The Community

Wellness Team

The Community Wellness Team provide wraparound care for older, frail or vulnerable people and keep them healthy and happy at home.

This nurse-led multidisciplinary team aims to reduce avoidable hospital admissions and readmissions, and keep people where they want to be – whether that’s a care home, with family or independently on their own.

The Team

The Community Wellness Team is made up of highly trained staff with a range of expertise. They include Nurse Practitioners, Specialist Nurses, Healthcare Assistants and Social Prescribers.

DDHF’s first project back in 2014 was a wrap around service for the most vulnerable 2% of people across the area. 

The aim was to provide consistent and continuous care, moving the work away from GP practices and freeing up time and appointments for others.

As the service has grown, more than 2,500 patients across our 12 member practices have been supported by the team.

How it works

There are two ways people can be referred to the Community Wellness Team.

First is through the clinical judgement of a GP who will know the patient well, understand their medical history and will discuss with them the types of support available.

The second is through a data-driven system of risk analysis. The RAIDR system combines evidence-based statistics with long-term health records to create a unique set of probabilities scores. 

Through this, proactive intervention can be planned for those at high risk of hospital admission or readmission, diabetes, dementia or a host of other long-term conditions.

How it helps

The team work with patients, their family, informal carers and other connected health care professionals to create personalised care plans.

Each plan is specific to the individual, but can include medication reviews, risk assessments of their home, and identifying their specific needs.

A named Care Coordinator manages the process for each patient, meaning a single point of contact liaises with numerous services to ensure, holistic, continuous care.

When the need arises, home visits and rapid response care packages are organised and delivered efficiently and effectively.