’t) and was de-mobbed three and a half years later. “35 years later my GP told me it would be wise to stop smoking as I had Asthma. He recommended nicotine based chewing gum on which I got hooked so I had to use Wrigley’s peppermint instead. I stopped smoking. “I was fit, played golf and squash but in 1996 when I came to live on the Isle of Wight a GP referred me to a Respiratory Consultant who told me that I had Emphysema. I had no idea what this was so looked it up and found that it was COPD (Chronic Obstructive Pulmonary Disease), a thickening of the airways in the lungs which cause lack of oxygen hence breathlessness. “I joined a new Silent Service – the Isle of Wight Respiratory team. What good fortune. I have been in their care ever since.” Tony describe the wide range of support he receives from the service from initial breathing (spirometry) tests, to exercises to help expand the lungs and tone the muscles in the well equipped gym supported by qualified specialist instructors (whilst all the while socialising with others with chest problems). He also talks about Breathe Easy, a very active support charity to the British Lung Foundation, the events they have and the money the raise. Tony goes on to talk about representing patients on the steering group providing guidance to the Clinical Commissioning group and how the “Isle of Wight are already ahead of many other larger such organisations on the mainland keeping the medical profession up to date with new practice drugs etc” He also acknowledges that the “Respiratory department has been very innovative” – through its use of “telemetric units in patients homes, where the patient puts in a finger to measure blood oxygen levels, it reads the results and sends them direct to the hospital department where they are monitored and if action is needed, a reassuring phone call, specialist nurse in the field or at worst an ambulance is called to help. This means constant surveillance, no hospitalisation for the patient just living a quiet life at home.” He sums up by saying “we are so lucky on the Island to have such a committed medical profession to look after us” You can read Tony’s full story at http://www.iwight.com/azservices/documents/2813-Tonys-story.pdf Working better together Key announcements New care navigators appointed In the last newsletter we told you about the funding that has been awarded from the My Life, a Full Life programme to Age UKIW to establish a care navigator pilot project. The project, which will run initially for a year, will provide support to older people to help them navigate the health and care systems on the Island so that they can make choices about the treatment and care they receive. Towards the end of February, four full-time care navigators were appointed. Charlotte Price, Debbie Bardell, Becca Cook and Danielle Filer (from left to right in the photo shown) are currently in training to take up their roles from the middle of March at three GP practices in Ryde and one in St Helens. The team are from a variety of backgrounds including health, housing, social work and information/advice services. They will work to support people, who have been referred by their GP, to improve their health and wellbeing. Part of their training includes the ‘Healthy Conversations’ training with the University of Southampton as part of the ‘Making Every Contact Count’ (MECC) agenda which aims to give staff the skills, confidence and knowledge to deliver brief advice and signpost individuals they come into contact with. The evaluation of the project will be undertaken in partnership with the My Life, a Full Life programme team. For more information contact Nik Attfield at Age UK IW on 01983 525282. Fulfilling Lives: Ageing Better – Partnership funding awarded and research underway The Isle of Wight is one of 32 local authority areas to have been successfully shortlisted in the first stages of a £6m funding bid through the Big Lottery Fund’s Fulfilling Lives: Ageing Better initiative. This initiative aims to fund community-led approaches that enable older people who are at most risk of social isolation and loneliness to lead more fulfilling lives. The Isle of Wight was successful owing to the collaboration taking place around the My Life, a Full Life programme and its vision for a new, more integrated way of delivering health and social care services on the Island.