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Community assessment and rehabilitation teams in Cornwall [Sept 2000; 9-8]

Developing multi-disciplinary assessments which cross the boundaries between health and social care
Why was the initiative launched?
What was done?
Tips for success
To find out more contact

Why was the initiative launched?

When the implications of the Community Care Act 1993 were being assessed in the Cornwall Healthcare NHS Trust, the need for skilled multi-disciplinary assessment of the health and social care needs was identified as crucial for those patients on the threshold of institutional care. A Community Assessment and Rehabilitation Team (CART) was established to undertake this task. The plans included the evaluation of the team in the initial year.

After a successful pilot, two teams are now operational. They were some of the earliest community rehabilitation teams to be established. They offer rehabilitation to people over 16 years of age with temporary or continuing disability - at home, in residential or nursing home care or other appropriate community setting.

What was done?

The CARTs consist of full-time physiotherapists and part-time occupational therapists and each with their own secretarial support. When the teams were first set up they had identified nursing support - but over time links directly with the appropriate district nursing services have been established. This has proven to be a more effective approach. Other disciplines are called in as necessary. £40,000 was allocated for the initial pilot phase: this sum was later combined with existing resources to provide an overall budget of £80,000: separate provision was made to cover the associated nursing costs.

The project is service based - at home, residential care, nursing homes and as appropriate in the community. Each of the two teams serves rural communities - some with market towns - with populations of about 42,000. The teams provide a community assessment and rehabilitation service by:

  1. Allocating referrals to the most appropriate team member, who assesses and decides the most appropriate package of rehabilitation.
  2. Working closely with the care management process in the design of care packages.
  3. Maintaining close links with referring agencies - hospital and community based health and social care staff. The CARTs can refer patients to any of these and arrange admission to hospital for intensive rehabilitation if necessary.

The teams accept referral from all sectors of local services, i.e. from consultants, general practitioners, hospital and community based therapy and nursing staff and social care managers. Access is by telephone or fax with the secretarial staff trained to assemble - on a generic referral form - the necessary information from referrers.

Does it work?

The evaluation strategy included two main elements. First, a comparative study of cases referred to CARTs and a control group of social services clients - examining changes over time within and between the two groups. Second, a qualitative analysis of interviews with general practitioners, community nurses, social care managers and CART team members. In addition a secondary analysis of case notes of patients discharged from CARTs was undertaken.

A number of methods were adopted to ensure that the evaluation of the work was thorough: these included the use of a modified Bartel ADL index, the Philadelphia geriatric centre morale scale, the care givers strain index, Glasgow community stroke project needs assessment questionnaire. In addition a questionnaire was designed specifically for the project.

The evaluation and on-going management of the approach has demonstrated significant benefits, including:

  1. Increased patient and carer satisfaction with services
  2. Reduction in disability for those patients without terminal illness.
  3. Increased numbers of patients able to continue living in their own home.

The project has reinforced the merit of single patient documentation and case notes.

Analysis of the case notes confirmed that the CART therapists in 72% of the cases (36) and 68% of these goals were met set treatment goals for patients.

An important message from the interviews with team members was about the danger of allowing the teams to become separate entity rather than an integrated element of the local community teams. One team members said ' because CARTs were set up as a separate team, an entity of its own, this has sort of created barriers around us as a team and I've had conflict with the social services OT because she thought I was poaching her patch . .'.

The evaluation also raised questions about the rehabilitation role of nurses and suggested that this aspect of the approach required further investigation, i.e. how best to provide nursing contributions to the team's work. The evaluation suggested that an eldercare specialist nurse might be more appropriately attached to the team than the district nurse.

Tips for success

  1. Manage the launch of services incrementally - avoid raising unrealistically patient and service user expectations
  2. Ensure that lessons from the initial stages are reflected in plans for ‘roll-out'.
  3. Provide training for clinicians who have not worked in a community setting - at induction and as they ‘settle in' to their new role.
  4. Ensure that links between newly established teams and existing teams are maintained - don't allow space between the new CART and the existing community teams to develop.
  5. Consider carefully how to provide the nursing contribution to the Team - be clear what skills are needed.

To find out more contact

Lynne Kendall
Cornwall Healthcare NHS Trust
Porthpean Road
St Austell PL 26 6AD
Telephone 01726 291009
Fax 01726 291080

The following material is available:
  1. Project evaluation report
  2. Local information sheet for one of the teams.

ImpAct bottom line:

  1. Pilot phases are a valuable way of learning about the impact of new developments - but allow time for reassessment before ‘rolling out' the new service - build on the good and rebuild the bad.


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