A ‘Virtual Ward’ approach to supporting vulnerable and at-risk groups in the community

Sharon Morgan, Associate Director of Nursing, Community Services, County Durham and Darlington NHS Foundation Trust

Background to learning

During the COVID-19 pandemic, adapting the ways which nursing staff support people in their own homes has been vital in continuing to provide high quality care, good patient experience and minimising transmission of COVID-19. Within County Durham and Darlington NHS Foundation Trust (now part of the North East and North Cumbria integrated care system) they established ‘Virtual Wards’ to do just that.  A ‘Virtual Ward’ offered a systematic approach to providing enhanced support using local intelligence, for vulnerable people in the community especially those with the most complex medical and social needs.

This case study explores how nursing colleagues at the Trust and in the care home worked together to provide enhanced monitoring support using a ‘Virtual Ward’ model.

Learning and advice to be shared

Virtual Wards offer ‘wrap-around’ support to people in their homes ensuring they can receive care that meets their needs in a timely fashion with the aim of reducing the need for avoidable hospital admission. Working collaboratively, people can either be added to the ‘Virtual Ward’ list as they leave hospital to return home or can be added by partner professionals from across the multi-professional team when they are identified as requiring additional support. The supporting clinicians have a daily-updated list of those on the ‘Virtual Ward’. District Nursing colleagues review regularly to ensure individuals’ health and wellbeing is supported through a range of interventions and support offers as required. These include:

  • Review of a person’s ‘Plan of Care’ to ensure this continues to meet the person’s individual needs and adapting this where appropriate
  • Ensuring appropriate referrals have been made and specialist input is available. For example a consultant follow-up post discharge or from District Nursing teams in the community
  • Review of the person’s emergency health care plans and/or longer term wishes such as lasting powers of attorney or if appropriate DNACPR’s

This new way of working has strengthened partnerships between nursing and social care teams across the locality by:

  • supporting and facilitating teams across care homes, integrated care partnerships (ICPs), North East and North Cumbria integrated care system (ICS), NHS Trusts and Social Services to work in an integrated way
  • providing district and community nursing on-call contacts to nursing colleagues and carers in the community for real-time advice and support
  • increasing the in-reaching of specialist services and supporting the relevant upskilling of staff in care homes to reduce the number of avoidable admissions to hospital
  • supporting nursing colleagues across hospital and care home sectors during what remains a difficult time
  • developing existing telehealth systems in care homes to include wound care pathways
  • establishing ‘Mutual Aid’ models of support sharing expertise and resources across organisations at the start of pandemic which will continue going forward

The benefits of ‘Virtual Ward’ approaches have been recognised seen during the pandemic as:

  • Helping to keep people in their preferred place of care
  • Facilitating safe and timely discharge
  • Admission avoidance where appropriate
  • Encouraging collaborative and Individualised patient care
  • Improved communication between all services, people and their carers
  • Development of new Mutual Aid Models and supporting Integrated working

Would it be beneficial to retain these changes?

Nursing colleagues and local communities welcomed the use of the ‘Virtual Ward’ approach during the pandemic and plan to continue and expand it for the future. This will support professionals to ensure people who receive care remain at the centre of their care, allowing the most vulnerable to benefit from high quality care at home whilst safely helping to reduce the number of avoidable admissions to hospitals in the long-term.

For any further detail on this case study or to connect with Sharon, please contact: england.1professionalvoice@nhs.net