Plans to help people stay well for longer in their own homes are taking a step forward.
Bolton Council is working with its health partners to deliver an integrated health and social care system in order to improve services closer to home and prevent unnecessary hospital stays.
Together with NHS Bolton Clinical Commissioning Group, Bolton NHS Foundation Trust and Greater Manchester West NHS Mental Health Foundation Trust, the council is to establish new Integrated Neighbourhood Teams (INT) and expand its Staying Well project to help older residents in the borough.
Currently, there are more than 44,000 people aged 65 and over in Bolton, and more than 13,000 of these are at risk of developing future health and social care needs.
Predictions show that around 3,500 people have a high risk – 50 per cent likelihood - of being admitted to hospital within the next 12 months. That’s six and a half times more likely than the average resident.
A further 11,000 people aged 65 and over have a 20 per cent likelihood of being admitted to hospital, which is two and a half times more likely than the average resident.
The INTs and Staying Well project seek to reduce that risk by identifying people who will benefit from early intervention in the community, and hopefully avoiding a hospital admission further down the line.
The first phase of INTs will be introduced in the west of the borough, starting with two GP practices in Westhoughton, and will include community nurses, social workers, physiotherapists, occupational therapists, community psychiatric nurses and GPs.
Their work will focus on the larger cohort of residents with a 50 per cent likelihood of hospital admission – those with long term conditions and the frail elderly.
The roll-out of the pilot Staying Well project will focus on those residents with a 20 per cent likelihood of hospital admission, and will include people with long term conditions that they are currently managing at home with medication or other therapies.
The Staying Well team will see extra health and wellbeing co-ordinators assessing the needs of individuals and working with them to help maintain their independence and enhance their quality of life at home.
The Deputy Leader of Bolton Council, Councillor Linda Thomas, said: “With a growing, ageing population and increased pressure on resources, we have to think differently about the way we deliver health and social care.
“A lot of people with long term conditions currently manage their conditions at home but are at an increased risk of being admitted to hospital within the next 12 months. These new teams will be able to target support to those people who need it, and thus help to prevent unnecessary hospital stays.
“By identifying people in the community and offering some form of early intervention and lifestyle enhancements, we will hopefully reduce the number of people who may develop an eligible need in the future and thus relieve some of the pressure on our borough’s health and social care system.”
It is expected that both teams will be operational by September 2014.
* The new posts will be funded by the Better Care Fund. Approximately 17 FTE employed by Bolton Council for the Staying Well project and approximately 3 FTE for the first phase of the Integrated Neighbourhood Teams, with more to follow in future years.
* Staying Well was established just over 12 months ago as a targeted prevention and early intervention method offered to older people in order to increase their opportunities to enjoy long and healthy lives, feel safe at home and connected to their community.
* Health and wellbeing co-ordinators work with individuals to assess their needs, focussing on things like mobility issues, emotional wellbeing, personal care and daily tasks, health matters and support from family and friends.
* Support and signposting to relevant services motivates individuals to change their behaviour and improve their health and wellbeing.
* The Staying Well scheme is for people who have long term conditions but who aren’t in receipt of statutory health and social care services.