The final King’s Fund case study (funded by Aetna and the Aetna Foundation), in the “Co-ordinated care for people with complex chronic conditions” series, investigates integrated health and social care teams, known as Community Resource Teams (CRTs), working with people living at home in mostly rural Pembrokeshire. This model of care a part of the wider integrated care strategic programme termed “Care Closer to Home”.
The CRTs are establishing cooperative links with teams based in a local hospital to ensure patients receive the same benefits of coordinated care when admitted to hospital.
Key topics arising from this study comprise:
- Voluntary sector involvement.
- Cooperation with the acute sector, to prevent unnecessary admissions and facilitate discharge.
- Continuous learning and development, via reflective practice and evaluations which promote open learning and quality improvement.
- Recognition of the importance of appreciating team members’ roles and contributions.
- Performance measurement geared to organisational development.
“The main goals of the programme are to improve or restore the quality of life and confidence for people with complex health and social care needs, and to reduce avoidable admissions to hospital. Four community-based teams bring together professionals from health, social care and the third sector to provide care for patients with complex needs at home”.
Thiel, V. Sonola, L. Goodwin, N. [and] Kodner, D.L. (2013). Developing community resource teams in Pembrokeshire, Wales: integration of health and social care in progress. London: The King’s Fund, October 2013.