Projects list

Promoting healthy ageing (prevention)

Communicare in Southampton

Communicare in Southampton is a charity that can help anyone who needs support in particular those who have little or no support from elsewhere. We help through befriending and supporting isolated people across the city. Our new project is to organise 12 community tea parties throughout the year particularly focusing on sheltered housing and residential warden controlled accommodation. The events will include activities to promote physical and mental activity promoting health and well-being.

Connect To Support

Connect to Support Hampshire is an online information and advice guide and directory of services for adults with care and support needs who live in Hampshire. This website is intended for all residents who want to find out about local groups, activities and services within the community as well as formal care provision. It is also intended for people who may wish to arrange their own care provision.

Use of Stem Cell glue in Total Hip Replacement Revisions

Hip replacement is a successful intervention that treats end stage osteoarthritis. However around 8,000 hip replacements per year in the UK are revisions of failed primary implants. Revision hip replacements are not as successful and failure due to loosening and infection are more common. An autologous stem cell glue, which is sprayed onto the implant surface at surgery, has been developed. This glue contains antibiotics and stem cells, which combats infection and enhances implant fixation. This invention is about to go into a clinical trial at the RNOH

Getting Granny Going

I am evaluating the project as an employee of the University of Portsmouth. It is a 3 year project to develop a range of outdoor activity projects along the coast and in parks for inactive Grandparents aged 55+ to get active with their family and friends. The project will identify best practice in intergenerational delivery for these audiences and test the effectiveness of reaching older people through family influencers and the use of non traditional settings and programmes.

Enhanced Health Care in Care Homes pilot (EHCH)

The pilot is designed to bring health care services into the 15 care homes selected for the pilot. The part delivered by Southampton primary care Ltd is seeing residents and offering comprehensive geriatric assessments for each resident, medication reviews, long term condition reviews, sign posting to other services. Our team compromises a ANP, GP, HCA, Physiotherapist, OT and Dietician.

Evaluating the feasibility of the Nutrition Wheel & validating the questions

A research assistant from Bournemouth University aims to recruit up to 20 volunteers (working with older people in the community in Dorset) to use the Nutrition Wheel with older people they come into contact with. Data will be collected on the number of people the Nutrition Wheel was used with and likely risk of undernutrition, and focus groups / telephone interviews will be held to obtain qualitative feedback on the use of the Nutrition Wheel (e.g. ease of use, understanding the instructions etc). We will also use volunteers / care navigators working in Hampshire (through contacts with previous projects) to trial the Nutrition Wheel. In addition, we are currently validating the four ‘outer questions’ of the Wheel with the ‘MUST’ screening tool. We will then carry out further projects to support the wider application of the Nutrition Wheel.

Living, not existing:Social Groups for older people

A pilot project exploring the benefits of weekly occupation-focused social groups held for older people who may live alone or in isolation in Wiltshire and the surrounding areas. The groups will be facilitated by a therapy outreach ‘Early Supported Discharge’ team in collaboration with an older person’s support service, who work alongside a local GP surgery and Age UK. The benefits of this are two-fold: to provide longer-term therapy goals for people to remain motivated to engage with occupations past the initial intense input from the ESD team; and to facilitate an integrated approach to help older people remain independent in their own communities, and delay or prevent the need for care. The project is funded by the Royal College of Occupational Therapists’ ‘Innovation Award 2018’.

Information and Advice Service Hampshire

We provide information and advice to any older person, their family, friends, carers or neighbours, on services and activities available to them. We can carry out benefits checks and assist with applications including form filling. We advise and assist on aspects of finances, housing, care and support, health care issues, transport, carer support, consumer issues, help in the home and legal information. We can assist people find reliable tradespeople and practical help. We provide information over the phone, via email and face to face including home visits where needed.

Older People's Area Link

Opal helps older people (50+) in Hampshire to find out about local activities and services. These include help with shopping, befriending services, lunch clubs, local leisure activities and much more. We can also discuss transport options, as well as wider issues such as benefits claims, community care and help at home. This information is available over the phone, but if someone needs extra help to find out about services, a local volunteer can visit them at home once or twice to chat through the options. Visits are especially suitable for those who find it difficult to communicate on the phone or who have lost confidence due to a change in circumstances such as a house move, bereavement, illness or loss of mobility.

Village Agent Service

The scheme supports older people in rural areas, assisting them to access information and the support services they need. As an active member of their local community a Village Agent directs people to the information about such things as day care, foot care, computer training, transport for shopping and medical appointments, finding reputable tradespeople and help around the home. Village Agents operate in a variety of ways, from supporting individuals in their own homes, to running drop in advice clinics at local community venues, to organising social and well-being activities that encourage people to remain active and avoid loneliness and isolation.

Time of Your Life Campaign

Time of your Life is a project aimed at looking forward to retirement and it was a collaborative approach with Southern Health Geriatrician, primary care and commissioners to put together a Z card to promote 10 top key messages to concentrate on in preparation for retirement. 1)Think about your current health and wellbeing needs, 2)understanding ageing is natural, 3)Keep moving, 4) Stay in touch with friends, family and your local community 5)Be Creative, 6)Prevention is better than cure, 7)Think about Finances, 8)Make home work for you, 9)Get everything in order, 10)Plan your care.

Eat Drink Move

Eat, Drink, Move is part of a national initiative linked to #endpjparalysis and #last1000days looking at how we can value every moment of our patients’ time while they are in hospital. 65% of patients admitted to hospital are 65 or older and a person over 80 who spends 10 days in a hospital bed will lose 10% of muscle mass. This could be the difference between going home and going to a home.  UHS has taken on this concept and called it Eat, Drink, Move as we are also focussing on the importance of eating and drinking well while in hospital. We are working closely with the dieticians and Serco to ensure this is happening. We are also developing the role of Patient Support volunteers through funding from Helpforce who will be trained to enable them to undertake the roles of mobility volunteers, meal time assistants and time for you involvement. This volunteer role will be enhancing the work undertaken through the Eat, Drink, Move initiative. Through these projects we hope to promote physical activity of patients in hospital to reduce the risk of de-conditioning and consequences of this.

Living with frailty (mild / moderate)

Hospital Homecoming

Communicare in Southampton is a small local charity, based in the heart of Southampton, we are a friendly, neighbourhood charity that enriches the lives of lonely and isolated people in and around the city.The new project 'Hospital Homecoming’ will support vulnerable people leaving hospital that would benefit from low level, good neighbourly support in the early stages of returning home. Some of things we hope to help clients with is light housework/making some food/checking the house for them prior to coming home/ having a cup of tea and chat with them or shopping/picking up prescriptions for them. We are creating ‘patches’ in the city and each Communiteer will be within a 10-minute walking distance from the service user. We will use WhatsApp as the main communication method and people can respond if they are available when a request to help gets sent out.

Hospital to Home Service

To improve the patients’ experience of being in hospital and support their journey through rehabilitation and discharge. To improve social engagement activities to contribute to their health and well- being e.g. craft, Wii therapy, exercises and reminiscence. To identify issues of concern regarding patient’s discharge work with the ward team to make for a GOOD discharge and prevent re-admission. To share with the MDT all essential/useful information gleaned from Pt to support their stay in hospital and prepare for a timely discharge. To provide info and signposting and provide a sense of well-being including podiatry and haircare. Post discharge check -up phone calls

Dorset Frailty Toolkit

A project spanning primary and community services to give a model for the ongoing case-finding for frail patients from various sources. It also shows a way to approach to care planning to enable primary and community services to enter data on the same template – the outputs of which can be viewed by any healthcare professionals with access to the summary care record. It gives options for enhancing MDT processes with a consistent approach and gives access to frailty e-learning module and supporting leaflets.

Frailty Clinic Chandlers Ford

Facilitated meetings were funded and lead to the establishment of a monthly clinic for people living with frailty. A consultant physician works alongside a social care lead in a GP surgery with access to the GP, a mental health care lead, and the community team. It is an integration of health and social care. Patients are identified by all members of the community team and referred via the GP. A combination of mobility problems, carer needs and often memory problems was the best indicator of frailty. Patients had an holistic assessment over one hour then half an hour social care advice. Carers and relatives were involved at all stages and social care input was given for the home environment, benefits and advanced care plans and respite arrangements. Initially set up with goodwill this became a service reconfiguration with no additional cost the NHS.

Crisis (decompensation) / Severe Frailty

Frailty Support Team: proactive and reactive care for people living with frailty in the New Forest.

Reactive: managing people through a phase of acute decompensating of frailty to enable them to stay at home safely. Referrals coming from GPs and SCAS as well as the on call consultant at Lymington Hospital Proactive: supporting Care Homes in managing people living with frailty and ensuring robust escalation of care plans are written and agreed with residents and their families Care homes selected on their need for proactive support.

Acute Frailty Pathway (IOW)

As part of a wider group (looking at end to end system wide Frailty Pathway) we have begun working on an acute frailty pathway to implement early identification (screening at front door) and holistic overview assessment (CGA) to identify key risk and needs and facilitate timely discharge and handover of care to the most appropriate community teams. The programme is reviewed and modified through a PDSA cycle.

End of Life

The Red Bag Scheme – supporting transitions between care homes and hospitals

Following a successful project in Sutton, Surrey the concept of the red bag has spread to Hampshire and is being trialled in a number of care homes and hospitals across the Winchester and Basingstoke areas. The red bag is a repository for the key items belonging to an individual on admission to hospital. It comprises the care plan and has a space for medication, hearing aids, dentures and other items the person needs to function.

General / Training

Hydrate in Care Homes - Hampshire

Hampshire County Council owns and manages over 23 care homes across the county caring for over 900 people. Hydration has been identified as an issue and following a small trial of Hydrate in Care Homes in a few of their care homes they have decided to spread this to all their Care homes. Hydrate in Care Homes is a set of steps that educates the staff team and introduces resources and processes. In NE Hants and Farnham this approach was evaluated and shown to reduce falls, UTIs and hospital admissions. It was then spread across Kent, Surrey and Sussex and similar outcomes shown. Hants CC has a project team that is implementing this work.

Developing e-learning for Frailty

Following on from an initial project to develop e-learning titled: An introduction to Frailty aimed at all staff that come into contact with patients, we have now developed a further e-learning platform to enable senior staff to treat people living with frailty. This project has been aimed at senior clinical staff including doctors, nurses and AHPs who do not specialise in older people’s healthcare. The purpose is to ensure a consistent approach to managing the healthcare needs of people living with frailty wherever their clinical setting.