Living Well Team: Putting personalisation at the heart of care 

The South Lincoln Healthcare Living Well Team supports people with long-term conditions to live independently and improve their wellbeing.

Working within primary care, the team includes Occupational Therapists, Care Coordinators, Health and Wellbeing Coaches (via One You Thrive Tribe), and Social Prescribing Link Workers (via Lincolnshire Voluntary Centre Services). 

Their approach centres on what matters most to individuals and their families, offering early intervention, personalised support, and seamless coordination across services.

This way of working helps people build resilience, manage their health, and stay connected to their communities, reducing crises, hospital admissions, and reliance on emergency services. 

The diagram below shows how the Living Well Team sits within the South Lincoln Healthcare Primary Care Network.

WATCH: A leading approach to frailty

Team Lead and Advanced Clinical Practitioner Sean O'Sullivan talks about South Lincoln Healthcare's leading approach to frailty.

Embedding personalised and strengths-based practice

With support from the It’s All About People team, the Living Well Team has embraced a personalised, strengths-based approach. This has been an evolving journey of learning, reflection, and change. We’ve helped nudge, challenge, and inspire the team to embed these principles into their everyday practice.

Led by Sean O’Sullivan, a passionate advocate for personalisation, the team has completed training in shared decision-making and personalised care and support planning.

They team also use Our Shared Agreement and the Five Foundations as guiding principles.

Co-Production: Designing with, not for people

The team has actively embraced co-production, working with a small group of local people to redesign paperwork used to initiate relationships with individuals identified through risk stratification. The original materials were often seen as too clinical and complex.

Together, staff and people with lived experience co-produced a simplified letter and revised “What Matters to You” materials. These now include clearer activation questions and more accessible language.

The feedback has been overwhelmingly positive—many recipients shared that no one had ever asked them, “What’s important to you?”

This shift has helped individuals prepare for more meaningful and personal conversations with the Living Well Team.

Conversations that matter

The team regularly uses motivational interviewing and shared decision-making techniques to explore what matters most to individuals and their carers.

They also use locally-developed It's All About People activation questions to understand how motivated and confident people are in looking after their own health and wellbeing.

These conversations build trust and uncover people’s hopes, goals, and confidence in managing their health, or activation level.

Together, they co-develop personalised care and support plans tailored to each person’s needs. These plans are shared across services and provided to individuals, ensuring continuity and coordination.

Working together

The Living Well Team meets regularly with the wider Neighbourhood Team as part of their case management process.

The wider team is made up of colleagues from community nursing, therapies, social workers, mental health practitioners, social prescribing link workers and health and wellbeing coaches, and many others from the Voluntary, Community Faith, and Social Enterprise (VCFSE) sector.

These strong relationships with local partners, and with the individuals they support, make conversations about next steps smoother and more more effective.

Being embedded in the Neighbourhood Team means they can collaborate directly with colleagues, rather than simply referring people to services and hoping for the best. This approach allows real-time updates on progress, challenges, and opportunities, ensuring joined-up care.

Whether the need is medical, social care, mental health support, a lifestyle change, or a community connection to reduce loneliness, the Living Well Team coordinates and helps people access the right support at the right time.

Impact and outcomes

The Living Well Team’s approach has led to:

• Increased completion of Personalised Care and Support plans and ReSPECT plans
• Improved communication between GP teams and the Living Well Team
• Enhanced person / patient engagement and satisfaction
• Timely referrals addressing both clinical and social needs
• Better access to care in the right place, at the right time

Local GPs have shared:

• “Since the Living Well Team got involved, I’m not seeing as many complex older people now.”
• “I see fewer people who’ve fallen through the gaps.”

Capturing real-life outcomes

The Living Well Team is now working with the It's All About People Team to develop and refine the People Stories Template, capturing real-life outcomes.

Thematic analysis of seven people's stories showed clear improvements once the Living Well Team became involved, highlighting:

• Trusting relationships
• Person-centred care
• Effective coordination and communication
• Multi-agency working
• Support for carers and families
• Improved housing conditions
• Reduced isolation and loneliness
• Focus on independence and self-care

Why this work matters

Without the Living Well Team, the consequences would be significant:

• Deterioration in outcomes for individuals
• Increased social isolation and loneliness
• Fragmented, uncoordinated care
• Longer waiting lists
• More people in crisis, receiving reactive rather than personalised care
• Increased silo working
• More unnecessary GP appointments
• Higher demand on urgent and emergency services
• More admissions to residential care

The Living Well Team is not just a service; it’s a lifeline for many. Their personalised, proactive approach prevents crisis, promotes independence, and ensures people feel seen, heard, and supported.

For an example of the impact the living well team can have, READ Rose’s story.

And we'll also be releasing a Personalisation Podcast very soon with Helen, a Care Coordinator at South Lincoln Healthcare.