Pembrokeshire community resource team care planning/co-ordination process

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Part of Co-ordinated care for people with complex chronic conditions

The four community-based teams in Pembrokeshire bring together professionals from health, social care and the third sector to provide care for patients at home. This organogram illustrates the care planning/co-ordination process.

Pembrokeshire co-ordinated care planning process



Referrals come from several sources: team members can introduce patients they are already caring for if they think they would benefit from a care co-ordinated approach. GPs also refer patients to the team, as do the hospital-based teams, consultants and specialists.

Referrals come through a contact centre run by the local authority and staffed by social care assistants. The contact centre is advertised in the community as a calling point for people who feel they or their relatives may need help in their everyday lives. People can phone the contact centre directly and social care staff also use it to make referrals. The social care assistants take case histories using a holistic health and wellbeing template that also records economic and living circumstances. Once a referral is accepted, a professional help desk staffed by medical and social care workers assesses cases to determine the level of care needed. If a case requires face-to-face assessment, it is referred to the relevant community resource team (CRT).

Care planning and co-ordination

CRTs meet weekly to discuss cases. The meetings are chaired by a team co-ordinator who is responsible for disseminating information among team members and exchanging information with GP practices. Team co-ordinators also assign tasks to team members and follow up on implementation and outcomes. The team co-ordinator also has a caseload. Ideally, all CRTs should receive administrative support for meeting organisation and note-taking but only one team does.

Patients referred to the service are assigned to a care co-ordinator based on the initial assessment provided by the referrer, the patient’s location, team members’ workloads, and whether they are already known to a team member. Assessment of a patient’s needs and acceptance as a CRT case is based solely on clinical knowledge and judgement of the health team and the expertise of the social workers.

The care co-ordinator visits the patient at home, tailors an individual care package in co-operation with the patients and their carers, and assigns tasks to CRT members and specialist staff. Care co-ordinators strongly encourage patients and their carers to create an emergency and contingency care plan in case a patient is admitted to hospital or if a carer falls ill. They also offer carers an assessment of carers’ needs in line with a Wales-wide policy that seeks to improve carer identification and support.

Patients are given a risk-based code of red, amber or green, resulting in higher or lower frequency of visits and discussion at the team meeting. If a patient remains stable (code green) for several weeks, they are discharged from the service to lower level services. If their health deteriorates, patients can be admitted to short-term intermediate, residential or hospital care until their condition improves. If the deterioration is permanent, the patient may qualify for continuing health care and the CRT’s involvement in care provision is reduced or stops. In future, predictive risk modelling will help both the triage process and case identification.