One Referral, One Visit: Timely Integrated Care for Swallowing, Nutrition and Medication Management in Care Homes

Cwm Taf Morgannwg University Health Board

Introduction:

This project set out to reduce waiting times by 70% for care home residents with complex swallowing, nutrition, and medication needs. Fragmented referral pathways caused harmful delays, often resulting in hospital admissions and duplicated assessments. Residents were frequently assessed out of context and without familiar carers, undermining person-centred care. A new model was needed to deliver equitable, timely, integrated support.

Methods:

Using a three-phase Plan-Do-Study-Act (PDSA) improvement model, the team introduced a single-point referral system for joint multidisciplinary virtual consultations between Speech and Language Therapy, Dietetics, and Pharmacy. Co-designed referral and reporting tools, shared documentation, and VR-based staff training were key components. The model was scaled across Bridgend and supported with digital inclusion tools and governance from TEC Cymru. Stakeholder input, including care staff, residents, families, and GPs, shaped each stage.

Outcomes:

The initiative exceeded its goal. Waiting times reduced from 15 to under 3 weeks, with 100% of residents seen within the 14-week target. Hospitalisation rates dropped significantly: 78% of high-risk residents avoided admission during multidisciplinary involvement, and 68% remained out of hospital six months later. Staff confidence increased, and documentation duplication decreased. The project is now embedded as standard practice in Bridgend and has been recognised as a Bevan Exemplar.

Learnings:

The project showed the impact of inclusive, person-centred design and collaborative leadership. Continuous measurement and co-design with staff, residents, and families were vital. VR training and digital tools supported equity and scalability. Earlier family involvement and adoption of Microsoft Teams might have improved early implementation.

What Next?

VR training is being embedded with CPD accreditation. PREMs and PROMs are being co-developed with families. The model is being piloted in other Welsh regions, with lessons shared nationally to inform integrated care across disciplines.