Transcript Slide 1

Wandsworth Virtual
Wards
- Pilot Project March 2009-2010
Dr Michelle Best & Dr Iram Sattar
September 2010
CfWI produces quality intelligence to inform better workforce
planning, that improves people’s lives
Outline
Background
Virtual ward structure and function
Patient Pathway
New initiatives
Challenges
Evaluation
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
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 decisionmaking
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
Virtual Ward Team
Social
Workers
Intermediate
Care Team
Pharmacist
District
Nurses
Specialist
Nurses
Community
Matron
GP
Ward Clerk
Mental
Health
Team
Palliative
Care
Team
Community
Physio
& OT
Drug &
Alcohol
Team
Patient Selection
Patients >18 years of age
Consent from GP & patient
Patients at high risk of admission highlighted by
PARR
GP referrals (previously)
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
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
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
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
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
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
Feedback/Comments
 Family
 “I am extremely happy that my mother’s health and coordination 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”
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
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
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.
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
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
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