Dr Shelagh O’Riordan is a Consultant Community Geriatrician at Kent Community Health NHS Foundation Trust and Clinical Director for Frailty in East Kent. She is a Professional Advisor to the Community Services team at NHS England and a former Chair of the BGS Community Geriatrics SIG. She tweets at @jupiterhouse1.
It’s that time of year again when we reflect on what we are doing and ask, have we done enough for people living with frailty to mitigate against the effects of winter on our acute services? Virtual wards/hospital at home are part of the solution, and now is the time to ensure they are as effective as possible, efficient in terms of staff time, and providing good value for money. When run well, virtual wards improve flow in hospitals by:
- Providing an alternative to hospital care for patients who would otherwise need to be treated as an inpatient (step up)
- Allowing patients to be discharged before their episode of care is completed to receive hospital level care at home (step down)
Top tips
- Focus on admission avoidance pathways. There is increasing evidence that points to step up frailty virtual wards offering the highest rewards, for both patient outcomes and saving bed days. Step up models prevent admission for people living with frailty who are most at risk of deconditioning and getting stuck in hospital.
- Set up a step up frailty virtual ward if you don’t already have one. Can you start on a small scale in care homes? Can you link your urgent community response (UCR) teams with your hospital geriatricians or with GPs to provide consultant level support and allow increased acuity of patients accepted?
- Prioritise care homes in your UCR/frailty virtual wards. Can they directly refer to you to avoid admission?
- Take direct referrals to all virtual wards / hospital at home from the ambulance service - particularly for frailty virtual wards. If your virtual ward does not have direct referrals from your ambulance service, consider setting this up to reduce conveyance directly to hospital.
- Link your virtual wards with community services such as community respiratory, heart failure and urgent community response. If your frailty virtual ward and urgent community response are not working closely together, or even the same team, then there is a huge amount to gain from sharing resources and skills.
- Maximise use of respiratory, heart failure and other virtual wards for people living with frailty. Ensure people with frailty are not being excluded and learn how to maximise use in this population, which is most at risk in hospital.
- Ensure virtual ward enablers are in place and at scale to maximise the use of virtual wards. This includes point of care testing which can ensure timely diagnosis and prevent admission; integrated pharmacy services to support safe and effective use of prescribed medicines and devices; access to remote monitoring to ensure the most effective use of your staff; and safe monitoring of your patients.
- Focus your resources on virtual wards which can accept large numbers of patients rather than multiple small virtual wards run by separate teams. Evidence shows that running virtual wards at scale improves efficiency and safety.
- Link your virtual ward services to your local single point of access (SPOA) in the community (if you have one). Can patients discussed at SPOA be referred directly to a virtual ward to avoid admission? Can you utilise community diagnostic hubs or direct access investigations to avoid attendance to ED or admission?
- Look at the length of stay (LOS) on your virtual wards. Are they longer than they would have been in hospital? Is there room to reduce the LOS, even by small amounts, and therefore increase throughput in your virtual wards?
- Work to get direct access to the ambulance stack to pull patients onto your virtual ward. This has potential to get patients earlier into your ward and avoid ambulance attendance completely. This works best when working directly with your urgent community response teams in the community.
The way I look at it, we can carry on trying to do more of the same this year, and accept that many people living with frailty will end up stuck in ambulances and in ED departments, or we can try doing something different and really invest time in Frailty Virtual Wards/Hospital at Home! Good luck!
