Interprofessional Approaches to Non-complex Wound Care in a Welsh Residential Home for Older People

Care services in Wales are facing the dual challenges of increasing demand and decreasing resources so in 2014, the Welsh Government set aside a national Intermediate Care Fund. Llys y Bryn residential home for older people in south west Wales was identified as a pilot site to develop interprofessional management of non-complex wound care between care home staff providing direct care to the elderly residents and district nurses in the community. There were two distinct elements to the rapid evaluation, essentially focussing on non-financial and financial benefits of the project. These were collected via a semi-structured interview and cost saving analysis respectively. The project was well received by all stakeholders and it sought to improve the quality of life for the residents in the home. The financial elements proved challenging to estimate with certainty but even by conservative estimates, there may be a financial return on investment after six months at the care home. More research is needed so as to build up an evidence-base to support possible expansion of the project and to underpin national policy on service integration between health and social care.


Introduction
Similar to other counties of the United Kingdom, care services in Wales are facing the dual challenges of increasing demand and decreasing resources. In order to address this challenge, at least in part, it has been suggested that the integration of Welsh health and social care services might provide some increased efficiencies [1].
In 2014, the Welsh Government set aside a national Intermediate Care Fund to develop integrated projects across health and social care [2]. Llys y Bryn residential home for older people in Llanelli, south west Wales, was identified as a pilot site to develop interprofessional management of non-complex wound care (NCWC), such as those amenable to moisteriser [3]. Two drivers to the project were as follows. Firstly, the local NHS, Hywel Dda University Health Board (HDUHB), had monitored the visits of the District nurses to the home and NCWC was consistently a task of high volume and high frequency. Secondly, the local authority of Carmarthenshire County Council supported care home staff receiving training in NCWC in order to promote their professional development, improve services and reduce the District nurses visits.
The NCWC training that was delivered was accredited in accordance the AGORED framework (www.agored.org.uk) and included undertaking tissue viability risk assessments within Llys y Bryn. It also included undertaking appropriate treatments and dressing of lesions and wounds. The session covered both the theory and practice, with the latter under the supervision of District nurses [4,5]. This also included shadowing District nurses into the community and showing evidence of the competence.
The staff that received the training was all female employees at Llys y Bryn and they were considered by the manager to be sufficiently senior and skilled to benefit from the training. The staff had wide ranging backgrounds and ages, including straight into work after leaving school.
In March 2015, 10 senior care home staff received training in NCWC from the HDUHB tissue viability nurse (TVN). Alllowing one month to practice this skill, this evaluation was based on 3 months experience. It is acknowledged that this report is limited but that it paves the way for more robust research. and has led to improved quality of life for the residents in the home. Other benefits include improved record keeping, more confidence among staff and better working relationships between Llys y Bryn care home staff with District nurses. There was also concensus that there is a strong appetite among staff to recieve more training, for example taking blood pressure and pulse measurements. Table 1 presents a summary of some of the comments that were received from the care home staff. These are aggregated, anonymised and selected to illustrate the consensus that emerged during the evaluation. The comments also show the high degree of satisfaction staff received ( Table 1).
The financial elements proved challenging to estimate with certainty but it is possible to estimate that a full time member of staff will use their training on more than half of their shifts, 6 days on and 2 off. This will be a combination of new wounds [10] and ongoing management but even by conservative estimates, there may be a financial return on investment after 6 months at the home. This might has been reached at the time of the evaluation as the care home staff estimate that there has been substantial reduction in district nurse attendance by approximately 50%.

Discussion
The reason that this project is important is because health and social care provision in Wales has different service delivering and governance frame works. Yet, the two sectors are initimately linked and the hypothesis being explored in this project relates to the alleviation of pressure within healthcare by up-skilling social care practitioners. As a related point to this, training of healthcare and social care practitioners, in this case in a care home, is also often seperate which can give a perception of seperate systems. This project was intended to focus on a holistic package of care for people across the two systems.
The evidence strongly suggests that training Llys y Bryn staff in non-complex wound care has been an effective return on investment. The financial estimates suggest this will be reached after approximately 4-6 months in terms of reduced District Nurse attendance. This is a conservative financial estimate because it excludes other benefits such as improved quality of life for the residents and improved working between Llys y Bryn care home staff and district nurses. There are other benefits such as a more confident work-force who now want to learn new skills.
This study contains a number of limitations. For example, followup district nurse data and satisfaction surveys of the older people in the home would give a more complete picture and these two data sources would provide an opportunity to triangulate the findings from this single source study. However, this 'real time and real world' evaluation supports expanding the model to other care homes, with more rigorous analysis built in from the outset. It is acknowledged, however, that this is a small sample and this limits the transferability to other settings.
In conclusion, there are no simple or quick solutions to the

Study design
As part of the Intermediate Care Fund [6], there were requirements to evaluate the project. There were two distinct elements to the rapid evaluation, essentially focussing on nonfinancial and financial benefits of the project. The non-financial elements were set out in a semi-structured questionnaire and the staff who received the training were then invited to a brief interview. These two elements were selected to give the best and most wide ranging impression of the impact of the project and were considered to be complementary parts within the project.

Data collection
The data was collected by a combination of desk top modelling and field work. On the former, this looked at the financial aspects of the project and made estimates as to the likely cost implications of the work. The field work involved direct interviews with the staff and the semi-structured questionnaire was developed in collaboration with the manager of the home. Initially, there were also plans to include the district nurses in the project evaluation but service pressures prevented this being achieved within the timescale of the rapid evaluation. So the scope of the evaluation was only recorded by intervieweing care home staff [7] who typically have social care [8] skills around washing, dressing and support rather than medical training.

Data analysis
The financial element was a basic cost benefit analysis. It was estimated that for staff to attend one day training and undertake work books to demonstrate their competence would cost about £500 per participant once the backfill time for the TVN and District nurses was taken into account. On this basis, £500 equivalent time saving on District Nurse call out was therefore taken to be a break-even position.
Given the variation in NCWC, it is difficult to accurately estimate what this saving would mean in practice. In consulation with the TVN, a basic model was constructed in which saving about 30 h District Nurse time per participant would be break-even. So if one management of non-complex wound care saves 30 min of District Nurse time, approximately 60 cases is break-even, or about 1 per week for 1 year.

Ethical considerations
There are no ethical issues to rise since the staffs interviewed were not known previously to the interviewer, the report author. All transcripts were recorded anonymously and held by the interviewer before being shared initially with the Project Board. These transcripts were used a crude proxy measure for other areas of interest, such as quality of life.

Results
Based on six interviews of care home [9] staff held on July 21 and 22 2015, some non-financial elements emerged with a degree of concensus. The training was well received by all stakeholders