The Virtual Ward (grasping opportunity!) RBW 14/5/15

Why Virtual Wards? Respond to growing needs of people with chronic health problems Emergency admissions rising – undesirable for patients and costly in terms of hospital care. (No one explanation for rise in emergency admissions – part patients factors, part health systems – no one solution either) Develop approaches that are preventive before crises emerge Linked structure for managing high risk patients in community settings

Purpose of Virtual Wards Avoid preventable hospital admissions Support discharge Chronic disease management Enhanced preparation for scheduled care Enhanced medicine management Enhanced local access to diagnostics & Rx Active Rehabilitation

Where to Start? Predictive Modelling: the frailty register Identify a group of patients at increased risk of emergency admissions or needing more complex care.

Frailty Register at Builth GPs selecting 5 patients each from their own lists Meeting with DNs to review their existing caseload and select further patients We’re aiming for a total of around 30 patients initially (start small, review workload, build confidence) Other strategies: QOF data, MSDI, Inpatient data, A&E data, OOH reports etc

Virtual ward team at Builth GPs DN team Nurse specialists (eg respiratory) Physio / OT Pharmacist Social Worker Voluntary Sector Ward clerk (Invited if input required - CPN, Mac Nurse, Tissue Viability etc)

Virtual ward A patient is offered "admission" to a virtual ward if general agreement that there is a high risk of a future emergency hospital admission (acute on chronic illness, exacerbations, or complex issues needing more structured, coordinated care). Patients remain in the community and receive multidisciplinary care at the patient's home, by telephone and/or at a local GP practice.

Virtual Ward Structure Weekly MDT meeting (Review of frailty register, review of virtual ward patients, agreed admissions and discharges) Daily “office –based” virtual ward rounds to discuss patients on the virtual ward in person or by telephone. The virtual ward staff share a common medical record. Admin support OOH service flagging

Virtual Ward - MDT (Builth) Probably a Monday (potentially all GPs available to attend; often post weekends more decisions required; ensure care plans set up for the week ahead) GP to chair at Builth Surgery Direct entry into GP record EMIS Patients read coded in and out of the Virtual Ward Virtual white board – to be developed 1 hour duration from 1pm. RV of virtual ward – progress, admissions, discharges, Rolling review of frailty register.

Virtual Ward – Daily Round (Builth) Fixed time each morning by losing 2 GP appts. 9am to 9.20am. GP and DN present as a minimum. Ideally face to face but, as we run a branch surgery, telephone may be necessary at times. Discussion of virtual ward patients only. Direct entry into GP record (EMIS). Updating of the virtual whiteboard

Virtual Ward Responsibility (Builth) Buddy system of 2 doctors to improve continuity: Doctor A – lead Doctor B – Backup Both mandatory attendance at weekly MDT A & B Cover the virtual a ward for one or two weeks at a time (to be decided)

Virtual White Board (Builth) Information summary for the virtual ward at any point in time highlighting responsibilities and planned care Headings: Patients name, admission date, responsible GP, MDT members involved, progress, action points etc Move away from a fixed White Board that doesn’t fit with MDT and Multi site working

White Board Patient ID: MDT 2/3/15 Admitted to VW: 25/2/15 History: CCF, PVD, Ulcers on toes On-going problems: Pain++, amputation recommended, recent bloods OK Care Plan: Continue weekly bloods, pain control, chase op date Care Coordinator: Outcome: Review 9/3/15 Duration of stay: Admission avoided:

Read Codes (Builth) Admit virtual ward 8Hv Discharge virtual ward 8HgE   On frailty register EMISNQON5 Removed from frailty register EMISNQRE476 Patient declined inclusion on frailty register EMIS NQPA350 Admitted to Glanirfon 13F6 Discharged Glanirfon 8HEZ

Problems of Virtual wards Needs clear lines of responsibility & leadership GPs already working at capacity (slick integration at Practice level required) Increased GP visits?? (Brecon say no) Social Services the rate limiter as usual (limits who can be admitted to the Virtual Ward) Increased use of secondary care??

Benefits of the Virtual Ward Currently well funded Enhanced team working and team satisfaction Enhanced medicine management Active rehabilitation Support discharge Positive patient stories Enhanced patient confidence in home care Moving further away from “GP does all”

Future Developments Further development and audit of the frailty register More in depth anticipatory care of those on the frailty register to prevent virtual ward admission Increased use of virtual ward for DGH discharges GPs taking a more consultative role