Case study: supporting people living with frailty in Hull and East Riding

Summary

In Hull and East Riding, the team working as part of City Health Care Partnership CIC are at the beginning of their frailty ward journey.

Their aim is to implement a safe and effective virtual ward, enabling them to care for people in the place they call home. This requires integrating acute frailty emergency department teams, intermediate care, urgent care, specialist community frailty team and other providers, including Primary Care Networks.

How does the virtual ward work?

A health or social care professional, such as a paramedic, GP or community nurse will call the frailty team to refer a potential patient. They will assess them over telephone or video to identify any clinical problems or issues and agree if they’re suitable for a virtual ward.

Having full access to a person’s records and sharing advance care plans across primary and secondary care is vital.

We’ve found that using video with people and their relatives for advance care planning is valued and effective. Clinical support workers can access urgent diagnostics including bloods, ECGs and bladder scans, and we are about to pilot blood point of care testing and digital stethoscopes.

We prescribe electronically which helps us cover a large geographical area, provide oral and subcutaneous treatments, and by working with infectious disease colleagues, we can also provide patients with intravenous antibiotics.

We follow up with people whilst on the ward through a mix of assessment methods including telephone, video, and face to face in the place they call home, and at the frailty centre. Every care home has a tablet to support virtual consultations We are also training care home staff on recognising signs of deteriorating residents so we can respond quicker.

Nursing and therapy teams can react within 2 hours, between 8am-8pm, 7 days a week, and respond to people’s needs.

What benefits have you seen for patients?

We’re enabling more people with frailty, or at the end of their lives, to be cared for in their preferred place of care. The people we care for, and their carers are saying they’re more satisfied too.

We’re better integrated with providers, for example, with acute hospital frailty teams, Primary Care Networks, community nursing and palliative care.

Have you any tips for other teams setting up a virtual ward?

Shared learning from other areas is important, we have been particularly influenced by Leeds and Bradford models.

We hope to see better coordination of care and communication within teams to allow more people to be cared for in their preferred setting. Trying to reduce readmissions, unnecessary attendances in A&E and trying to help people on their rehabilitation journey, with earlier identification of people who are deteriorating and better care of delirium in the community.

Effective data sharing is vital and a common theme if you’ve got multiple teams providing care. Have clear leadership, especially clinical input. It helps when you have strong ICS leadership with project leads on specific areas.

What’s next?

We’d like to develop the skills of our face-to-face clinical teams so they can provide more intravenous therapies, allowing us to offer more traditional hospital-based treatments in the community.

Authors:

Dr Dan Harman and Dr Anna Folwell, Consultant Community Geriatricians, City Health Care Partnership CIC.