The Succeed Thrive Empower Pennine (STEP) service works with the highest attenders at A&E across Pennine Lancashire. High attendance is defined as attending A&E more than 10 times within a 12 month period. The service works with people who may be recognised as having multiple diverse needs spanning mental health, physical health, social care and wellbeing. It assesses individual ‘holistically’ to identify their full range of health and social needs and jointly develops a care plan with the service user, their family and other professionals, volunteers and community groups. The STEP service is an all age, community based, integrated, non-clinical service. STEP ‘Navigators’ provide an holistic assessment, Multi Disciplinary Team (MDT) care planning (incl. crisis plan), ‘intensive’ case management, Emergency Department in-reach and longer period of support to move individuals out of their cycle of crisis events and embed coping mechanisms.
CLAHRC NWC will evaluate STEP to determine the effectiveness of the service in achieving its outcomes with a view to informing ongoing service design, commissioning decisions and wider system development in Pennine Lancashire. Specifically, to assess the impact on: a) return on investment for the CCG and the wider system b) reduced repeat A&E attendance and admission c) improved integration between community and acute settings; and d) socio-economic health inequalities.