Lead service provider/commissioner
Type of knowledge
Type of knowledge:
Type of evaluation:
Outcome evaluation; Survey
Prevention service description
• a Single Point of Access (SPA) and assessment for all referrals • a SPA to the wider resources provided by the voluntary sector • provides a triage service to identify referral pathways for patients and appropriate follow on support • uses the Patient Activation Measure (PAM) assessment tool as a stratification tool, so that the service can target and support people with the lowest level of self-management and with the most needs • provides tailored health coaching, goal setting and motivational interviewing based interventions; bespoke to the needs of the patient, including home visits, based on their PAM assessment • provides information, advice, signposting and referral to other services • takes a lead on community development by recruiting volunteers to supplement the intervention work provided by the services Wellbeing Support Officers and to develop additional resources for patients; building capacity within the voluntary sector by supporting smaller groups to deliver more services and mapping of resources and services available for older patients within the borough.
A particular innovation of the service is using the PAM assessment tool to proactively identify and support older people with the greatest potential to be further empowered to self-mange and participate in their own care planning and health and wellbeing; in line with NHS Self Care Agenda.
Befriending, mentoring and peer support; Information and advice; Community services; Low-level support; Social prescribing; Self-care; Community capacity building
Target client group(s):
Older people; Adults with long-term health conditions