Integrated Plus Social Prescribing

Integrated Plus is a social prescribing support service delivered by Dudley CVS and funded by Dudley Clinical Commissioning Group as part of Dudley’s integrated care model.

The Integrated Plus service supports people aged 16 and over who frequently visit their GP, who are at high risk of hospital admission and/or who are vulnerable and could benefit from social prescribing interventions. The service aims to look at the whole needs of a person, regardless of what those needs might be and jointly find solutions to problems faced.

Integrated Plus identifies opportunities for people to become more involved and active in their community to help improve their wellbeing. Our team also help to ensure people are accessing services and activities appropriate to their needs.

• Provides holistic non-medical support to people aged 16 and over
• Supports people to become less reliant on medical services
• Encourages and supports people to get connected into wellbeing services and activities, often delivered by the voluntary sector
• Aims to improve quality of life and help people find a sense of purpose in their lives

Our Integrated Plus team consists of 1 manager, 8 Social Prescribing Linker Workers and 1 Project Development Worker:

• 6 Link Workers each cover one Primary Care Network area within Dudley and accept referrals from GP surgeries and via weekly Integrated Care Team meetings
• 2 Link Workers work closely with Russell’s Hall hospital and West Midlands Ambulance Service to provide longer and more intensive social prescribing support to frequent attenders of A&E services and frequent callers of 999
• Project Development Worker oversees our voluntary sector social prescribing fund, manages new and exciting projects to enhance the social prescribing offer and works to build relationships between the voluntary and community sector, Link Workers, GP’s and NHS teams.

Our Link Workers:

• typically meet people for the first time within their own home or out in the community (subject to Covid-19 restrictions)
• spend quality time listening to people and finding out what matters to them
• explore a wide range of non-medical challenges with a person and work with them to find solutions
• help people identify their strengths, skills and assets and support them to take control over their own health and wellbeing
• attend Integrated Care Team meetings with GPs, district nurses, social workers, mental health nurses etc. They ensure that the social needs of patients are discussed, and that the voluntary and community sector is represented
• support people to overcome barriers they face when accessing support, e.g. they may chaperone someone to a group if their
  confidence is low or support them to access a grant if they’re struggling financially

• Dudley GP surgeries can access the Integrated Plus social prescribing referral form on EMIS
• Integrated Care team members can refer a patient to be discussed at weekly Integrated Care Team meetings or contact their Link Worker directly to discuss a referral
• If you’re a member of the public who is looking for support, please contact your GP surgery to discuss whether a referral to social prescribing would be appropriate for you

For more information please contact integrated.plus@nhs.net

The Voluntary Sector Social Prescribing Fund is for the voluntary, community and social enterprise sector (VCSE) in Dudley borough to help develop and provide creative, person-centred care and support for people referred to social prescribing. The aim of the fund is to:

• Help improve health and wellbeing
• Develop and provide new creative activities with people
• Help achieve longer term recovery once people have been helped to resolve crisis situations such as housing, financial issues etc
• Help unlock people’s passions, gifts and talents
• Help nurture connections between people and increase social connections

There are no closing dates, your group or organisation can put forward an idea any time when inspiration strikes!

If you would like more information about this service contact Jack Rubery: jack@dudleycvs.org.uk