This case study is part of a research project undertaken by The King’s Fund and funded by Aetna and the Aetna Foundation in the United States to compare five successful UK-based models of care co-ordination.
What does the service aim to do?
The key aim of the Esteem Team is to support people with mild to moderate mental health conditions and complex social needs at an early stage to prevent deterioration and admission to secondary care services. It aims to empower patients to take control of their own lives by offering guided therapies and tools for self-help.
How is the service structured?
The team employs six link workers who provide care co-ordination for complex patients. The link workers act as patients’ navigators through the health and social care system and typically have a social worker background and/or personal experience with mental health conditions. The Esteem Team can refer patients to a wide variety of statutory and voluntary sector services including social services, debt advice agencies, substance abuse counselling, therapeutic services and peer support groups.
Link workers form close relationships with their patients, building their confidence and self-esteem. They will visit patients at home and accompany them to appointments if required. The Esteem Team’s work is not time-limited: patients will be discharged from the service only if the link worker and the clinical co-ordinator agree on discharge using guidelines developed by the service.
What is distinctive compared to the standard practice of care?
The patient is never left unsupported: if a therapy or care intervention is not successful they are encouraged to try a different service through Sandwell Wellbeing Hub. The care co-ordinator makes a referral to the new service so that patients cannot get ‘lost’ in the system. This differs from standard practice where a patient can access a certain number of therapy sessions and have to seek a new referral from their GP once these end or if their condition has not improved.
What are the key lessons?
- Co-production and patient inclusion
Patients and service users were involved in the initial design of the service and continue to play a large role in service delivery. This facilitates buy-in and trust, while harnessing patients’ expertise ensures the service is patient-centred and responsive.
- Skill mix and staff roles
Many staff in the hub have first-hand experience of mental health conditions; this contributes to a shared understanding of the issues patients may be facing and helps to gain their trust.
- Awareness-raising and relationship-building
The Esteem Team relies strongly on relationships with other services, particularly those in the voluntary sector, to offer patients access to a range of services and support groups.
- Holistic care tailored to patients needs using a stepped care approach
The Esteem Team tailors care packages to the specific need of patients. When link workers refer patients into services they remain embedded in the Sandwell Wellbeing Hub system, this means the Esteem Team retains an overview of their care and can pick up cases quickly if a patient’s condition deteriorates.
Contact details for more information about the service
For more information about the Sandwell Esteem Team, please contact Lisa Hill, Primary Care Mental Health and Wellbeing Lead, on Lisa.firstname.lastname@example.org
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See more of our work on co-ordinated care
- Watch our video to find out more about the Esteem Team's approach to care co-ordination
- View our organogram showing the Esteem Team's care planning/co-ordination process
- Read the Esteem Team patient stories
- Find out more about the project: Co-ordinated care for people with complex chronic conditions