Outcome 4

We will increase the percentage of older people living well and independently in Dorset.

Why it’s important

What we’ve been doing

What are we going to do

How we’ll measure progress

Why it’s important

We work together with our two councils to create a plan called the Better Care Fund. These plans are designed to help improve the care and support available to you. We also connect with the councils’ plans for adult social care and housing to make sure everyone is coordinated. We are also developing a plan specifically for carers.

Right now, our communities are facing different challenges. In Dorset, our community and voluntary sector have come together to provide support to people experiencing challenges such as cost of living or feeling lonely and isolated. This includes providing food banks where people can get emergency food, supplies and safe spaces where people can go if they are lonely or need help. The good news is our communities are coming together to tackle these challenges.

These initiatives show how strong our communities are and how we can support each other in difficult times. To make sure you get support tailored to your needs, we are using something called personalised budgets. This means you can decide how you want to use the support you receive based on what is most important to you It gives you more choice and control over you care.

Another approach we are using is called reablement. This approach is about helping you become more independent and stay in your own communities. Instead of going to hospital, we provide support and services to help you recover and regain your abilities. This way, we can reduce the number of hospital admissions and help people stay independent in their own homes.

What we’ve been doing

We want to make sure our children, young people, and their families get help for their mental health as soon as possible. We have a plan called the Emotional Wellbeing and Mental Health Strategy for Children and Young People to help us to do this. We have used a model called ‘THRIVE’ to change how we work so all children have the best chance to be happy and well.

We have also improved specialist help for parents who may have mental health difficulties during pregnancy or after having a baby. We know dads and partners need help too, so we have something called DadPad to give them support.

Community support is important to help you stay well. We now have more people called ‘social prescribers’ who help through GP practices. They can listen and support you to identify what is important to you, make changes in your life and connect you with things happening in your local area.

We have a special group made up of different organisations working together to prevent suicides. We have a plan to make sure we take action and help people when they need it most. We have been working hard to improve the services for those in crisis and need more support with their mental health and emotions. For university students in Bournemouth, we have created a special place called the ‘University Retreat’. It is a safe place where students can go when they need help and support. It is important that they know they are not alone and that there are people who care about their wellbeing.

Sometimes it can be difficult to get all the different services running together smoothly. We have been working hard to make this better, especially in primary care. We want to make sure everyone gets the help they need. For example, we have been focusing on making sure people with a serious mental illness go for a yearly health check. This helps people stay healthy and get the right support. We also have a programme called LiveWell Dorset. It helps people make positive changes in their lives to become healthier both physically and mentally.

We have a group called the Health Inequalities Group (HIG) focusing on making sure everyone has a fair chance at being healthy. The HIG brings together people from a wide range of organisations to reduce health inequalities for people of all ages. The HIG works with the Community Conversations programme to understand what is important for people from different communities and to find ways to tackle the barriers to being healthy.

Looking after our staff who deliver services is important too. We have a number of staff wellbeing offers including an enhanced service through Here for Each Other and projects to help our staff to stay active.

What we are going to do

We will focus on helping you stay healthy by preventing problems before they start. It is important for each of us to take care of our own health and do what matters most to us. Following our Integrated Community Care Model, we will work with you to understand your needs. We will listen to your opinions and make sure we provide the services most important to you. We will support organisations in the voluntary and community sector to help people in the best way possible. We will review our services to make sure they are easy to access when and where you need them.

We are creating a programme called the Anticipatory Care Programme to help older people live well at home. Our goal is to make sure they can easily share any concerns they might have about their wellbeing, independence, social connections, and staying healthy. We want to connect people with the support they need, and we want to do this on a larger scale to reach more people. If older people have a fall this can be a trigger that affects how independent they can be. Using the information we have we can understand the needs of different groups of older people and provide the right services. Keeping physically active can help to prevent falls, while those who are already frail may need more targeted support.

Our approach is to be proactive and prevent any issues from becoming more serious. If you need help, we want to work closely with you to understand what you want in order to live your best life. It could be as simple as continuing to enjoy gardening, meeting friends, pursuing hobbies, or learning new skills. We believe in the power of community support. For example, we can help create support groups like community kitchens that offer a lunch club. These places bring people together, provide them with a nutritious hot meal, and offer support and companionship.

We are working on a project to better understand the needs of frail residents in care homes. Our focus is on developing and testing a special plan called a frailty pathway in two areas. This pathway aims to prevent hospital admissions and help residents in returning home with support, focusing more on preventing admissions.

To make sure people get the best care we are using a team of experts from various healthcare fields. They will work together to provide the right care for people in their homes whenever possible.

We are also exploring the use of technology, like a smart application on a phone, to monitor residents’ health, such as blood pressure. We are working with community partners and agencies like the police, fire services, and post offices to keep an eye out for any signs that someone may need help, like if their curtains are not drawn.

During this project, we will be testing different approaches in different areas. In one area, the focus will be on preventing older people from going to the hospital, while in another area, we will focus on helping people when they come back after being in hospital. An external company called Medicare will help us identify any changes in the health of care home residents early on. This way, older people can get more help and support from a team of healthcare professionals.

At first, we will start testing this with just one or two residents, then gradually increase to 15 people in each area. As we learn more, we want to include frail older people who live in their own homes too.

As the pathway develops, we will extend it to include frail people living in the community. We have a special virtual ward that can help up to 20 frail individuals. This will support us to make sure everyone who might be frail gets the right monitoring and support. When appropriate, we want to help people move from the virtual ward to needing less monitoring, so they can still be independent.

We are creating a hub to help monitor the health of people who have recently left hospital. This hub will be starting in the east and focus on supporting people with respiratory, cardiac, and frailty conditions. It will allow us to check their health from a distance. As we make improvements, we will also use the hub to prevent people from needing to go to hospital.

We are currently developing different plans for people with respiratory, cardiac, and frailty conditions. These plans are based on our Core20PLUS5 priorities and aim to keep these conditions stable and monitored. To make this all this happen, we need to work together with primary care and the councils to make sure you have access to digital technology and feel comfortable using it. This is important because having access to information, advice, and services, not just about health, will help you stay independent and feel more in control.

We are reviewing our urgent and emergency care services to make sure they work together in a more joined up way. Working with Healthwatch Dorset, we are finding out what you think about urgent and emergency care services and using your experiences to improve the services we provide. We want to work with you to develop services which mean you can be treated as close to home as possible.

This might be through urgent community response teams, urgent treatment centres, and other units. But when you do need to go to a hospital, we want this to be as quick and as safe as possible. If you have to stay in hospital, we only want you to stay for as long as you need to and help you to get home as soon as possible.

How we are going to measure progress

We have a number of measures that we will monitor which will tell us if we are helping you to access the services you need in the right place.

You will see:

  • fewer people being admitted to hospital as a result of a fall

  • maintained or increased physical activity in older people

  • more people being treated at home, or within their care home using digital monitoring, including virtual wards or integrated community services teams

  • better access to urgent response services as close to home as possible. You should only have to go to an emergency department when you need to

  • better access to same day emergency care

  • more people waiting less than four hours to be seen in one of our emergency departments

  • more people being discharged from hospital into their own home or place they are living quicker