Frail elderly on ‘virtual ward’ keeps them well at home and out of hospital

Case study summary

Hundreds of frail elderly people are being monitored through a ‘virtual ward’ which helps keep them out of hospital. Doctors, nurses, social care staff, physios and others in West Dorset discuss patients who are put on a rolling ‘virtual’ list each week if thought to be at risk of hospital admission.

 

It is the NHS’ latest example of integration where NHS and social care staff work more closely to improve services.

Over 18 months the new approach, in Weymouth and Bridport, has seen a reduction in unplanned admissions to Dorset County Hospital, the lowest rate of the three acute Trusts in the county.

The ‘virtual ward’ is unique in that as well as discussing the patients’ medical issues, the presence of a social care worker brings in wider issues and everything is discussed from family problems and social care packages to equipment needed, lifestyle problems like excessive drinking or even issues with pets.

Any problem set to impact on the health of the patient is then dealt with by the most appropriate member of the team usually through a home visit.

Special health and social care coordinators, which straddle the NHS and social care teams, have information about all those aged over 75 and registered with West Dorset GPs and if they go into hospital they receive an alert and begin to plan for discharge.

It often alleviates pressure on GPs who do not need to spend time phoning social care services or trying to organize other services in short appointments.

The approach is being rolled out across Dorset and other areas of the country are running similar schemes to pinpoint elderly people and help support them better at home.

Consultant geriatrician Dr Riaz Dharamshi, who leads the Bridport Integrated Hub, said: “We started our service with no extra money but a desire to do something different and a really clear vision. We wanted to provide something better for people than just going in and out of hospital unnecessarily.

“Since we started we’ve seen an enormous reduction in acute need from that population; where we have them we’re seeing a reduction in acute admissions, and in the areas that don’t have them a rise.

“The health and social care co-ordinator role is very important, it’s a simple post but makes a huge difference alongside the integration of IT systems. It could be any number of people who go out to see the patient including a paramedic if needed. It’s just the same people doing their jobs in a slightly different way.”

Over the next few weeks the first parts of the country formally begin to work as integrated care systems, a key milestone as England makes the biggest national move to integrate care of any major western country.

The aim is to adapt to profound shifts in the patterns of ill-health and offer a service that supports an individual’s complete needs rather than treating each body part, illness, or care problem in isolation.

ntegrated care systems are comprised of all local health and care organisations, including local government with social care, working in partnership and pooling resources.

Dorset is one of the most advanced systems having calculated in 2016 that a do nothing approach would create an annual financial gap in the local health economy of almost £230m by 2020/21.

The overall aim of the Bridport Integrated Hub is to work as one community team supporting GPs and primary care colleagues.

Using a risk stratification process they identify the older frail in the population, identify the person’s individual needs, design pro-active care planning and keep them safely out of hospital.

From the hub they provide telephone specialist advice to GPs and care homes, undertake virtual ward reviews, provide a coordinated rapid response to patients in crisis, undertake proactive planning to avoid admissions and work through proactive case management for very frail, high risk patients.

The local inpatient community hospital also has a single medical team that oversees beds and the virtual ward as well as working in the community and reducing the numbers of people involved in a person’s care.