Integrated care and 'virtual wards' help prevent unnecessary hospital admissions

A new model of integrated care sees multidisciplinary teams monitoring older people with deteriorating health to help them avoid the need for emergency care

A new model of integrated care sees multidisciplinary teams monitoring older people with deteriorating health to help them avoid the need for emergency care

Primary healthcare nurses are helping to keep frail older people in their homes and out of hospital with a revolutionary ‘virtual ward’. Virtual wards operate in the same way as hospital wards, but the patient stays at home as much as possible.

Picture: Alamy

Nurses, social care staff, doctors, physiotherapists and other healthcare staff work together to provide intensive monitoring of people in west Dorset who are thought to be at risk of admission to acute care.

The two virtual wards in the towns of Weymouth and Bridport are at the forefront of the moves in England to integrate health and social care to provide a more holistic approach for patients.

People who are identified as deteriorating – generally older, frail people with multiple long-term conditions – are referred to the team and put on a ‘virtual’ ward list.

As well as discussing medical issues, the presence of a social care worker means discussions can include family problems, social care packages, equipment needed, lifestyle problems such as excessive drinking or issues with pets.

Integrated hub

When a patient is referred to the Bridport Integrated Hub, the most suitable person, or couple of people, will visit to assess their needs. This could be a district nurse, occupational therapist, someone from social services, mental health staff, the local hospice team, occupational therapist or physiotherapist.

The staff at the hub, which has been running for about two years, will then come up with a plan of the care needed to keep the patient at home if possible. When patients need more care than can be provided at home, they can be admitted to the community hospital. Patients who do need acute care are discharged as soon as possible, either back to the community hospital or their own homes.

Jon Kimber, lead for the community rehabilitation team and district nursing, says: ‘Our philosophy is to do what we can to keep people at home. We identify the frail, vulnerable people at as early a stage as possible so that we can work with the patient, their relatives and the whole team to stop emergencies and unplanned admissions happening.'

Hospital is not the right place for frail, older people and if we can assess them and come up with a early plan, that is much better. When a patient does have to go into the acute hospital, we say that the patient is on loan and we want them back as soon as possible.’

Red list

Working in a multidisciplinary way, with a single point of referral, is essential to the model. Community matron Beverly De Lisle says that the virtual ward has up to ten patients on the red list and they will be discussed informally each day and formally reviewed by the whole multidisciplinary team (MDT) at meetings held twice a week.

She says the support of the MDT allows them to care for patients at home who otherwise would end up in secondary care.  

‘It is one referral, and that is the biggest difference,’ she says. ‘When a patient is referred, we have an MDT discussion about what is needed and decide who is going to visit, and that includes social services, mental health teams and the hospice team. These patients are complex, and as a community matron you are generally out there on your own. It is nice to come back and have a whole team from different professions that can share in the decisions.’

'We identify the frail, vulnerable people at as early a stage as possible so that we can work with the patient, their relatives and the whole team to stop emergencies and unplanned admissions'

An essential part of the team are band 3 health and social care coordinators, who straddle the NHS and social care teams and have information about all those aged over 75 and registered with west Dorset GPs. They coordinate the work and if patients go to hospital they receive an alert and begin to plan for their discharge.

Integrated care systems in England

The ten initial areas are:

  • South Yorkshire and Bassetlaw
  • Frimley Health and Care
  • Dorset
  • Befordshire, Luton and Milton Keynes
  • Nottinghamshire
  • Lancashire and South Cumbria
  • Berkshire West
  • Buckinghamshire
  • Greater Manchester (devolution deal)
  • Surrey Heartlands (devolution deal)

The four new areas announced in May are:

  • Gloucestershire
  • West Yorkshire and Harrogate
  • Suffolk and North East Essex
  • North Cumbria

Integrated care pathways

On average, a patient will spend about three weeks on the red list of the virtual ward, although they can stay involved with the team at a less intensive level for longer, if necessary. Often the same patient may come back to the hub at a later date, but the team’s knowledge of them and their health means staff can care for them more effectively, Ms De Lisle says.

Consultant geriatrician Riaz Dharamshi, who leads the Bridport Integrated Hub, says there was no funding for their project. ‘We started our service with no extra money but with a desire to do something different and a clear vision,’ he says.

‘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 need for acute care from that population. Where we have them we have seen a reduction in acute admissions, and in the areas that don’t, have seen a rise.’

Holistic care

The work in Dorset is part of a move to develop integrated care systems taking place in 14 areas in England. The system is a way to adapt to the profound shifts in patterns of ill health where many older people are living with multiple long-term conditions by offering a service that supports a person's complete needs rather than treating each body part, illness or social care problem in isolation. 

Weymouth GP Karen Kirkham, who leads Dorset's integrated care system, says over the first year there was a 10% reduction in unplanned emergency admissions to hospital from the cohort cared for by the team.

The team has monthly meetings with local GPs about their patients to ensure they work together. The model can help overworked practices, says Dr Kirkham, who has just become national clinical adviser for primary care with the NHS England transformation team.

The Weymouth and Bridport model is now being introduced in other areas in the county with local variations.

Working together

‘Three to four years ago we were working in silos; we had community services, social care and GPs all doing their own thing,’ she says. ‘This approach has taken a massive strain off GPs. It doesn’t mean we are not involved but we become part of the wider team. The evolution of integrated care systems is breaking down barriers and creating a culture of teams working together. There is value in us linking together, working together and making the services work better together. That is the ethos you get when you start on this journey – it is a different way of working.’

Key facts

  • In an integrated care system, NHS organisations work in partnership with local councils and others to take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve
  • These systems are intended to care more effectively for the high proportion of patients, who are often older, and have multiple long-term conditions
  • Incurable long-term conditions now account for half of all GP appointments, almost two thirds of outpatient appointments and seven out of ten inpatient bed days 
  • Local services can provide better and more joined-up care for patients when different organisations work together in this way, according to NHS England
  • For staff, improved collaboration can help to make it easier to work with colleagues from other organisations
  • The first 14 areas of the country are now formally beginning to work as integrated care systems, a significant milestone as England makes the biggest national move to integrate care of any major Western country

Erin Dean is a freelance journalist

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