South Staffordshire service helping older people to stay healthy and independent

A pioneering health and information service launched across South Staffordshire is making great strides in supporting older people to stay healthy, safe and independent in their own home.

The Care Navigation Service is delivered by Age UK South Staffordshire and South Staffordshire Community and Voluntary Action (CVA).
It is a free service helping community health teams to increase the levels of access to information and support that people who are undergoing challenges in their lives can get in the local community.

The partnership programme is commissioned by Cannock Chase, Stafford and Surrounds and South East Staffordshire and Seisdon Peninsula Clinical Commissioning Groups.

CCG Senior Primary Care Commissioning Manager Mark Jenkinson said: “Care navigation supports a range of health professionals to work with the voluntary and community sector to ensure vulnerable people get the right care in the right place at the right time.

“The programme works alongside local health, social care and voluntary sector teams to point local frail, older people -some of whom have long-term health conditions – in the right direction for support and allow them to live more independent and healthier lives.”

Patient referrals are made directly to the Care Navigator programme by community matrons, district nurses and social workers.

Case study

A woman in her late fifties living alone in Codsall with multiple complex health conditions was referred to the care navigator programme in May 2016.

She had moved to the area a few years ago to be closer to her daughter and family as her health was deteriorating, but although her supportive daughter lived close by she worked full time and was unable to visit during the day. The patient was struggling, feeling depressed and anxious about her future, and was lonely with no friends living locally.

The care navigators matched her with one of their volunteer buddies to offer friendship and reassurance and helped the patient to access Citizens Advice help with benefit payments and community information.

A local church representative invited her to the local weekly luncheon club, arranging minibus transport for her. The patient also joined the local craft club in Codsall Library and started to attend the ‘Forget Me Not’ club.

The buddy reported that the patient’s confidence and happiness had improved, that she had made friends and that she enjoyed attending the groups every week.

While the buddy has now been assigned to help someone else, she lives close by and is on hand should the patient need any help in an emergency and still meets the patient at one of the local groups.

Patients covered by the scheme:

Patients in the Seisdon Peninsula CCG registered with Wombourne Gravel Hill medical practice, Wombourne Dale medical practice, Kinver Moss Grove medical practice and Calverley medical practice (including Pattingham branch surgery)
Patients in the Stafford and Surrounds CCG registered with Penkridge medical practice, Brewood medical practice (including Wheaton Aston and Coven branch surgeries)
Patients in the Seisdon Peninsula CCG registered with Bilbrook medical practice, Perton Lakeside medical practice, and Tamar Medical practice (Perton), Featherstone medical practice and Russell house medical practice (Codsall)
Patients in the Cannock Chase CCG registered with Huntington, Essington, Great Wyrley and Cheslyn Hay medical centres

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