Talk to you about our Passport to wellbeing - Collaboration in community based care - working in partnership to enhance health and wellbeing
The topic "Collaboration in Community based care - working in partnership to enhance health and wellbeing" was chosen by delegates when we surveyed them a few months ago. showcase some user stories, your strategy, how you got buy in and how you collaborated with the VCSE sector
Top Co allows us to reinvest profit for good 2 subsides: Housing and Liberty commercial R&M, Gas servicing across the country
Own and manage In Cheshire West and Chester, where the project I’m going to talk about is based, we manage 5,500 council homes in Ellesmere Port and Neston on behalf of the council on a 10 year contract (until 2027), in winning this contract, what made us stand out was our vision to improve lives which we deliver through our community impact strategy.
Using profit for social purpose, we go beyond the traditional landlord
As part of annual report which can be found on the ForViva website you’ll find out Community outcome statement these are auditable accounts as important to us as our financial accounts we also have annual outcome statements for each of our activities – social prescribing being one of these activites
why is a housing provider delivering a social prescribing project. For us, the reason is obvious! Home is the corner stone to wellbeing Somewhere to live, someone or something to love and something to do
We are often at the centre of the communities in which we work, in some cases, we can have a relationship with a person that lasts from birth until death. We see ourselves as a natural coordinator within the area, forming relationships with people, services and the VCSE sector.
The Kings Fund promotes the population health approach to improve physical and mental health outcomes, promote wellbeing and reduce health inequalities across an entire population.
While the NHS has a critical part to play but these challenges cannot be met by the health and care system alone; a much broader approach that pays more attention to the wider determinants of health and the role of people and communities is required and this is where Housing comes in…
Community Impact strategy is built on the needs of people in which we work national data, local, individual Homes, wellbeing, access to learning/training/ work, people feeling safe where they live,
As with most social prescribing projects it’s about connecting people to support in their community, however, it has to be more than signposting, it’s about working with people to support them to access provision, to provide an arm around and to work with them to develop the skills to be able to improve their lives and manage their conditions.
When we talk about collaboration, we’re not just talking out collaboration with partners and organisations, but also collaboration with people.
Working in partnership with organisations including GPs, Cheshire West and Chester Council and the community and voluntary sector, we connect people to support across four key themes: 1. Health and Wellbeing- including low level mental health and loneliness and isolation 2. Financial wellbeing- this could be debt management for maximising income 3. Ability to manage your home- this can be anything from somebody who is hoarding to somebody who is struggling to keep on top of things 4. Volunteering, employment and training
When a tenant accesses the Passport to Wellbeing project they have a number of referral routes: We work in partnership with the GPs at the Westminster Surgery in EP and also our Housing officers can make a referral.
The reason for this is that the GP might be comfortable with making a referral within the Health and Wellbeing theme, but our Housing Officers often see people in their own home, so they can see where a person might be struggling to cope, or if they are in financial difficulty.
This referral then comes into the Wellbeing Team at FH, an in-house service which provides person centred, wraparound support to help people to maintain their independence and sustain their tenancies.
The team will then call the individual within 3 working days and make an appointment to visit them in their own home; at this visit they undertake the baseline assessment, which is SWEMWBS and also a series of local scales around financial wellbeing and the ability to manage their home.
This used to start the conversation about the person’s context and reasons for referral and the social prescription is then co-created, using the activities on the system.
Once created an email is sent to the providers to notify them and they are expected to call the individual within 3 working days to confirm the activity and welcome them.
If needed the wellbeing coordinator can accompany the individual initially to make them feel more confident about attending. This ‘arm around approach’ is really important for some individuals, who may have felt isolated, or be low in confidence, to get them across the threshold.
After this, the coordinator is available for support on the phone and will visit the individual after 6 weeks and then 3 months to check progress and re-take the assessments.
However, we’re not rigid with process, it’s more of a guide than a hard and fast rule, which allows us to be truly person centred and be more flexible with the contacts and level of support.
We use Elemental to coordinate this process; it allows to manage it from end to end- from making the referral, recording the assessment, making the social prescription and measuring impact.
We were lucky in that we had the framework for our intervention through our Community Impact Strategy.
Firstly we got all our key partners around the table and pitched them- would they be interested in getting involved?
We were clear in what we wanted to achieve, to improve lives around 4 key themes- H&W, Financial Wellbeing, Managing my home and Volunteering, Employment and Training and then we worked out some shared outcomes.
We were realistic and set tight perimeters. This was a pilot, we wanted to test the model on a limited number of individuals in a tight geographical area, and this was important for partners, so they could understand the potential demand on their capacity and if it was within the scope of their project e.g. Cheshire Fire came to the table, and although they were highly supportive of the project, the tight geographical scope meant that they couldn’t be a formal partner
We had a conversation about need and demand we were seeing and the existing activities that could be coordinated to address the need.
After this had been established we worked to establish a clear process (tenant journey), created our service standards and the KPIs we wanted to achieve.
Since the start of the project 18 months ago we have:
• Had 100 referrals • Had 32 people completing the service • Generated 120 social prescriptions • Of those completing 96% have seen uplift in one or more of their wellbeing scores.
• All the organisations have benefitted in terms of their reputation, this is building trust in communities and improving reputations • All partners report better partner relations- the system provides us with shared case management, we have conversations with each other and are learning from the huge variety of skills and expertise available in the network • Embedding person centred approach across the locality- we are increasingly being brought into strategic health partnerships and conversations, such as the Primary Care Network’s approach to establishing their SP workers and are feeding into the new care communities that are being established as part of the Integrated Care Partnership in Cheshire West
Talk and engage- be clear about what you want to achieve and partners will let you know if they are able to come along on the journey Be prepared to adapt- we put processes in place but these are more of a guideline than a rule. We’ve not expected the level of complexity we’ve seen, so have ended up spending more time with individuals than originally anticipated Person Centred Approach- it’s about addressing the individual needs of the person and putting them at the heart of the journey and co-creating this is key to success Expect the Unexpected- there are things that have happened that we didn’t expect- the level of complexity we’ve seen, we have started taking a shared approach to case management, with the most appropriate organisation taking the lead, we have collaborated with Elemental and actively fed into the platform, new opportunities have arisen e.g our successful bid to the national lottery for the Making connections project to reduce loneliness and isolation and looking at collaborative bids to address the need in the community
Jenny Chapman, Wellbeing Lead at ForHousing, UnCo Keynote
A presentation to
Jenny Chapman –
Group Director of Innovation and Excellence
We’re a progressive landlord
that owns and manages more
than 24,000 homes and delivers
housing management services
for other landlords.
Who we are
Who we are
• Everything we do is for the good
of tenants and communities – and
being the best landlord we can be
• We invest in homes and spaces
to fuel people’s potential
• We work together,
collaboratively, with care to have
a lasting impact on
What we do
All the work we do is driven
by the community impact
strategy which sets out
Make a real
Community Impact Strategy