Community

Wellness Team

The Community Wellness Team provides wraparound care for people at greater risk of hospital admission, mainly those aged over 75, or with a history of unplanned admissions.

We’re a Nurse-led multi-disciplinary team working with patients all across Durham Dales on behalf of our 12 member GP practices. Our overall objective is to reduce avoidable hospital admissions, and keep people safe and well in their place of residence.

 

The Team

Our Community Wellness Team comprises staff with experience and expertise from a range of backgrounds with a range of expertise. 

They include Nurse Practitioners, Specialist Nurses, Health Care Assistants, Health Care Coordinators and Social Prescribing Link Workers.

The service originated in 2014 when DDHF was contracted to provide a wrap around service for the most vulnerable 2% of the patient population. This Vulnerable Adult Wrap Around Service became known as VAWAS.

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

In the years since, the service has continued to grow and has developed into a fully fledged Community Wellness Team, with a far wider remit than the original scope.

How it works

The team now works with a range of patients in a number of different settings.

As well as those identified as most vulnerable, there is an additional element which reaches out to people who are being discharged from hospital or different services. Assessments and personalised plans help to identify and tackle risks patients may face before they occur. 

More than 20 care homes throughout Durham Dales are also covered by the team, with quick access to advice and guidance, as well as proactive visits – both of which work to greatly reduce avoidable hospital admissions.

And Health Care Coordinators – a role evolved by DDHF to address unmet needs and a precursor to Social Prescribers – add a vital non-clinical layer to the service tackling issues from housing and mobility to social isolation.

How it helps

The Community Wellness Team provide a consistent and continuous level of high quality healthcare to people who need it the most.

A large majority of all care home visits across Durham Dales are carried out by the DDHF team, on behalf of individual GP practices. 

With that pressure removed, practices have more capacity to offer same day or prebookable appointments in their surgeries. And because of DDHF’s high standards and record of delivery, practices know their patients are getting the best possible care.

Our telephone triage system is another key benefit.

The team gather information,and assess whether options like monitoring, self-care or advice are appropriate, helping to reduce unnecessary admissions and visits. 

This boosts efficiency, gets people the right care quicker, and eases the pressure on secondary services like A&E.

Outcomes:

50%
Increase in Demand from Launch*
466
Home Visits every Month**
430
Patient Contacts every Month**

* March ’17 to December ’19

** Monthly averages, March ’17 to December ’19