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Using frailty virtual wards to prevent hospital admissions

Why change was needed

Prior to the introduction of frailty virtual wards, many older people who fell ill would be admitted to hospital in order to receive treatment. This experience can sometimes be disruptive to patients and take a toll on their mental health, as well as lead to increased dependence on ongoing support from the health service.

Two aspects of the ICS vision are to deliver joined up care close to home and to use technology to improve health and care. Virtual wards allow us to deliver on both aspects of this vision.


What we did

The introduction of frailty virtual wards allows patients to receive treatment in their own homes in circumstances where they would traditionally be admitted to hospital.

The Urgent Community Response (UCR) team are notified that there is a patient who requires support at home, either by the patient’s GP or by an alternative service, and they then provide ongoing support to the patient via regular in person visits and telephone consultations. They can do a range of tests to diagnose the cause of the illness, for example blood tests, and prescribe medication to ensure the patient receives the care they need to recover. Furthermore, because the team have access to several IT systems they are able to access the patient’s medical records.

Throughout the course of the patient’s treatment, the clinicians involved in their care, such as GPs and consultants, will be communicating with one another to remain informed on any developments and to have an input into the appropriate treatment and medication. Having the shared knowledge, skills and experience of a range of clinicians from across primary, secondary and community care is beneficial for the patient and increases the chance of a successful health outcome.

Virtual wards build on experiences from the Covid pandemic, where remote communication between different teams became crucial to delivering care and showed that a different way of working was possible. They combine this new way of working with more traditional face to face contact that is often so important, especially to older patients, to properly assess and treat a patient’s condition.

Being treated at home benefits patients because they are able to remain with their support networks, like family and friends, and some may have dependents or animals that they care for. It also reduces the risk of infection which could lead to further complications in the patient’s recovery

There are also benefits for the health service, as often the care provided by the UCR team can prevent an ambulance call out and hospital admission while still ensuring the patient receives the care they need.


What’s next?

The success of the frailty virtual ward means we will look at other areas of care where the introduction of virtual wards may be beneficial for patients.

We are always looking at how we can deliver on the vision of the ICS and using virtual wards to deliver care close to home and to support people to live independently help us to achieve this.


Patient story

Dawn, a 76-year-old from Long Itchington, had previously been diagnosed with arthritis in both of her knees and her GP prescribed her with morphine patches to help with the pain. The day after she applied the first morphine patch, she started to feel unwell. This continued for a few days, and she was unable to eat or drink so she started to lose weight.

When her GP followed up with Dawn after a few days to see how she was, her daughter informed them of how unwell she felt. Her GP suggested she went to hospital so they could assess her, but Dawn was reluctant to go to hospital as she felt too unwell to travel. The GP then suggested that the Urgent Community Response team could support Dawn from home using the frailty virtual ward to connect a range of healthcare professionals.

On receiving the referral, the UCR team assessed Dawn’s medical history by accessing the patient information IT systems and built a picture of the possible causes of her illness. The same day they visited Dawn and took a blood test to try and diagnose what was wrong.

When the results of the blood test came back, they showed that Dawn’s sodium levels were very low. The next morning the UCR team, using the virtual ward, spoke to the frailty consultant and agreed a plan of action that involved stopping a certain medication and reducing Dawn’s fluid intake. The team also informed Dawn’s GP of the plan so they could have input into the treatment plan.

Another blood test was done 2 days later and despite Dawn starting to feel better her sodium levels were unchanged, which caused the UCR team concern. Dawn was adamant she didn’t want to be admitted to hospital and so the team agreed to visit her every day and do new blood tests after 3 days to check the levels were normalising. Thankfully the results of these latest tests showed that her sodium levels were returning to normal and Dawn was feeling much better.

At the time the UCR team were supporting her, Dawn was waiting for an appointment with an orthopaedic surgeon to list her for knee surgery and was concerned that she wouldn’t be able to attend. The UCR team were in contact with the orthopaedic team at the hospital and if Dawn’s sodium levels had not returned to normal they were going to arrange a review for her at the frailty assessment area on the same day to avoid her having to make multiple trips to the hospital.

Thankfully her sodium levels returned to normal and she was able to be successfully listed for surgery.

Dawn was really pleased that she didn’t have to be admitted to hospital and was able to stay at home supported by her daughter Mel. She felt that being at home and having her home comforts, such as her favourite foods, helped her to recover quicker. She also praised the UCR team for their attentiveness and responsiveness throughout her treatment and couldn’t thank them enough for the support they’d given her.

Dawn’s story is a brilliant example of primary care, secondary care and community services all working in a joined-up way via virtual wards to deliver an excellent standard of care close to home.