The Role of Virtual Wards in Reducing Unplanned Admissions

1. The Role of Virtual Wards in Reducing Unplanned Admissions Maggie Ioannou MSc BA RGN RSCN RHV Director of Community Health Services Croydon PCT

2. Identifying Patients Key to success is in accurate identification of patients • Clinician referrals do not work • Threshold modelling (e.g. all patients aged >65 with 2+ admissions) do not work

3. Regression to the mean 50 45 40 35 30 Average number of emergency bed days 25 20 15 10 5 0 Intense year - 5 - 4 - 3 - 2 - 1 + 1 + 2 + 3 + 4

4. Emerging Risk 50 45 40 35 30 25 Average number of emergency bed days 20 15 10 5 0 - 1 + 1 + 2 + 3 + 4 - 5 - 4 - 3 - 2 Intense year

5. Predictive Risk Modelling • Kaiser Permanente and other US providers have been using this method successfully for 20 years • Their algorithms are proprietorial • NHS commissioned its own algorithms which can be downloaded free of charge by PCTs

6. Combined Model Intervention A&E data GP Practice data In-patient data Social Services data Out-patient data

7. Intervention

8. 10 Croydon Virtual Wards • Croydon population = 340,000 • 10 virtual wards • Catchment population of 34,000 residents per ward • One ward per 15 GPs • 100 “beds” per ward

9. Virtual Wards • Mimic hospital ward • Patients cared for in their own homes • No physical ward building, hence the term virtual wards • Patients case managed by multidisciplinary team • Ward Team headed by Community Matron

10. Virtual Ward A Virtual Ward B GP Practice 1 GP Practice 2 GP Practice 3 GP Practice 4 GP Practice 5 GP Practice 6 GP Practice 7 GP Practice 8 Virtual Ward A Community Matron Nursing complement Health Visitor Ward Clerk Pharmacist Social Worker Physiotherapist Occupational Therapist Mental Health Link Voluntary Sector Helper • Specialist Staff • Specialist nurses • Asthma • Continence • Heart Failure • etc. • Palliative care team • Alcohol service • Dietician Virtual Ward B Community Matron Nursing complement Health Visitor Ward Clerk Pharmacist Social Worker Physiotherapist Occupational Therapist Mental Health Link Voluntary Sector Helper

11. Medical Input • Community matron given the bypasstelephone number to the duty doctor at each of the constituent GP practices • Community matron able to book appointments to see the patient’s usual doctor

12. CICS Croydon Intermediate Care Service Expert Patients’ Programme • “Weekly” • 35 Patients “Monthly” 60 Patients “Daily” 5 Patients Discharge

13. 100 patients per ward • “Weekly” • 35 Patients “Monthly” 60 Patients “Daily” 5 Patients 5 (35  5) (60  20) = 5 + 7 + 3 = 15 patients for discussion each day

14. Admissions PREDICTED 0 PARR Score 98 100 Admissions OBSERVED 0 PARR Score 98 100

15. Key Strengths • Patients identified according to predicted need thereby reduces health inequalities and counters the inverse-care law • Multidisciplinary, multi-sector partnership • Eliminates duplication • Patient-focused • Simple intervention that is being adopted across the UK

16. Lessons learnt so far 1 • Wards must make sense to primary care teams • Takes time to integrate social care • Issues of confidentiality must be faced early • Impact across whole system is dynamic – in particular community nursing • Takes time to keep acute trust on board and not antagonistic

17. More lessons • Do not underestimate change management demands • Trying to map savings across HRG groups is very complicated • Important to remember that savings are whole system not attributable to one intervention • Public relations crucial • The price of winning awards!

18. What makes the partnership work • Genuine trust and respect • Shared vision that unplanned admissions are frequently avoidable • Communication at all levels • Sharing success; creating solutions together • Facing the difficult issues in an open manner – brush nothing under the carpet • Leadership • “Can do” environment