High Intensity Use Service
The Frequent Users Support & Empowerment (FUSE) team supports people who attend the Emergency Department (ED) at University Hospitals Plymouth five or more times in a year (understood from data from the emergency service), are over 18, and live in Plymouth postcodes.
We support people with an emotional dependence on ED who may have fallen through the gaps of either the mental health or physical healthcare systems. We support people who suffer from isolation, and who may have suffered trauma related mental health issues.
We offer our clients support, help and guidance regarding the issues that concern or block them, involving them in talking therapies to build their resilience and accompanying them to public spaces to rebuild their confidence. We buddy them to appointments or new groups exceeding the signposting offer, and liaise between the client and healthcare professionals. We refer clients to both voluntary services, healthcare services and interact with other geographical areas to support them. The team consists of Advanced Health Improvement Practitioners, a Senior Health Improvement Practitioner, and a Citizens Advice Plymouth Caseworker, allowing us to support most needs that arise.
We enable them by meeting people in their own homes and in their own communities, holding people as they face their journey and giving them a voice. We stay positive when people fall and are available to chat and give reassurance when needed.
A client may return to our service after discharge should they need our support again taking advantage of our Evergreen Offer. The Evergreen Offer is designed to provide short periods of interaction to restabilise the client and avoid them feeling set adrift.
We are not a referral service but are always happy to discuss and consider supporting someone highlighted to us by another organisation.
Building Sustainable Futures
Client Tina expressed her appreciation for the amazing support received from Advanced Health Improvement Practitioner Mark. Tina provided feedback on her positive experience from our service, and explained Mark has been “compassionate”, “straight to the point” and “listened”.
“I am now looking into the future and planning, when before I did not believe it was possible”.
Tina said Mark has empowered her through solution focused talking therapy and enabled opportunity to reclaim her life back.
Tina is now engaging with her local community and engaging in new therapy strategies, travelling and making new friends.
Making a Meaningful Difference Through Personalised Support
“I’d say, I have found you to be very helpful from a social point of view as I did look forward to our weekly meetings, as I wasn’t getting much social interaction, and found that helpful at times.
“I also thought about all the support you gave me in terms of getting wider support from other services, and feel that was really beneficial as I think a lot of things would not be in place now if not for you arranging these things and also having professionals meeting etc. I always found having a professional such as yourself with me in doctor appointments and such helped to gain better support/ results, as I have found going by myself, I’m not heard as much and maybe my communication skills aren’t as strong. That being said I’ve improved I think from our appointments.
“I think some of our conversations have also helped me relieve some of my stress and anxiety about everyday things and it helps to talk to someone who is the right person, and going on the walks got me out of the house which I found beneficial for my mental health.
“I also found the more we worked together that I over time have made good progress. I don’t nearly as much attend A&E / hospital as regularly now which is great because I think at a certain point you do find it’s not a helpful or therapeutic place for oneself, but I don’t think I’d have got out of that loop without all of our interactions and the support you’ve offered me. While it took time, I think I’d found your approach of listening to me, having a softer approach and a good level of emotional support and understanding of me, really helped me progress mentally and physically rather than clinical approaches and as you know I’m quite avoidant of them.”
So overall, I’d say you have benefitted my life a lot in the last year, and I’d say a lot of positives have come out from the FUSE programme. …I think genuinely that things would be the same as they were if I didn’t have your input as for last year up until last 3 months I only had you as a support system, so you have had a very good impact on me.”
News and achievements
FUSE has been shortlisted for the South West Care Awards 2026 in the Digital Transformation in Care category. The nomination recognises the partnership between FUSE, Citizens Advice Plymouth and Cornwall Partnership NHS Foundation Trust’s High Intensity Use (HIU) service, which works together to provide joined-up, person-centred support for people moving from hospital into the community.
By combining health, wellbeing, social and economic support, the partnership helps people access the right help at the right time. It has also developed a collaborative approach to information sharing across voluntary, community, social enterprise and faith (VCSEF) organisations, creating trusted partnerships that support safe, secure, trauma-informed and continuous care for individuals.
____________________________________________________________________________________________________________________
In September 2025, the FUSE team was awarded ‘Highly Commended’ at the 15th annual HSJ Patient Safety Awards, in the Community Care Initiative of the Year category. Read more.
____________________________________________________________________________________________________________________
The FUSE Team were shortlisted for the Health Service Journal Patient Safety Awards in 2025, in the categories ‘Urgent and Emergency Care Safety Initiative of the Year’ and ‘Community Care Initiative of the Year’.
In 2024 the team were finalists in the Health Service Journal Patient Safety Awards in the category ‘Best Use of Integrated Care and Partnership Working in Patient Safety’.
____________________________________________________________________________________________________________________
The FUSE team held a successful event at Foulston Park in June 2025. It was a great experience networking with stakeholders and partners such as Plymouth Energy Community and Citizens Advice Plymouth, while listening to heart-felt client testimonies.
We heard innovative discussions from University Plymouth Research CO ACTION and Cornwall High Intensity Use Team Lead. It was brilliant to share ideas, and best trauma-informed practice, as well as to discuss challenges and potential solutions to improve collaboration and communication between secondary and primary care, and voluntary, community and social enterprise colleagues from across the city of Plymouth.
____________________________________________________________________________________________________________________
In February 2025, University Hospitals Plymouth NHS Trust was been rated the most improved Trust in England in relation to the 4-hour target, despite increased demand for the Emergency Department.
Click here to read more or watch the video to the right for more information.
Survey
We would be grateful if you would complete a survey based on your experience of this service.
Use this QR code:
