Meghan White
Betsi Cadwaladr University Health Board
Finalist – Award for Working Across Boundaries, Advancing Healthcare Awards 2025
Background
The UK’s health and social care system is straining under rising complexity in older adults’ needs. One in seven people aged 85+ live in care homes, contributing to approx. 185,000 emergency admissions and 1.46 million bed days each year. Alarmingly, an estimated 35–40% were potentially avoidable (NHS Long-Term Plan, 2019). In Wales, delayed discharge remains a key pressure point and a local scoping at BCUHB (June 2024) found that 30% of care-home residents in acute beds required enhanced therapy and 17% needed a new placement or higher support, indicating that earlier, community-based intervention could have prevented admission or shortened length of stay.
At the same time, the social care workforce faces >150,000 vacancies and around 30% annual staff turnover, driving inconsistent monitoring and risk-averse escalation to emergency services (Quality Care Group, 2025). Together, these factors sustain a reactive, crisis-driven model that is costly and delivers poorer outcomes, which underscores the need for proactive, therapy-led in-reach to keep residents well, at home.
In response, a pilot was implemented in two Flintshire care homes, funded by Welsh Government’s AHP Investment Fund, to test an in-reach occupational therapy model delivering early, responsive, function-focused assessment grounded in prudent healthcare. The model draws on the AHP Framework for Wales (2020), NHS Wales’ Six Goals for Urgent and Emergency Care, and the UK AHP Public Health Strategic Framework (2024), which emphasise place-based, preventative, multidisciplinary care—shifting from reactive crisis response to proactive support that keeps residents well, at home.
Aims and Objectives
Overarching Aim: Provide timely, specialist care in care homes to keep residents independent, reduce avoidable hospital admissions, and make best use of NHS resources.
Objectives:
- Prevent decline early through proactive intervention.
- Build staff skills to improve care quality.
- Strengthen communication between care homes, community services, and hospitals.
- Use resources wisely to avoid waste and duplication.
- Ensure fair access for all care home residents.
Approach
The pilot was designed using a co‑production approach, informed by local scoping data and national policy drivers. The service model was co‑designed with input from:
- Care home managers and staff from two participating homes in Flintshire.
- NHS BCUHB occupational therapy leads and wider allied health professionals.
- Representatives from the National AHP Lead for Primary and Community Care.
- Flintshire local authority partners.
The design focused on embedding specialist occupational therapy in‑reach provision directly into care homes, enabling timely functional assessments, targeted interventions, and workforce upskilling to support prevention and early intervention.
Outcomes
The pilot established a new operational model for delivering specialist occupational therapy directly within care homes. This model has produced a set of tangible outputs, tools, and processes that can be replicated across Wales.
Key outcomes:
1.Specialist AHP In‑Reach Service Model
- Embedded an occupational therapist within care homes to provide rapid functional assessments, targeted interventions, and on‑site workforce support.
- Created a tested and replicable blueprint for delivery across other health board areas.
- Bespoke Functional Outcome Measure
- Developed a care home‑specific assessment tool for self‑care, cognition, and leisure activities.
- Provided a standardised method for measuring functional ability pre‑ and post‑intervention.
- Rapid‑Access Equipment Assessment Pathway
- Introduced same‑day assessments and equipment provision, bypassing GP referral delays.
- Reduced duplication and waste from unsuitable or repeated purchases.
- On‑Site Training and Support Framework
- Delivered real‑time training in moving and handling, behavioural support, and functional care techniques.
- Produced a clear framework for wider adoption across Wales.
- Improved Communication and Coordination Processes
- Streamlined pathways for sharing information between care homes, hospitals, and community teams.
- Enhanced collaboration across health, social care, and local authority partners to support safe, efficient transitions of care.
- Proof‑of‑Concept for Scaling
- Demonstrated operational feasibility and alignment with national priorities.
Impact
The pilot delivered clear benefits across residents, staff and the wider system:
- Residents made meaningful functional gains (range 3–83%, median 44.5%) through early, targeted in-reach OT, helping people remain in familiar surroundings and retain independence.
- Day-to-day pressures eased as timely therapy avoided unnecessary emergency admissions, supported faster, safer discharges, and reduced reliance on GP referrals for mobility and equipment.
- Real-time training and support built care-home capability and boosted confidence with mobility, behaviour and specialist equipment.
- Joint working enabled better information sharing with hospitals and community teams sped up problem-solving and cut duplication.
- Financially, net of costs (£67,452), a single clinician achieved £81,734 cost avoidance (fig. 1) in six months (annualised £163,468); scaled across Wales 7 Health Boards, this equates to >£1.14m a year, all the while improving quality and resident outcomes.
Conclusions
- Early, specialist in‑reach care works and by embedding AHPs directly in care homes prevents deterioration, avoids unnecessary hospital use, and improves resident independence.
- Prevention saves money and this was evidenced by the model delivering measurable cost avoidance and system efficiencies while improving quality of care.
- Relationships are critical and building strong collaboration between care homes, NHS, and local authority teams underpins success.
- Upskilling staff has lasting impact so by implementing real‑time training, this builds workforce confidence and reduces reliance on external services.
- Data and stories are powerful and when combining quantitative outcomes with lived‑experience narratives this strengthens the case for scaling.
- Scalable and sustainable – The approach can be replicated across Wales with the right investment, policy alignment, and ongoing support.
- Stronger health and social care partnerships by streamlining pathways and communication between acute hospital services, care homes and local authorities, reducing inefficiencies, reducing waste and enhancing patient transitions.
- Greater community resilience was achieved in establishing a dedicated service for care homes, improving access to timely interventions and strengthening local support networks.
- Addressing health inequalities by ensuring all individuals, regardless of where they are resident, have equitable access to essential services, improving fairness and quality of care.
