Models of Work – Norfolk Integrated Housing & Community Support Services
NIHCSS provides supported living schemes with 24/7 support on site delivering personalised support to people experiencing mental distress. In addition, NIHCSS also provides community support by working alongside people in their own homes and in-reach support for people in acute mental health hospitals to support their discharge.
Purpose
We create a pathway for people to move from residential care to supported living and then to independence in the community. At each stage support is provided by an integrated staff team where support workers focus on people’s journey to mental wellbeing, are operating on the principles of psychologically informed environments and service user leadership, working alongside people to develop their insights, skills and ability to do things for themselves.
NIHCSS provides flexible levels of support to minimise the risk of difficult experiences impacting a person’s mental health, to be able to provide more intensive support when needed and increase the potential for long term mental wellbeing. Where approaches by services have failed in the past to meet an individual’s, we take a creative approach based on the strengths of the people who use the services and focus on their wishes to develop hope and resilience.
Referrals are accepted from Norfolk County Council Mental Health teams and Community Mental Health and Crisis Teams at Norfolk and Suffolk Foundation Trust (NSFT).
Partnership
NIHCSS is a delivered in partnership with St Martins Housing Trust, a charity specialising in homelessness and housing support in Norwich.
Commissioners
NIHCSS is jointly commissioned by Norfolk County Council and Norfolk and Suffolk Foundation Trust (NSFT).
Quotes
Couldn’t ask for better support. Staff have helped me build and grow so much.
I am so grateful for the support Kareem and the team is giving, it is changing my life, really enjoying my 2 hour slots
My support worker goes above and beyond to make sure I’m supported in the best way she can.
Please continue the hard work and support you provide as it really does make a difference to people’s lives. I can speak from experience, and changes which have been made in the past 4 years since moving into my 1st home and receiving assistance to help me live independently.
My support worker is great, she is a peer support worker so she understands that I may not always be well, she is kind and encourages me to step out and is flexible on the places we visit.
NIHCSS Specialist Housing Related Support (Structured Drug & Alcohol Treatment)
Purpose
This service supports people who are in structured drug & alcohol treatment with the aim to achieve successful outcomes through housing related support. Having safe, suitable and stable housing can be a crucial factor in support of successful drug and alcohol treatment. By working with our partners, we can offer a person-centred, joined up approach.
Partnerships
Together for Mental Wellbeing are working in collaboration with St Martins Housing Trust and Change Grow Live (CGL).
Commissioners
Two-year pilot project commissioned by The Office for Health Improvement and Disparities (OHID) and The Department for Levelling Up, Housing, and Communities (DLUHC) as part of the 10 year drug strategy.
SMI Tobacco Cessation
Purpose
Together have collaborated with SmokeFree Norfolk to deliver an exciting new enhanced service offering specialist support to people with a severe mental illness (SMI) to quit smoking.
Offering up to 6 months of support to deliver a programme based on the choice to make either an abrupt attempt to quit or a more managed gradual reduction in tobacco use. The programme of behavioural support coupled with pharmacotherapy and mental health expertise is tailored to suit the individual.
Commissioners
The service is commissioned by Norfolk and Waveney ICB and Norfolk County Council.
over 600 The SMI/Enhanced SmokeFree service which started in January 2023, has delivered over 600 support sessions to people with a Severe mental Illness who want to reduce or quit smoking.
14 individuals 14 individuals have already reached a 4-week quit marker and we have evaluated that the most popular treatment model is a Gradual Smoking Reduction. With that, each week a person reduces their smoking by 10% until over 12 weeks they are completely smoke free.
SMI Physical Health Check
Purpose
Together works with people registered on the Quality Outcomes Framework (QOF) SMI Register in GP practices across Norfolk and Waveney – supporting a greater understanding of the importance of good physical health and increasing awareness of entitlement to an annual physical health check (PHC) and the supporting interventions.
Working in collaboration with GP practices, Together staff, experienced in delivering specialist mental health services support individuals to book and attend their PHC and signpost them to intervention services.
Partnerships
Primary Care Practices across Norfolk and Waveney
Commissioners
The service is commissioned by Norfolk and Waveney ICB.
over 1500 people The figure from October 2021 – 17 August 2023 reveals that staff have contacted over 1500 people about the service and have successfully booked Physical Health Check Appointments for 762 of them. We’ve worked with over 22 GP Surgeries throughout Norfolk.
Quotes
One team member reported that one person who uses the service needs help as they were not allowed to be vaccinated due to partners. Now they are separated, the person called back and very much liked to book an appointment.
Staff reported that people like staying on the phone as they need someone to speak to. They said they don’t mind and take their time. One even stayed on the phone for more than 20 minutes.
Staff feel they are able to raise concerns regarding the mental health of people who use the service and notify GP’s on potential referral to Community Mental Health Team.
Staff are able to notify those who need home visits.
SMI Rehabilitation in Complex Psychosis
Purpose
Together Senior Recovery and Peer Support Workers make up a 22-strong multi-disciplinary Rehabilitation Team, providing wrap-around support for people experiencing psychosis who have not been able to benefit from treatments that have been offered.
The team includes occupational therapists, specialist nurses, social workers, a pharmacist, psychologist, and psychiatrist, as well as Togethers Specialist Recovery and Peer Support Workers.
The team develop personalised care plans and support people to get help with finances, housing and legal issues and other services provided in the community. The aim is to make sure people receive effective care and support to manage and improve their negative experiences of psychosis, enabling them to live as independently as possible as part of their journey to better mental wellbeing.
Partnerships
The rehab team is a collaboration between Norfolk and Suffolk Foundation Trust (NSFT), Norfolk County Council, Together for Mental Wellbeing, Change Grow Live and Norwich City Council.
Commissioners
The service is commissioned by Norfolk and Waveney ICB and Norfolk County Council.
49 People 49 People experiencing mental distress along with a number of difficult life circumstances complex mental health needs have been supported by Together
Quotes
Dan and Jo are Senior Recovery Workers within our new rehabilitation community mental health team based at Hellesdon. Dan and Jo are both kind and compassionate professionals who bring a broad range of skills to the team, in their roles as Senior Recovery Workers.
The input of Together as part of the team has been invaluable and highly respected by the clinical staff.
