1. CfWI produces quality intelligence to inform better workforce planning, that improves people’s lives Wandsworth Virtual Wards - Pilot Project March 2009-2010 Dr Michelle Best & Dr Iram Sattar September 2010

2. Outline  Background  Virtual ward structure and function  Patient Pathway  New initiatives  Challenges  Evaluation

3. Background  Established in response to overwhelming number of admissions to St George’s Hospital each winter  Aim- To reduce emergency hospital admissions by supporting patients in the community  March 2009 – March 2011  Initially 1 year pilot project  Covering 30 GP practices

4. What is a Virtual Ward?  Method of providing care to people in the community who are most vulnerable to repeated unplanned hospital admissions  “Virtual” - Patients remain at home  “Ward” - Case management approach to their care from MDT  Co-ordinate and optimise social, medical and psychological health  Main focus those with long-term medical conditions  Encourage self-management /involve in decision- making

5. Wandsworth Virtual Wards  x4 Wandsworth community virtual wards  Catchment area population =210 000  Currently >100 patients on the wards  Still admitting patients  Focus on increased turnover

6. Virtual Ward Team Community Matron GP Ward Clerk Social Workers District Nurses Specialist Nurses Palliative Care Team Drug & Alcohol Team Community Physio & OT Mental Health Team Pharmacist Intermediate Care Team

7. Patient Selection  Patients >18 years of age  Consent from GP & patient  Patients at high risk of admission highlighted by  PARR  GP referrals (previously)

8. Patient Selection - Predictive Risk Modelling  Estimates future risk of admission in next 12 months  Computer generated, eg PARR, combined risk tool  >70% risk score  PARR - uses hospital data and patient demographics to predict future risk

9. Patient Pathway  Initial (joint) Assessment at home  Consent  Each patient given:  Direct access number to ward  “Credit card” with contact details  Patient information leaflets  Care plan agreed with achievable goals

10. Patient Pathway  Regular ongoing follow-up of patient at home (including telephone consultations)  Patient also encouraged to contact us when unwell  Prompt follow-up at home after hospital discharge  Patient’s care discussed regularly at multidisciplinary team meetings  Discharge considered if :  Goals achieved  PARR score drops <70%  Uneventful care previous 3 months  Palliative care patients

11. Case Example  60yr old male - Cerebellar Stroke Dec 08  Balance & co-ordination difficulties  Social isolation  Multiple admissions Jan – June 09  Identified as “in need” of support by GP & by PARR  June – admitted on virtual ward  Regular visits at home  Input of services arranged (eg DNs help with insulin administration, WATCH alarm, FLASH, shopmobility)  Significant decrease in hospital attendances

12. Case Example  76y male with terminal lung cancer and COPD  SOB on home oxygen  Anxiety & depression  Drug & alcohol misuse  PMHx overdose and self-harm  Admitted to Virtual Ward & multi-disciplinary team involved –  SW, palliative care, DNs, Respiratory Nurse, Physio, OT, Pharmacist, Drugs & Alcohol team  Only x1 admission (on weekend) since admission

13. Case Example  40 year old brittle asthmatic  Multiple (>5) hospital admissions Jan-July 09  Non-compliant with inhalers when at home  Smokes  Socially isolated/ depressed  Not accessing GP services  Admitted to virtual ward (PARR) July 09  Regular home monitoring of asthma & medication compliance  Psychological therapy for depression  Smoking cessation clinic  No admissions since July

14. Feedback/Comments  Family  “I am extremely happy that my mother’s health and co- ordination of services is being taken care of (by the virtual ward)”  Patient  “ the virtual ward is marvellous”  GP  “you must be doing a very good job with ….. as I haven’t seen her in surgery since she was admitted on the virtual ward!”  Social Services  “I was wary of coming to the (first) multi-disciplinary meeting, but am glad I did and found it really helpful”

15. New Initiatives Communication with GPs  Secure remote access to practice computer patient records systems  Key to patient safety & provides valuable link between primary care & community healthcare

16. New Initiatives Communication with St George’s Hospital Automatic message alert when patient attends St George’s A&E Admission prevention as A&E can send home confident of review in community Also facilitates shortened hospital stay if patient is admitted

17. New Initiatives Communication with OOHs providers  Direct access with OOH providers via web-based special patient notes  Allows up to date medical info on virtual ward patients to OOH doctors/nurses.

18. Challenges  IT  Establishing remote access to GP’s computer records  Prescribing issues  Awareness  Establishing awareness in both primary & secondary care  GPs  Variation in GP practice responses  Patients  A few patients declined the virtual ward service

19. Evaluation  Qualitative Research  Patients & health professionals questionnaire  Case study  Quantitative Analysis  Joint analysis with Croydon and Devon Virtual Wards led Dr Geriant Lewis and the Nuffield Trust

20. Future  Provide acute visiting service in parallel  Facilitate early discharge through IV antibiotics provision in community  Integrate & expand Telehealth solutions  VWs commissioned (perhaps by GP Federations) as complete package of community care