The Community Wellness Team is a nurse-led, multidisciplinary team that supports registered patients at greater risk of hospital admission (primarily those aged over 75, or those on the unplanned admissions register) to remain in their preferred place of care, whether that be in their own home, living with relatives, or in a residential home.
The Community Wellness Team consists of Nurse Practitioners, Specialist Nurses, Healthcare Assistants and Care Coordinators, and is an expansion of DDHF’s pilot service for “vulnerable” adults, VAWAS. Referral to the service is determined by an individual’s emergency risk score, as calculated by the RAIDR risk stratification tool, or by the clinical judgement of their GP. Referrals can be made through the SystmOne Community Module, or by email contact with our Care Coordinators.
We operate a nurse-led telephone triage service for requesting visits, which enables us to convert a significant number of contacts to advice only. This has reduced the volume of visits required by approximately 25%. In fact, in the Durham Dales area, our practices carry out very few care home visits themselves: the Community Wellness Team picks up almost all of these. The service operates 7 days a week and 365 days a year.