Promising models of care in the transformation of care and support

We have identified a range of promising practice in relation to the five areas of transformative change.

1. Helping all people and families to stay well, stay connected to others and stay strong

• Local area coordination aims to support residents in the local community to ‘get a life, not a service’, empowering individuals to find community-based solutions instead of relying on traditional services.
• Community Connectors services help people to use and enjoy local community groups and activities to help people maintain their independence and benefit from peers and support networks.
• Social prescriptions are a tool for clinicians to work with patients to determine wider social and lifestyle aspects of their health and direct them to non-medical sources of support, services and care.
• Community Agents provides advice and support to older people and vulnerable adults, in particular those who are isolated. Many of them need general support and have level social care and health needs.

2. Supporting people and families who need help to carry on living at home

• Age UK Living Well scheme aims to improve prevention and resilience amongst older people with multiple long-term conditions by providing low-level support to day-to-day living and utilising asset-based resources to promote empowerment and wellbeing.
• Reablement services provide personal care, help with daily living activities and other practical tasks, usually for up to six weeks. Reablement encourages service users to develop the confidence and skills to carry out these activities themselves and continue to live at home.

3. Helping people to do enjoyable and meaningful things during the day, or look for work

• Community enterprises are very small (typically fewer than eight workers) local ventures that offer people the help they need to live the life they want. Community enterprises offer services and support that link to the social care, housing and health sectors.
• Employment enterprises, often micro-enterprises that help people, for instance with learning disabilities, to find training and employment
• Kent Pathways Service supports adults with learning disabilities to become more independent. People learn or re-learn skills that will help them to become more independent and need less support.

4. New models of care for adults and older people who need support and also somewhere to live

• Shared Lives is a service that provides family-based support for older people and people with disabilities. It enables people to experience ordinary family and community life and receive personal care outside more traditional care settings.
• Extra Care is a type of housing offering older people purpose-built accommodation that is supported by 24-hour on-site staff.

5. Equipping people to regain independence following hospital or other forms of health care

• Kent County Council hospital discharge project introduced social care discharge coordinators into hospitals to support the discharge process. They identify people who can be safely supported outside the hospital and then use a ‘reablement approach’ to ensure that they achieve maximum independence.
• Royal Volunteer Service, Hospital to Home staff and volunteers are embedded in community hospitals and acute trusts and work closely with staff and discharge teams to identify older people on wards who might need support on discharge.
• British Red Cross Support at Home volunteers support people with a minimum of two long-term conditions, with a focus on smoothing the process of settling back into a routine and help people to regain their confidence and independence after a hospital admission.