1. Clare Lewis1 Zena Moore 2 Tom O’Connor3 Declan Patton4 Linda E Nugent5
Examining the process and impact of risk stratification using a community virtual ward model to manage older persons’ complex care needs’
Clare Lewis1 Zena Moore 2 Tom O’Connor3 Declan Patton4 Linda E Nugent5
PhD student School of Nursing & Midwifery Royal College of Surgeons Ireland.
Professor and Head of School of Nursing & Midwifery Royal College of Surgeons Ireland.
Deputy Head & Programme Director School of Nursing & Midwifery Royal College of Surgeons Ireland
Senior Lecturer & Director of Research School of Nursing & Midwifery Royal College of Surgeons Ireland.
Lecturer & Programme Director School of Nursing and Midwifery Royal College of Surgeons Ireland.

2. In 20 years, 1 in 5 people walking down Grafton Street will be over 65
Older Population Growth Globally is predicted to at 140% by 2030 in Ireland since 2007 there has been a 32% increase in over 65 group

3. Frailty Clinical Condition Advancing Age Cognitive Decline Lethargy
Nutritional deficits
Deteriorating muscle strength
Weight loss
Greater risk hospital admission & institutionalisation
Reduced physical activity
Figure from Clegg A, Young J, Iliffe S, et al. (2013) Frailty in elderly people. Lancet;381:753

4. The Problem: Hospitals have become the default solution 50% of bed days are for older persons
An average length of stay for a frail older person is 70 days
In % increase in >75s presenting to ED in North Dublin
% increase in trolley waits (INMO 2015)
% increase in trolley waits (INMO 2016)
When healthcare system was designed – it wasn’t set-up to address ageing demography
Hospitals are the default solution – because we don’t have Integrated Services between Hospitals & Community Care
Hospitals are the stop-gap
It’s a very expensive solution to the challenge of caring for older people
An unsustainable model of care

5. Solution: Integrated Care Community Virtual Ward Model
Home Care is Cheaper and its where people want to be cared for
Reduces likelihood of infection
Frees-up hospital beds for people who need them
Etc – add your own notes
€ per day
€485 per week
€800 per day
€5,600 per week
Home care approx. 10% of Hospital Care costs

6. Studies CVWs
CVW in UK, embedded within primary care, chronic disease, lead by a GP and overseen by a community matron. Predictive risk tool (who was at risk of an unplanned admission). No significant reduction in ED presentations or admissions (Lewis et al 2013, 2014).
CVW in Canada, outreach approach, post discharge from hospital, dedicated team, chronic disease, had no impact on re-admissions at 30 days, 90 days and 12 months, LOS CVW 12 weeks.(Dhalla et al 2015).
CVW in Hong Kong, patients selected as inpatients, chronic disease focused, integrated approach, dedicated team, 12 week interventions, reduction in ED presentations observed and unplanned admissions at 6 months (Lin et al 2015).

7. Patient & Family (Home)
CVW Model Approach North Dublin
Patient & Family (Home) GP
Community Palliative Care
Community Psychiatry
Older Persons
Primary Care Teams
Community Intervention Team
Specialist Gerontology
Home Care Agencies
Voluntary Organisations
Clinical Case Manager
Day Hosp/ Rehab
Acute Care
Specialists Chronic Disease

8. North Dublin: Community Virtual Ward
Gerontology Services
Clinical Case Manager
Clinical Case Manager
Assessment
Virtual Ward Admission
High Risk: Red
Mod Risk: Amber
Triage
HOW …
Green: Low Risk

9. CVW Impact unplanned admissions & ED presentations North Dublin
Decrease in the number of bed days after interventions through the CVW (P=<0.001).
The number of ED presentations were lower post CVW (P= <0.001).
Median unscheduled admissions were reduced in comparison to the number of unplanned hospital admissions prior to CVW interventions (P=0.001).

10. Expanding on Previous Research
The value of Frailty as a measurement of risk in a severely frail group.
Risk prediction using risk scores- complex group older persons risk scores may remain high.
Large focus of risk scores is unplanned hospital admissions and ED presentations.
Do types of interventions and response determine level of risk.
What determines reduced levels of risk in a high risk group.
How are risks quantified and relate to those with poorer outcomes.
Focus of CVWs has been on chronic disease rather than older persons care.

11. Study Aims
To examine risk stratification through a CVW model and in older persons with complex health and social care needs. To identify the most common presentations of risk in the care of older persons with complex health and social care needs.

12. Research Questions Primary Research Questions
Do risk scores or presenting event determine overall risk?
How are lower levels of risk determined through this model of care?
Secondary Research Questions
Is Frailty measurement a reliable indicator of risk overtime in a high risk group?
Do risk scores significantly change with service interventions in a sick older population?
Are there key areas of risk that can be improved in this high risk group?

13. Research Design Methods Data Collection Sample
Non-experimental longitudinal study
Examining a population of older persons admitted to the CVW
Retrospective & Prospective data
Methods
Descriptive statistics
Regression analysis (multinomial & multivariate)
Data Collection
Baseline demographics
Medical history
Social history
Medication
Falls History
Hospital activity (ED presentations, unplanned admissions)
Risk Scores
Events
Service Interventions
Responses overtime
Collected on admission, transfer, re-admission and discharge
Sample
Convenience sample
> 65 years
Living in the community (residential care excluded)
Admitted to the CVW

14. Study Variables Independent Clinical Predictors Dependent CVW Outcomes
Age
Gender
Co-morbidities
Pressure ulcer risk
Falls
Incontinence
Frailty
Cognition
Nutrition
Function
Previous hospital admissions
Previous ED presentations
Informal supports
Type of events & severity
Number of events
Response overtime
Hospital re-admissions
ED presentations
No. re-admissions red
Complexity of interventions
Psychological, Emotional status
Medication

15. Conclusion
CVW in North Dublin has shown to reduce unplanned hospital admissions and ED presentations.
The PhD research will examine how patients are risk stratified, the relationship between risk scores, events, interventions and response overtime.
Examine the impact of Frailty measurement in a high risk group as a predictor of risk.
As the complexity of care in an aging population changes risk predictions using tools may not be sufficient in determining level of risk.
Health care professionals may be guided by the types of events, interventions and responses overtime in determining lower levels of risk.

16. Acknowledgements Thank You
School of Nursing & Midwifery Royal College of Surgeons Ireland
Nursing & Midwifery Planning and Development Unit North Dublin
Public Health Nursing Management Team North Dublin
Specialist Gerontology Services Beaumont Hospital & Day Hospital
Thank You