Hospital at Home (Virtual Wards)

Introduction

NHS England is committed to the expansion of virtual wards, necessitating patient engagement with home care technology. Literature suggests there is a technology adoption lag among older populations. We investigated if this lag was evident in geriatric virtual ward patients.

Methods

Data from three NHS trusts using a virtual care  platform (March 2021-August 2023) were aggregated to assess differences in perceived ease of use, technology adoption style, and measures of adherence. All patients received the Telehealth Usability Questionnaire Ease of Use (EOU) subsection (higher scores indicate higher EOU). Patients completed surveys via tablet, wore monitoring devices, and took blood pressure readings. We dichotomized age (<75 vs. 75+) and used Fisher’s exact and Wilcoxon-Mann-Whitney tests.

Results

Of 857 patients, 36.9% were geriatric (mean age 81.5 years). The younger group (mean age 59.1 years) had 541 patients. Gender was evenly split between age groups (p=0.62). Median EOU scores were 5.5 (geriatric) and 6.2 (younger) (p<0.001). Geriatric patients were more likely to avoid or delay technology adoption (82% vs. 56% in younger patients, p<0.001). Geriatric patients had higher adherence to the wearable device (median 95.3%) compared to younger patients (93.3%, p<0.001). Blood pressure (median 81.6%) and survey adherence (median 83.3%) did not significantly differ between groups (p=0.076, p=0.0501).

Conclusions

Despite perceptions and literature suggesting older patients are less comfortable with technology, our findings demonstrate high engagement in virtual ward technology. While differences exist in technology adoption and EOU scores, geriatric patients exhibit equal or higher adherence to remote monitoring tasks. These results challenge stereotypes and underscore the importance of incorporating technology in geriatric care.

Introduction: Wearable technology that continuously monitors physiological metrics has become increasingly popular and allows remote patient monitoring in virtual ward settings. Wearable technology has been shown to be effective in disease monitoring among younger adults. However, its use among older adults, including those with cognitive impairment, is yet to be explored. Aim: We aim to explore the acceptability of remote monitoring using wearable technology among older adults with delirium. Methods: Participants were recruited from an in-patient rehabilitation unit. Inclusion criteria included documented delirium and age over 65 years. Participants were enrolled until delirium resolved or until discharge. Wearable technology was worn continuously, except when being charged or the patient was washing. Device data was recorded every minute. Premorbid Barthel index and Hierarchical Assessment of Balance and Mobility (HABAM) was collected for each participant. Participants were assessed daily for delirium and mobility using the Memorial Delirium Assessment Scale and HABAM respectively. At point of discharge from the study, participants completed a questionnaire to gather feedback on their experience. Results: 20 participants were included, with a mean age of 83.0 years and an average premorbid Barthel’s index of 72. 6. Mean data capture from the wearable technology was 44.1% (12.8-65.8). None of the participants could independently manage the device. Three participants stated that the device interfered with their normal activities with five reporting the device uncomfortable to wear. However, nine participants stated they would wear the device again if asked to by a healthcare professional. Conclusions: Our findings demonstrate that wearable devices are tolerated by delirious older adults with delirium. We found that this group cannot manage these devices independently and need support from either a carer or healthcare professional. These results provides useful information to help pilot these devices among older adults with delirium in virtual ward settings.

Introduction

East Kent Frailty H@H provides an alternative to admission to an acute hospital for frail people who are acutely unwell. Treatment at home is often the preferred option for people living with frailty and prevents some of the complications associated with hospitalisation such as environmental delirium, loss of function, isolation from usual contacts and infection. However, it was not known whether H@H also reduced the workload of the acute hospital. 

Method

Frail people who are acutely unwell are offered treatment in H@H instead of admission to an acute hospital. Referrals were made by community clinician eg Primary care, community nurse, Single point of access, paramedics etc. Interventions include CGA based assessment, point-of-care blood tests, ultrasound, urgent outpatient x-ray, CT and MRI scans, Intravenous therapies etc. Data were collected using electronic patient records for the community and hospital services. The data collection period was April 22-Dec 23 Patients of 69 and over were included. SPA charts were generated for results.

Results

Before the introduction of H@H the number of non-elective admissions plus the corridor activity closely matched the predicted number of admissions. Since the introduction of the H@H there is a significant drop in the number of non-elective admissions plus the corridor activity compared to predicted admissions. This number (~400 per month) is similar to the number admitted to H@H. 

Conclusion

H@H Data validated by NHS England has demonstrated that for every 1.03 patients treated 1 non-elective admission to the acute hospital was avoided.

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.