Virtual Wards

A virtual ward is a cadre for providing support in the community to people with the most complex medical and social needs. The concept was developed in Croydon Primary Care Trust (South London) - and virtual wards are now being introduced in several parts of the UK (including Croydon, Brent, Hillingdon and Bracknell PCTs). Virtual wards use the systems and staffing of a hospital ward, but without the physical building: they provide preventative care for people in their own homes. The project won in four categories of the 2006 Health Service Journal Awards (the "UK's Biggest Awards in Healthcare") namely Primary Care Innovation, Patient-Centred Care, Information-Based Decision Making, and Clinical Service Redesign. This was the fist time in the 25-year history of the HSJ awards that a project won in four categories. In 2007 it won the "Transformation" category of the Public Service Awards run by the Guardian Newspaper [http://society.guardian.co.uk/publicservicesawards/story/0,,2182053,00.html] and was judged overall winner of those awards.

Key aims of Virtual Wards

The key aims of virtual wards are to:

*Act on evidence-based forecasts from predictive risk modelling;

*Provide multidisciplinary case management;

*Serve as a communications hub for all those involved in the care for these complex patients;

*Offer intuitive working systems that appeal to patients and clinicians alike.

Groups of approximately fifteen General Practitioners commission a virtual ward, i.e. one ward per 30,000 or so residents. A typical virtual ward has a capacity of 100 "beds". When one of these "beds" becomes vacant then a predictive algorithm (such as the The King's Fund PARR Algorithm [http://www.kingsfund.org.uk/health_topics/patients_at_risk/index.html] or the "Combined" algorithm [http://www.kingsfund.org.uk/health_topics/patients_at_risk/combined.html] ) is used to identify which of the 30,000 residents in the catchment area is at highest risk of unplanned hospital admission in the forthcoming year. Both of these algorithms can be used free of charge by NHS institutions, GPs etc. This resident is then offered a "bed" on the virtual ward.

Admission to a Virtual Ward

Admission to a virtual ward is determined solely by predictive modelling. This ensures that the patients admitted to a virtual ward are truly those who will benefit the most, i.e. those most at risk of unplanned hospital admission. The NHS in England owns two predictive risk models which were commissioned from a consortium led by The King's Fund. These predictive tools are known as PARR (Patients At Risk of Readmission), which was built by New York University [ [http://www.kingsfund.org.uk/health_topics/patients_at_risk/index.html] ] and the Combined Model, built by Health Dialog [ [http://www.kingsfund.org.uk/health_topics/patients_at_risk/predictive_risk.html] ) ] .

At the time of admission to the virtual ward, the community matron [http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4102377&chk=xGqdbU] visits the patient at home and conducts an initial assessment. This record, and all further entries by ward staff, is entered into a shared set of electronic notes. A summary from the GP computer system is pasted into these ward notes before the initial assessment, so as to provide background information and avoid unnecessary duplication of work. The GP practice is informed of all significant changes to the patient's management.

Virtual Ward staff

* The day-to-day clinical work of the ward is lead by a community matron. Other staff include a social worker, health visitor, pharmacist, community nurses and other allied health professionals.

* A key member of staff is the ward administrator ("ward clerk"). With a dedicated telephone number and email address, the ward administrator is able to collect and disseminate information between patients, their carers, GP practice staff, virtual ward staff, and hospital staff.

* Medical input is comes from daily telephone contact between the community matron and the duty doctor at each constituent GP practice. The matron is also able to book surgery appointments to see any patient's usual GP.

* The virtual ward develops close working relationships with organisations such as hospices, drug & alcohol service and voluntary sector agencies.

Daily routine

Members of the virtual ward staff hold an office-based ward round each working day. Patients are discussed at different frequencies depending on their circumstances and stability. Of the 100 patients on each ward:

*5 patients are discussed daily,
*35 are discussed weekly, with the remaining
*60 patients being discussed monthly.

The community matron can move patients between these different intensity "beds" according to changes in their clinical condition from day to day.

Communication

Every night an automatic email containing a list of each virtual ward's current patients is sent automatically to local hospitals, NHS Direct and GP out-of-hours cooperatives. This information is uploaded onto these organisations' clinical computer systems. Should a virtual ward patient present to their services (e.g. to a local A&E department) then the staff working there will be alerted automatically to the patient's status. They then know that by contacting the virtual ward administrator, they can obtain up-to-date details of the patient's care. They can also arrange early discharge back to the care of the virtual ward team.

Discharge from a Virtual Ward

The predictive model used for identifying patients for admission to a virtual ward is also used to prompt the virtual ward staff when it is time to consider discharging the patient. When a patient has been assessed by all relevant virtual ward staff, and has been cared for uneventfully for several months in the "monthly review" section of the ward, then the ward staff may feel that the patient is ready to be discharged back to the care of the GP practice. A discharge summary is sent to the practice, and a discharge letter (written using lay terminology) is sent to the patient. For the first two years following discharge, the GP practice conducts quarterly - rather than annual - reviews. This not only ensures that the patient is borne in mind, but these quarterly review data are serve as positive feedback to the predictive risk modelling algorithm.

References

External links

* [http://www.croydon.nhs.uk/sections/frame.html?sec=182 "Croydon PCT"] ("Virtual Wards Webpages")
* [http://www.networks.nhs.uk/networks.php?dir=202 "NHS Networks"] ("Virtual Wards Microsite")
* [http://www.kingsfund.org.uk/current_projects/predictive_risk/index.html "King's Fund"] ("King's Fund Predictive Modelling Project)