Developing community resource teams in Pembrokeshire, Wales

This case study looks at integrated teams of health and social care professionals, known as community resource teams (CRTs), who work to co-ordinate care for people living at home in the largely rural county of Pembrokeshire. This model of care is one aspect of a wider strategic programme of integrated care, called Care Closer to Home.

What does the programme aim to do?

The main goals of the programme are to improve or restore the quality of life and confidence for people with complex health and social care needs, and to reduce avoidable admissions to hospital. Four community-based teams bring together professionals from health, social care and the third sector to provide care for patients with complex needs at home.

How is the programme structured?

Care co-ordinators act as the main point of contact for patients and work with the team, patients and carers to tailor individual care packages that enable people to manage their long-term conditions and avoid unnecessary hospital admissions.

Professionals in the CRTs include social workers, occupational therapists, physiotherapists, district nurses, voluntary sector service brokers and specialist nurses. The voluntary sector service brokers arrange for additional services from local charities, such as befriending, dog walking or gardening, while the CRT can also call on the services of dieticians, speech and language therapists, and other health and social care professionals.

What is distinctive compared to the standard practice of care?

Pembrokeshire’s approach is distinctive in its overarching efforts to provide co-ordinated and seamless care, focusing on both vertical and horizontal integration. Still under development, the co-operation between CRTs and teams based in the local hospital seeks to ensure that patients continue to receive co-ordinated care even when they are admitted to hospital.

What are the key lessons?

Voluntary sector involvement

The involvement of the voluntary sector in CRTs has enabled the teams to include non-statutory services in the care package that contribute greatly to patient care or provide support for carers.

Co-operation with the acute sector

Operating as part of the wider Care Closer to Home project, the CRTs’ co-operation with acute-based teams to prevent unnecessary admissions and to facilitate discharge has helped patients to remain at home.

Continuous learning and development

Within the programme, managers have sought to encourage continuous reflection on the experiences of staff and patients, and evaluate organisational procedures to improve the programme. This has facilitated a culture of open learning and improvement.

Importance of appreciation of team members’ roles and contributions

A key point to emerge was the importance of understanding and appreciating the roles of others in improving care co-ordination. Such relationships require time to develop: interviewees indicated that after 18 months of working in CRTs, there has been a lot of progress, but there was still some way to go.

Performance measurement in step with organisational development

While key performance indicators should be agreed early and data collection systems developed for performance measurement, it is equally important to ensure that the teams are in a position to deliver on these measures before their performance is judged. In Pembrokeshire, CRTs were given key performance indicators that reflected their organisational status and their capacity to gather data.

Videos from the project

The Community Care Closer to Home project in Pembrokeshire seeks to identify and manage people in the community who are most vulnerable to an unplanned emergency admission or exacerbation of their chronic illness. We spoke to the team about how care is delivered and how the approach has helped avoid hospital admissions and reduce numbers entering long-term residential care.

Angela Watwood shares how the Community Care Closer to Home project delivers care and how the approach has helped avoid hospital admissions and reduce numbers entering long-term residential care.

Contact details for more information about the service

For more information about community resource teams in Pembrokeshire, please contact Angela Watwood, Head of Community Health and Social Services, on [email protected] or David Morrissey, Assistant General Manager, Community Health and Social Care, on [email protected]