Patients across Cardiff and the Vale of Glamorgan are avoiding unnecessary hospital stays thanks to better care and support in the community and their own homes.
Three Community Resource Teams (CRT) operate across Cardiff and Vale University Health Board and have adopted a seven day working pattern to include weekends and bank holidays and appointed additional staff to care for more patients.
During 2015, the CRTs saw over 2,000 patients in a primary care setting which prevented unnecessary hospital stays and admissions. The extra resource has meant 245 additional patients have been supported by the CRTs at weekends and bank holidays during the first six months of the expansion. This relieves pressures on hospital beds and enables patients to receive care in their home environment.
The CRTs work closely with GPs and the Emergency Unit to ensure patients are either seen at home following an urgent referral from their GP or taken home from the Emergency Unit, whether this is to prevent an unnecessary hospital admission or enable a discharge at the weekend.
Many patients that are diverted to the CRT from the Emergency Unit have experienced a fall so they have access to a comprehensive falls management programme to help them to regain their confidence and reduce their risk of future falls.
Mary Jones from Penarth was referred to the Community Resource Team following a fall. She said; “I was terrified to do anything before the team came out to see me. It was the fear of falling that held me back but since working with the Community Resource Team I can now walk into my kitchen without using my frame which I never thought I would be able to do.
“My confidence is getting stronger and I have a friend that comes in and helps me to complete my exercises every day which is helping me to get better. I’m happy now and I feel so much better that I can do things without thinking about it and I can’t thank the team enough for their support.”
The increase in the CRT resource is in line with the Health Board’s strategy ‘Shaping our future wellbeing’ which has a focus on ‘Home First’, to “enable people to maintain or recover their health in or as close to home as possible.”
The CRTs work closely with GPs, patients, families and carers to arrange for care packages to be implemented in the home reducing the need for hospital admissions in the first place.
The extra resource aims to free up GP’s time where the team will work with patients before they get a stage where they are admitted to hospital. The improved access for patients will also lead to improved communication for GPs, district nurses and other health board colleagues in dealing with patient care.
Sue Morgan, Director of Operations for Primary Community and Intermediate Care at Cardiff and Vale UHB said;
“The additional staff in the Community Resource Teams means that more people are able to either return home from hospital earlier or avoid hospital admission in the first place. The CRTs are well placed to work with individuals and provide the extra support that is needed to help them to regain their independence following an illness or injury.”
Dr Haydn Mayo, GP lead for North Cardiff Cluster Group said; “Our cluster group has been working closely with the Community Resource Team with a further two nursing posts appointed to work with elderly patients following falls.
“GPs can now identify frail and vulnerable patients in the community and refer them for assessment by the CRT team. This enables patients to remain in their own home where they are appropriately supported by the appropriate professional.
“This is a big benefit to the individual patients but also supporting GPs and the local health community.”
The teams work with a variety of patients over 18 years of age who require care and support at home and may have conditions such as fractures, strokes, Parkinson’s Disease, MS, road traffic accidents or a life limiting condition. They work with patients in their own homes and identify individual goals to help patients regain their independence and rely less on family, carers and the care sector.
The multidisciplinary integrated teams consist of health staff from Cardiff and Vale UHB including Physiotherapists, Occupational Therapists, Dietitians, Speech & Language Therapists, Nurses and Consultants; local authority staff from Cardiff Council and Vale of Glamorgan Council including Occupational Therapists, Registered Managers, Homecare Managers and home care staff and voluntary sector staff including Age Connects and the Red Cross.
The CRTs offer a wide range of support services including reablement, rehabilitation, medical and nursing intervention but also supplementary services such as financial advice and benefit support.
Valda Morgan from Cardiff received a referral to the Community Resource Team following a nasty leg injury after she slipped on her stairs. Her husband Bryan said: “The unbelievable amount of care my wife has received at home over the last four months has been phenomenal.
“The Community Resource Team have been outstanding in the way they’ve really taken on board her care, bearing in mind she has been living in one downstairs room since early November.
“They have arranged numerous items like a commode, a bed rail to fit a single bed downstairs, and handrails on the stairs. They have also organised two visits per week from Age Connect Carers to help with bathing. She also has frequent visits from a physiotherapist who has worked really hard to get my wife well on the road to recovery.”
Marion Rolley, 82, attended the Emergency Unit on Boxing Day after fracturing her shoulder while playing on a swing with her grandchildren. After being kept overnight for observation and seeing a physiotherapist the next morning the CRT was contacted to support her discharge home to stop her being admitted to hospital. Mrs Rolley was very independent but was now in a collar and cuff and unable to use her one arm.
Mrs Rolley returned home and the CRT visited her the same day to talk to her about her needs and recovery plan. She reported that her main difficulties would be with personal care, making food and drinks, getting on and off the bed and using the bathroom. The Occupational Therapist provided some equipment to assist Mrs Rolley and gave advice on the safest ways of using the bathroom and bed with a fractured shoulder.
A reablement plan was agreed between the patient, Occupational Therapist and a Homecare manager with twice daily visits from a carer to support with personal care and meal preparation.
The CRT Physiotherapist developed a therapy plan, providing an exercise programme to ensure optimum recovery from her shoulder injury. The plan was set for six weeks with regular reviews from the health and care staff involved.
At the end of the tailored programme she was fully independent with all personal care and meal preparation and able to go out in the community.
In a thank you letter to the team Mrs Rolley said; “I couldn’t have managed without you. Your work is very much appreciated.”
