For Salford Together, our focus is on promoting wellbeing and independence for the city’s adult population, looking at both the individual and the environment.
The environment is the city of Salford and how the programme looks at the ‘bigger picture’. Across the city, we are looking at standards, in health and social care, including private services, creating communities where everyone feels valued, and ensuring older people remain a key part of society.
For the individual, four levels of support and need have been identified, with an emphasis on allowing citizens to maintain their independence and when intervention is required it is at an early stage and coordinated across health and social care teams to ensure proactive and targeted support is received.
The four levels are set out below:
- Able – where the citizen is independent, active and self-managing. The focus at this level is about keeping them healthy and well. They may not be accessing health and social care services at this stage, and the emphasis would be for those who are ‘able’ to think about what is keeping them well and how they can maintain their independence for as long as possible. There is a strong focus on the local community and what it can offer to maintain a healthy life rather than health and social care assistance.
- Needs some help – this citizen is more vulnerable, may be a carer or lives alone, may have early dementia or an acute issue which is short-term and once addressed will become self-managing once more. At this level, they may only need assistance in managing a newly diagnosed condition or learn about how they can support themselves. The emphasis is on planning and prevention and a focus on meeting the needs of those who ‘need some help’ effectively and support them to move back to an ‘able’ level.
- Needs some more help – requires more regular care, such as a home care package, regular district nursing support or intermediate care. This level is for those who receive support a few times a week and have multiple needs. At this stage, the focus is on the patient or service users’ preference for future care and how they would like to be supported if their condition was to worsen. There would also be consideration on how to improve their condition and provide them with the support they need to get back to ‘needs some help’ where possible.
- Needs a lot of help – this citizen requires round the clock support and will most likely be in a care home or care may be provided by their intermediate family. At this level, sensitive discussions would be had around the patient or service users’ preference for end of life care. Support would be provided to people to ensure they have some control about their preferred place of dying and their wishes at that time. The focus is on ensuring comfort and respecting the wishes of those at this stage in their life.
A wellbeing plan has been created for those who are in the ‘Able’ category, and a Shared Care Record with a wellbeing plan in place for the remaining three levels, with more content in the plans as each person’s needs become greater.
At an ‘able’ level, the plan will focus on the five ways to wellbeing, providing advice on activities and social interactions, which will be based on the each person’s preferences. The plan is based on the NHS Five Ways to Wellbeing, which provides suggestions for activities that are proven to keep you healthy and well.
As the level of need increases the plan will become more detailed, to cover a care plan. This would include information such as who their Care Coordinator is, who to contact in and out of hours and the shared care plan, which will be agreed between the person and the services providing their care.
At the ‘needs a lot of help’ level, an end of life care plan will also be included.