Hospital & Community Navigation Service in Hertfordshire
Get free countywide Social Prescribing Service in Hertfordshire to improve health and wellbeing. Support for hospitals, communities, GP practices, and patients. Integrated services since 2017 to reduce inappropriate demand on health services.
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Hospital & Community Navigation Service
What is the service? A free countywide Social Prescribing Service for Hertfordshire, designed to support individuals to improve and maintain health and wellbeing Providing support for Hospitals Communities GP Practices and Patients Linking/Navigating individuals to appropriate support with a no wrong door ethos We have continued to offer face to face support throughout Covid
Overview of the service Created in October 2017 Integration of five pre-existing services in Hertfordshire Delivered in partnership with 7 voluntary sector organisations working on one system To provide one access point for support across Hertfordshire For professionals, voluntary organisations, family, friends and self referrals
Overview Continued One of biggest SP providers in England (if not the biggest) Recruited/inducted 26 LWs for 19 PCN s since start of 2020 Grew to 93 staff overall from just over 40 at the start of 2020 Integrated teams of Community, GP and Hospital LW working across 7 localities 19,000 referrals in 2021/2022, which came from hospitals, GP Practices, Community & Self Referrals
Our Aims & Outcomes Aim To help people improve their health and wellbeing, maintain their financial stability and in turn reduce inappropriate demand on health and adult care services Outcomes Improved personal wellbeing Reduction in hospital admissions/readmissions Appropriate use of primary care Appropriate use of homecare Reduced social isolation
Evolving Service More responsive and integrated (within sector and between sectors) Able to add new services within HCNS quickly: 2 week Enhanced Discharge Wraparound Service Pathway 0 welcome home calls Outreach to quarantined travellers Specialist teams for projects Waiting Well Support
HCNS Hospital Discharge Support HCNS Integrated with Hospital Teams/Urgent Referral Routes Telecare/Careline HILS/ Meals on Wheels Mobility Aids Decluttering/Hoarding/Bed Moves Transport to GP & Hospital appointments Wellbeing Checks in the Home Shopping/Prescription collections Winter pressure, hospital surge support
Enhanced Wrap Around Service 2135 Referrals into HCNS since March 2021 80% of Referrals are actioned within 24 Hours Referrals being received from Acute, Community Hospitals/Rehab Units & Out of County Hospitals We offer deep cleans, decluttering, hoarding support, bed/furniture moves, hot meals, food parcel delivery, domestic support cleaning & laundry , shopping & prescription collections
Public Health Budget To enable safe hospital discharges Case Study - Veteran
Pathway 0 Contacting all patients Over 65 discharged on Pathway 0 on Day 1 and Day 5 after discharge In July HCNS have contacted 3789 patients To offer support to help them stay safe at home and reduce the risk of readmission
Waiting Well Pilot Linking NHS data with VCS organisations to support those who are currently waiting longest for operations and treatment A pilot for integrated care showcasing the VCS, and a good example of Community-Based Interventions in action A pilot project within Watford General Hospital launched July 2021 and now running within Lister Hospital The service uses trained volunteers to complete a triage call who then refer them to other services for help or support including GP meds reviews We contacted 2166 patients covering pain, orthopaedics and ophthalmology pathways
PCNS Vaccination clinics during Covid Population Health Management Healthier Weight and Lifestyle HCNS contacted patients with a BMI over 30. Carers Support over 300 patients contacted Diabetes Support HCNS contacted BAME males between 40-49 who were low utilisers of services HILS Active Ageing Project HCNS contacted 200 patients
New Projects in 2021/2022 Veteran - HCNS are single point of contact for Veterans within Hertfordshire we have a Veteran lead and Veteran Link Worker Afghan Resettlement - we have supported our Afghan refugees and have a Resettlement Lead and Refugee Link worker Ukraine Guests - we continue to learn and support our Ukraine guests with housing crisis, host breakdowns and support in the community we are currently recruiting 2 Ukraine Link Workers Sensory Support - we have recruited a Sensory Link Worker with lived experience who communicates with the teams via BSL who will supporting others in the community with sensory needs
