Hospital at Home (Virtual Wards)

Introduction

Increasing prevalence of people living with frailty is a key challenge to healthcare providers. One solution may be virtual wards (VWs). Our research sought to: examine different frailty VW models; and determine how, why and under what circumstances VWs may work effectively. During our early research, NHS England (NHSE) started roll-out of short-term VWs intended to treat acute patients with frailty crises at home instead of hospital. We expected our work to inform NHSE policy, especially how to ‘do’ VWs better.

Methods

We conducted a rapid realist review of frailty VWs, searching published and grey literature for evidence on multidisciplinary VWs based in the UK, using a literature-based definition of VWs. Information on how and why VWs might ‘work’ was extracted and synthesised iteratively into context-mechanism-outcome configurations (CMOCs). Throughout we engaged closely with clinicians and patient/public contributors. The iterative nature of the realist review led to emerging understanding.

Results

From 28 documents, we identified two VW models: longer-term, proactive care wards admitting patients at high risk of a frailty crisis; and short-term reactive care wards for people experiencing a frailty crisis. Using evidence from both models, we generated 12 CMOCs, under three themes. First, building blocks for effective VW operation (e.g. common standards agreements, information sharing, a multidisciplinary team planning patient care remotely). Second, how the VW delivers the frailty pathway (e.g. patient selection, assessment, proactive care). Third, Patient/Caregiver empowerment. Mechanisms included motivating professionals (e.g. a ‘team-of-teams’); buy-in; building relationships: professionals, patients and caregivers. VWs should be set within frailty management guidance, and a whole-system approach to care is needed. For sustainability of VWs, proactive care for people at high risk of a frailty crisis should be provided.

Conclusions

This review has implications for optimal implementation and sustainability of frailty VWs, through proactive care and a whole system approach.

Introduction

University Hospitals Dorset (UHD) wants to provide hospital level care to patients with frailty, in their own home. Our frailty virtual ward (VW) team consists of a consultant geriatrician, lead nurse, pharmacist, advanced nurse practitioner, nurses and therapists. We have a capacity of 20 patients across Bournemouth, Christchurch and Poole localities. Our patients receive care at home for acute medical conditions supported by remote monitoring, blood testing, face to face assessments and daily Geriatrician input. We are collaboratively working with our community partners seeking to provide complete CGA in the patient’s home.

Methods

Establishing the service was non-linear and required multiple improvement cycles. Our VW fits alongside our frailty SDEC, day hospital and interim care team. We developed a SOP, a patient flow pathway and processes for medication prescribing and delivery supported by the Royal Voluntary Service. We screened our frailty wards for suitable patients and in May 2023 we tested by taking our first patient home. Subsequently our processes have developed around the patient’s needs. Through multiple PDSA cycles we tested various screening techniques, 7 day Geriatrician input, nurse recruitment, remote monitoring and used patient feedback to guide further service development and improvement.

Results

We are an established frailty virtual ward with 20 beds.

Conclusion

The UHD Frailty VW has developed out of a need for an early supported discharge and admission avoidance for our older patients. Through multiple PDSA cycles, we have established a virtual model that we feel is providing safe, hospital level care for patients with acute medical presentations. We hope to expand through recruitment and funding with an aim to deliver excellent quality care to patients with frailty in their in their own home. Our ambition includes closely working with South West Ambulance Service for further admission avoidance and developing a home IV pathway.

Introduction:

Home Treatment Service (HTS) is a frailty Hospital at Home team that provides comprehensive geriatric assessment, hospital level diagnostics and treatments for people in their own home. This option of care is often suitable for people living with frailty or those with advance care planning directing them to community options. The team is dynamic with many disciplines within it to allow urgent care provision.  HTS is formed of ACPs, SAS Doctors, Therapists and Healthcare Assistants.

Referrals used to be from direct clinician discussions only via a triage line but more recently has increased links with the Acute and Ambulance Trusts. This has been done by providing a Multi-Disciplinary Team that interacts with visiting paramedics via a clinical navigation hub (CHUB). 

Home Treatment Service now has two main referral routes as illustrated by the infographic below.  The CHUB has increased the interaction with paramedics in real-time when people are experiencing an acute medical crisis.  This has allowed rapid access to senior clinical decision makers allowing holistic patient-centred joint decision-making with often complex and frail patients.

Method:

61 HTS referrals from the CHUB were compared with 61 direct clinician referrals from December 2023 to February 2024.  The NEWs score, length of stay (LOS) and Advance Care Planning (ACP) documents were analysed.

The data also interprets the index of deprivation codes for all patients using the 2019 survey.  1 is the most deprived LSOA (Lower Super Output Area used to compare) and this score is a measure of deprivation based on measurements of seven different domains.

Results:

The average LOS under HTS via the CHUB was 2.61 days and 3.65 days for direct referrals.

27% of NEWS scores from the CHUB were high compared with 14% from direct referrals.

48 out of the 61 (78.6%) patients identified as requiring HTS by the CHUB had no ACP documents (the presence of a DNAR was not counted as this does not give community options). 37 out of 61 (60.6%) had no ACP on direct referral to HTS triage.

NEWS SCORE

CHUB HTS Referral

Direct HTS Referral

Low and Medium

45

51

High

17

9

The source of referrals were analysed further to consider the geographical areas that patients were referred from by considering the English Indices of Deprivation 2019 data available (Indices of Deprivation 2015 and 2019 (communities.gov.uk)).  This was to allow consideration of any difference in access to either referral route according to markers of socioeconomic deprivation.

48 out of the 61 (78.6%) patients identified as requiring HTS by the CHUB had no ACP documents (the presence of a DNAR was not counted as this does not give community options). 37 out of 61 (60.6%) had no ACP on direct referral to HTS triage.

Conclusion(s):

Referrals directed to HTS proactively from the CHUB have a higher percentage of NEWS scores that would require hourly observations and access to urgent medical assessment.  The CHUB explores community options while weighing benefits and risks of transfer to hospital in real time.

The Length Of Stay between the two referral sources is not hugely different and suggests that HTS are identifying patients requiring similar management regardless of source of referral.

The CHUB gives options to patients with fewer advance decisions recorded to support the direction of their care during a medical crisis.  The CHUB allows HTS to access a different group of patients who may not have had routes to HTS enabled previously.

The pattern of spread of cases across the Indices of Deprivation groups are not hugely different between the referral routes.  This may be because referrers consider social factors when referring or because of the acuity found during assessment.

Introduction:

The Gloucestershire Frailty Virtual Ward (FVW) is a novel multidisciplinary collaborative project which seeks to improve care for frail older patients. We describe our experience, reflect on lessons learnt and plans for future service development.

Methods:

The Gloucestershire FVW was started in early 2023. It arose from an understanding that the needs of frail patients can often be better met in their own homes, by utilising a combination of digital technology combined with improved working across organisational boundaries at the primary/secondary care interface. We reviewed data from all patients admitted onto our FVW between October 2023 and March 2024.

Results:

66 patients were included. The majority of patients were ‘step-down’, having been in hospital prior to FVW admission. The minority were ‘step-up’, having been referred from community colleagues. Clinical frailty scores ranged from 2-8, with a mean of 6. During this period, our FVW managed a range of different clinical problems. The most common reason for FVW admission was infection, then heart failure, delirium and acute kidney injury. Most patients were admitted for the management of a single problem (58%), although a significant proportion had 2 or more problems (42%). Our FVW conducted a variety of interventions, including blood tests, face-to-face reviews, amending medications including antimicrobials, diuretics and analgesia. Our FVW was also involved in decisions around the withdrawal of active care and initiation of a palliative approach.

Conclusions:

Our FVW has helped facilitate early discharge and avoid hospital admission, with associated benefits to both patients and the acute trust. As a new service which aims to sit between primary and secondary care, we have encountered logistical and governance challenges associated with working across organisational boundaries. Additionally, we have found that the use of digital technology can cause anxiety for patients and place additional strain on carers.

Introduction: Hospital at home (HAH) is growing apace in the United Kingdom, offering hospital-delivered treatments at home. In parallel, increasingly structured alternative training pathways are being created to enable doctors to train outside of formal specialty training programmes. With a need to train doctors to work in community settings, a HAH rotation within a locally developed internal medicine training (IMT) programme at one large NHS Foundation Trust was evaluated.

Method:

A questionnaire was designed to review the alignment of HAH rotation experience with the IMT curriculum and its acceptability as a clinical rotation within an IMT stage 1 equivalent programme. The questionnaire was distributed to all doctors who had previously undertaken a HAH rotation at junior clinical fellow level in the previous five years. Free-text responses were analysed with thematic analysis.

Results:

23/27 responded (85%). 74% had pursued IMT following their non-traditional training year. 78% agreed that HAH would be a suitable placement for a 4-month IMT rotation, with 74% interested in a HAH role following completion of training. HAH offers core content in internal and geriatric medicine. Curriculum coverage within a HAH rotation included improved confidence in clinical decision making, leadership, risk management, multidisciplinary team working and increased exposure to advanced care planning and palliative medicine. Being part of contextual, personalised medicine with shared decision making central was also cited as beneficial over traditional hospital rotations. Disadvantages were a lack of exposure to core IMT procedural skills, resuscitation and fewer opportunities to attend outpatient clinic.

Conclusion:

Whilst limited to one geographical service, results indicate that HAH is a prime learning environment for internal medicine training as part of a carefully balanced programme ensuring access to all curriculum competencies. Where sufficiently developed, HAH rotations can be included in IMT programmes delivering much needed generalist skills. 

Introduction Hospital-at-Home (HaH) is an innovative care model delivering hospital-level care to community patients. A key priority for Bromley HaH has been to streamline strategies, providing integrated, individualised care for patients with heart failure (HF). Our study revealed that our length of stay (LOS) exceeded the 7-day target, and readmission rates surpassed the 0-10% target. Recognising the complexities of managing HF in the community, we evaluated the impact of a new HF bundle to enhance clinician confidence, reduce LOS, and improve outcomes and service capacity. Method An adapted HF bundle was developed in collaboration with local cardiologists to integrate services. The bundle included standardised assessment/management tools, technology-enabled care (point-of-care and remote monitoring), and clear discharge criteria. It was implemented alongside departmental teaching, HF clinic/MDT attendance for experiential learning, and weekly consultant-led MDMs to build confidence. Retrospective data was collected before and after the bundle's introduction to assess impact on LOS and readmission rates. Results Between February 2023 and May 2024, 48 unique patients were seen (mean age 81, 28 hospital step-downs, 20 community step-ups). Initial clinician surveys showed 83% lacked confidence, 75% struggled with diuretic titration, and 60% unsure about optimising prognostics. Baseline data from February 2023 to January 2024 showed an average LOS of 13 days and a readmission rate of 15.7%. Post-bundle implementation, average LOS reduced to 10.95 days, and readmission rates dropped to 7%. Clinician surveys reported increased confidence, and over 90% of service users rated their care as excellent. Conclusion The implementation of our HF bundle significantly improved clinician confidence, halved readmission rates, and reduced LOS, thereby increasing patient throughput and service capacity, and achieving a 41% reduction in cost per bed-day. The study also contributed to the development of a dashboard to continuously monitor the effectiveness of these interventions and highlight areas of further development.

Introduction Swansea Bay Health Board is covered by eight community clusters (240 virtual beds), each with their own Virtual Ward (VW) MDT which provides community based Comprehensive Geriatric Assessment and reablement. The VW governance structure includes the routine collection of person centred metrics. There is no recognised PROM or PREM specifically designed for needs of frail older people and PROMs and PREMs are rarely used to inform quality and continuity in services at transitions of care (e.g. at discharge from hospital) Methods VW data from June 2023 to February 2024 was analysed. Patient-reported outcomes and experiences (PROMS and PREMS) were collected by the VW team at set timepoints in the patient journey. Data was collected using the PRO-MAPP digital interface ensuring inter-user consistency. Results 1858 VW patients, 1094 (58.9%) female, median age 86 years. The majority, 1044 (56.2%) were referred from secondary care, primarily from acute frailty services, with the remainder identified by primary care. In total, 418 PROMS and 344 PREMS were collected. PROMS - Reported improvements in mobility, self-care, usual activities, pain and anxiety & depression (p001 after vw input. prems – the majority of patients found had been explained well prior to referral (84.0%), were contacted promptly (95.6%), staff professional and friendly (100%), provided patient-centred care (94.2%), contactable (92.4%), glad they avoided or reduced length hospital admission (95.3%). when speaking with 72 care-givers, happy patients' needs met (100%) positively impacted their lives as carers (90.1%). discussion there was high patient care-giver satisfaction service. prom data suggested a significant positive impact on outcomes. not all referred have sampled which is missed opportunity variability between collection clusters. 

Hospital at Home (HaH) provides high acuity clinical care for patients in the community. HaH teams are varied and multidisciplinary. A successful HaH service depends upon streamlined communication between multidisciplinary team (MDT) members, facilitated by an integrated knowledge base. Whilst training protocols are under development, there are currently no published teaching programmes for HaH. We responded to this unique challenge by devising a teaching programme for the HaH team at St John’s Hospital, Livingston.

Methods: We identified learning needs within our team with a preliminary survey. We conducted a literature review to select four competency resources which were mapped to five domains: clinical care; pharmacy; service design and delivery; anticipatory care planning and palliative care; and ethical and legal guidance. We formalised a weekly teaching session and linked teaching topics to the core competencies. We conducted a review at 3 months and 6 months to assess the impact of the programme on staff learning and clinical confidence.

Results: A tailored teaching programme with domains linked to multidisciplinary competencies increases staff confidence in the clinical management of common HaH presentations. Our bespoke programme has successfully delivered teaching that caters for multiple clinical backgrounds.

Conclusions: HaH teams represent an opportunity to learn from MDT colleagues with diverse training backgrounds and offer a unique challenge in tailoring teaching to multiple learning needs. A formal programme with clear, identifiable domains linked to learning objectives provides an essential framework for staff to demonstrate engagement with professional development, allows staff to develop personal teaching skills and cultures a strong collaborative learning environment. Going forward, we aim to evaluate the impact on staff competence and formalise a cyclical HaH cucciculum for circulation to the NHS Lothian HaH teams with scope for wider dissemination.

Introduction

The UK is expanding provision of acute medical care in peoples’ own homes through Hospital at Home (H@H) and virtual wards. Our H@H service is training junior doctors to meet the growing clinical need in this environment. We describe the use of simulation training to improve the H@H induction process.

Methods

From their experiences in H@H, junior doctors identified specific training needs to build relevant competencies. From this feedback, PDSA cycle one involved junior doctors designing a dedicated simulation training (H@H-SIM). Stations addressed clinical, practical and advanced communication skills required in H@H using high- and low-fidelity simulation. PDSA cycle two used post-course evaluation to refine H@H-SIM through introduction of FP10 prescribing stations, point-of-care testing (POCT) and greater emphasis on practical skills. Revisions were evaluated via participant questionnaire before and after the H@H-SIM.

Results

Cycle two of H@H-SIM involved twenty doctors. The clinical scenarios, prescribing and practical skills stations, including POCT and IV administration, were perceived as the most useful parts of training. Overall self-rated confidence in knowledge and skills to work in H@H improved from a mean of 6.9 to 7.7/10. Before H@H-SIM, 60% were ‘not confident’ with recognising end of life (EOL), IV administration or decision-making around remaining at home; 10% with advance care planning (ACP). After H@H-SIM, 10% felt ‘not confident’ with recognising EOL or ACP and 5% with IV administration. Concerns persisted with using equipment, prescribing and availability of senior support. An additional station on recording ECGs was suggested. 

Conclusions

Working in a H@H context and seeing patients in their homes can be daunting for junior doctors. H@H-SIM embedded into induction is one way to prepare doctors for this role, improve their confidence and has potential for wider replication.