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Chapter 4: Multi Professional Working Models

What’s included in this section:

  1. Enhanced Community Care 
  2. Community Nursing vision and framework
  3. Care Homes immunisation model  
  4. National Community Nursing Specification
  5. Multi professional team models and support, to work with people to enable them to live well
  6. Holistic long term condition reviews - coming soon
  7. Workforce competence and knowledge framework for care homes - coming soon
  8. Multi professional workforce models for care homes; to support care team around the person - coming soon
  9. National District Nursing Dashboard - coming soon
  10. Definition & measure of avoidable admission/attendance - coming soon

Enhanced Community Care 

The aim of the Enhanced Community Care  model is to support organisations to deliver joined up, outcome focused, evidence-based community services, through a place-based multi-professional working model of care.

The Enhanced Community Care model will include:

  • Nationally agreed definition of Enhanced Community Care and core principles and examples of good practice.
  • Testing to demonstrate proof of concept
  • A set of agreed outcome measures to demonstrate successful achievement of the model 

This project is intended to contribute to, and not duplicate local initiatives and wherever possible align with existing work being undertaken within Health Boards and other regional and national organisations.

Plan on a Page - Enhanced Community Care

Enhanced Community Care [summary paper]

Enhanced Community Care 

What is integrated community based health & social care? Infographic.

Community nursing vision and framework

The aim of the National Community Nursing Vision & Framework is to support organisations to achieve joined up, outcome focused, and evidence-based community nursing services.

The Community Nursing Vision & Framework will include:

  • A Nationally agreed Vision for Community Nursing
  • A National Framework which outlines the ambitions of Community Nursing
  • An action plan outlining how Community Nursing will achieve this ambition
  • A set of agreed outcome measures to demonstrate successful achievement of the framework

This project is intended to contribute to, and not duplicate local initiatives and wherever possible align with existing work being undertaken within Health Boards and other regional and national organisations.

Care homes immunisation model 

The aim of the National Care Home Immunisations Model is to support delivery of specific (appropriate) immunisations within the Care Home’s with nurses, by Care home employed nurses.

The work planned to achieve this National Care Home Immunisations Model will include:

  • Developing a Nationally agreed Care Home Immunisation model for the administration of flu vaccines to.
    • Residents in care homes with nursing
    • Care home staff using a peer-to-peer model
  • Identifying clinical governance, policy, and training requirements
  • Identifying options for funding
  • Testing the model to demonstrate proof of concept
  • Making recommendations on the potential for other vaccinations to be delivered via a care home immunisations model

This project is intended to contribute to, and not duplicate local initiatives and wherever possible align with existing work being undertaken within Health Boards and other regional and national organisations.

If you’d like to know more about this piece of work, you can contact us via the Strategic Programme Primary Care SPPC@wales.nhs.uk 

National Community Nursing Specification

The National Community Nursing specification outlines at a strategic level the overarching principles, characteristics, and functions of Community Nursing in Wales for individuals aged 16 and over. The experience of individuals and families using or accessing community nursing services are at its centre, via the use of core principles focused on providing person centred, preventative, safe and effective services.  Its aims are: 

  • Standardise care where possible to reduce variation and raise quality
  • Simplify systems and processes to make people’s experience better and nurses working lives easier
  • Promote collaboration with other nurses and professionals around the person

The specification is not able to comprehensively cover all areas of practice and specialism that Nurses working in the Community provide. Therefore, this specification focuses on General Practice Nurses, Specialist Nurses and District Nurses and their teams.

Community Nursing Services do not work alone and are an essential part of the wider nursing team, multi professional team and health and care system.

Standardising key elements of Community Nursing Services will promote greater collaborative working between nurses and understanding of community nurse’s role and value within the wider multi professional team. This will be important as traditional role boundaries change and nurses increasingly work in new models of care to meet the challenges of our health and care system.

The specification promotes Community Nurses to come together to review the way they work across pathways for people aged 16 and over. It encourages nurses to think about different models of working, how to share and learn from one another and advocates for a move towards a preventative population-based approach to support the people they care for.

Recognising the value Community Nurses offer, the specification outlines how nurses should be enabled to lead and support research and service improvements, have clear development and career pathways and be supported via access to regular clinical supervision.

Community Nurses offer strong clinical leadership and governance to their services and the wider health and care team. This, alongside a consistent approach to the way they work, will enable nurses to further lead, develop, and/or support current and new services, to meet the ambitions of the Primary Care Model for Wales.

National Community Nursing specification

Appendix 1 – Self-assessment form which covers all key aspects (i.e., sections 4 – 12) of the National Community Nursing Specification

Letter from CNO and Alex Slade - National Community Nursing Specification