Indeg James and Dr Sioned Richards work in the intermediate care team in Carmarthen in west Wales. In this blog, taken from our recent report on innovation in west Wales, Thinking outside the box, they reflect on how a joined up approach has improved patient care and attracted staff.
We call ourselves the cavalry in the community. We are an intermediate care team, with a GP, advanced nurse practitioners, physician associates, therapists, social workers, the third sector and Delta Wellbeing, which is a local authority trading company, wholly owned by Carmarthenshire County Council. Our sole purpose is to help patients get home, which might mean admission prevention or speedier discharge.
Across Carmarthenshire, our three community resource teams and intermediate care hub provide a range of health and care services particularly for older, frail and vulnerable people. The model takes a multi-agency approach including more seamless working between health and social care, along with other agencies and the 3rd sector working together in each locality. The priority is on prevention and early intervention. For patients with chronic conditions or who need end-of-life care, people can access community hubs for a range of assessments, advice, support and treatments, or the team can go out to visit people in their homes.
We are a Carmarthenshire service which means that Hywel Dda patients in Ceredigion or Pembrokeshire don’t have access to these services. We try to work across local authority boundaries to standardise pathways and ways of working, but that’s a work in progress.
We’re the only place in Wales working like this. As an intermediate care team, we work across four pillars of care: reablement (helping the patient to become independent again), crisis response (when a patient in the community could be intercepted before arriving at the hospital front door), home based (when a patient needs a bit of extra support) and bed based (when a patient doesn’t need an acute hospital bed, but isn’t well enough to go home). The key thing is that there’s a single access point, a one-stop shop where we are all co-located and able to flex our response based on patient need.
We were contacted when the hospital was in black alert and asked to do whatever we could to get people out of hospital. We can no longer work in silos: we need to work together, be in the same place so we can avoid scrambling around the same group of patients. If we’re all working to different referral lists, we spread our energies and resources very thinly. So, we centralised all of the referrals for discharge, and we aim to turn people around in 72 hours. We’re hitting that target in about 86% of cases. There’s a lot of joint working and shared learning. We blur professional boundaries and ask how we could work differently within our competencies. Ultimately, it’s about the discharge to assess model: if we can evaluate a person in their home environment, we can make the best decisions with them about their care. Because we are a multi-agency team, we can move the patient easily between the four pillars of care, depending on how they improve or deteriorate from day to day.
We work closely with the acute frailty team in the hospital to prevent admissions. And we’ve recently begun an ambulance pilot: one of our paramedics, based in our office, will pick patients off the 999 stack, ring them, make a clinical assessment and decide whether our crisis response team would be a more appropriate intervention. Perhaps they need some extra equipment – then we send in a therapist straight away. It’s fantastic. We’re making a big impact: of the 640 patients we’ve triaged in the past 3 months, we prevented 65% of them from coming to the hospital. Where we can keep a patient at home, we can send the ambulance to more serious medical emergencies. It’s magic.
The co-location of services in an open plan office means that our paramedics can talk to our physiotherapists when an ambulance call comes in – they can avoid unnecessary interventions. If we weren’t in the same space, those ad-hoc conversations wouldn’t necessarily happen.
Unfortunately, we can’t support the patients who are waiting for long-term care packages at present. That’s the real challenge: if we can’t solve the problem of social care capacity, patient flow through our service becomes blocked. Our vision is that all patients should be discharged home to assess, so that we can better support the patient in their own home.
The funding is all temporary too; we’re asking the health board to recruit members of staff with regional integration fund monies, but that puts the organisation at financial risk in the long term. We work Monday to Friday, 8am–5pm, but everyone puts in extra unpaid hours, staying late, dropping equipment on their way home… We’d like to extend our hours. In an ideal world, we’d run a 24/7 service.
There’s an appetite among health and care professionals to work in intermediate care. We have no problems recruiting. It’s exciting; people want to come and work where they are empowered to innovate. We know that there are growing health inequalities, and access to healthcare services can differ depending on which day of the week you get ill. It’s uncomfortable for us.
There’s a lot of educating others and raising awareness that we can do in the acute setting. We go into the hospital to sit with our colleagues and go through their caseloads with them, trying to get people home that day. Often, if you don't work in the community, you don't know what's out there. You might think that there's only one solution – social worker referral. But it doesn’t have to be statutory services all the time. We want to empower our acute colleagues to think differently and trust in community care again.
Basically, we decided to think differently, to combine forces and make change. There’s nervousness in the team about the winter to come, but definitely a sense that we’re stronger together. If we’re pooling our resources, we're working smarter and better together. We want to be close to the hospital and to our community resource teams by upskilling our staff and sharing knowledge. We’re hoping to bridge the gap between acute and community care and break down those walls. It’s the right thing to do for the patient and for the health and care system.
Carmarthenshire community lead for physiotherapy
Dr Sioned Richards
GP lead, Carmarthenshire intermediate care
Hywel Dda University Health Board