Location: Cornwall

About: The Living Well programme aims to help people to build self-confidence and self-reliance by providing practical support, navigation and coordination to those most at risk of increased dependency and hospitalisation. The programme was developed out of the award-winning Newquay Pathfinder, which was initiated by Age UK Cornwall and Isles of Scilly, NHS Kernow Clinical Commissioning Group, Cornwall Council and local health and social care providers, with funding from Age UK.

Living Well staff work in teams including the voluntary sector, district nurses, GPs, community matrons, social workers and mental health nurses to provide wrap-around support. The intervention starts with a ‘guided conversation’ between the individual and an Age UK coordinator who is trained in motivational interviewing. This conversation helps individuals to identify their goals and a management plan is developed to support their achievement. Trained volunteers then provide continued support to build individuals’ social networks, helping them to connect to their community, and increasing their physical and social activity, which in turn improves their health and wellbeing.

Past activities have included everything from helping a previously housebound gentleman to go for a walk on the beach, to supporting a lady to improve her functional ability so that she could walk to the bathroom to wash her hair. Clients are pro-actively identified using a range of criteria including: having at least two long term conditions; having a social care package and having recent unplanned hospital admissions.

The core elements of Living Well include:

• Understanding the population – using risk stratification, case finding and local knowledge to identify people at high risk of hospitalisation; recognising social isolation and loneliness as factors that contribute towards a crisis;
• Guided conversation – an unscripted engagement to identify individual needs;
• Community involvement and mapping – through conversation with local leaders to identify existing resources and find the ‘community makers’;

Information sharing – sharing data across all sectors, using common protocols and management plans.

The project is currently in a test phase. The cost per person is approximately £400. Outcomes of the scheme are measured using the Warwick-Edinburgh Mental Wellbeing Scale (see Appendix 3). In the first year of the Newquay scheme clients recorded on average a 23 per cent improvement in their wellbeing scores. An average improvement of 20 per cent has been recorded in the first few months of the West Cornwall scheme. The evaluation of the pilot in Newquay showed a minimum 29 per cent reduction in the cost of hospital admissions and further cost savings across the health and social care system. A similar trend is being seen in initial data analysis of the West Cornwall cohort. In Newquay there was a 4:1 return on investment.

Participant Quote:

“It’s helping me to push myself to get back to contacting the world around me”

Who: NHS Kernow CCG, Age UK and Cornwall County Council

Address: Living Well
The Sedgemoor Centre
Priory Road
St Austell
Cornwall, PL25 5AS

Tel: 011726 627800

Web: http://www.kernowccg.nhs.uk/about-us/pioneer