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Community based resilience planning: Introducing the Stay Well Plan

Kirsty Jordan
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Throughout the UK increasing demographic pressures and reducing budgets are leading to higher demand for health and social care services. 

The situation in Newport is no different with the population of those aged over 85 expected to increase by 74%, to an estimated 6,000 people, by 2030. As a result, integration is now a key focus. However, in practice, integration is often hindered by isolated working and traditional thinking, separating citizens into pathways of ‘acute’, ‘primary’ or ‘social’. A desire to overcome these challenges was the catalyst for development of the Newport Older Person’s Pathway (NOPP).

Peopletoo has supported the development of the NOPP, a partnership between Newport City Council, Aneurin Bevan University Health Board and Age Cymru Gwent, in which Stay Well Plans are developed to keep people living independently and in their own homes, avoiding or delaying their need for high-cost health and social care services.

The pathway is a move away from traditional referral based services to an ‘intelligence’ based risk stratification model, utilising health and social care data to identify people who are deemed as being in the top 3-7% of the population at risk of accessing high cost services.

Working with this group of people and their carers, has provided unique opportunity for partnership working with third sector organisations. The bespoke care facilitator role, created with Age Cymru Gwent, has been key in promoting and expanding community provision, utilising low cost services to support people to remain well at home.

The are facilitator works alongside individuals and their carers to co-produce a Stay Well Plan, using motivational interviewing techniques to facilitate positive behavioural change. Rather than being an assessment for services, a holistic view of wellbeing is taken and individuals are empowered to take control of their own needs.

A novel approach to evaluation has been adopted by developing a linked dataset of individual level data across multiple systems. This can monitor how often the target cohort are accessing services, compared with those who opted out of the programme and the wider 75+ population.

Findings to date identify:

  • A significant reduction in A&E attendances and Emergency Admissions for participants
  • Fewer participants accessing Social Care services than people that opted out
  • Increased access to benefits such as attendance allowance, allowing people to access community support independently

Working together has facilitated provision of the right support at the right time.

See our Community Based Resilience Planning model -

Read more detail on this topic -

Kirsty Jordan, services manager, Peopletoo

Column sponsored and supplied by Peopletoo

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