Abstract
Patients at high risk of emergency hospitalisation are particularly likely to experience fragmentation in care. The virtual ward model attempts to integrate health and social care by offering multidisciplinary case management to people at high predicted risk of unplanned hospitalisation. To describe the care practice in three virtual ward sites in England and to explore how well each site had achieved meaningful integration. Case studies conducted in Croydon, Devon and Wandsworth during 2011-2012, consisting of semi-structured interviews, workshops, and site visits. Different versions of the virtual wards intervention had been implemented in each site. In Croydon, multidisciplinary care had reverted back to one-to-one case management. To integrate successfully, virtual ward projects should safeguard the multidisciplinary nature of the intervention, ensure the active involvement of General Practitioners, and establish feedback processes to monitor performance such as the number of professions represented at each team meeting.
Highlights
Patients at high risk of emergency hospitalisation typically have multiple chronic conditions, which are often compounded by psychological and social issues. [1,2] As a result of these complex and interacting needs, high-risk patients are more likely to experience fragmented care and to derive greater benefit from improvements in the integration of health and social care [3]
Any hospital avoidance programme must target patients who are both at high risk of a future unplanned hospitalisation and who are likely to respond to the proposed intervention [4]
We focus on the virtual ward covering South Molton and Chulmleigh; a further 22 virtual wards have since been established across the county of Devon, which build on an existing infrastructure of complex care teams
Summary
Patients at high risk of emergency hospitalisation typically have multiple chronic conditions, which are often compounded by psychological and social issues. [1,2] As a result of these complex and interacting needs, high-risk patients are more likely to experience fragmented care and to derive greater benefit from improvements in the integration of health and social care [3]. [1,2] As a result of these complex and interacting needs, high-risk patients are more likely to experience fragmented care and to derive greater benefit from improvements in the integration of health and social care [3]. The virtual ward model attempts to integrate health and social care by offering multidisciplinary case management to people at high predicted risk of unplanned hospitalisation. The composition of a virtual ward team will vary according to the needs of local high-risk patients It may include a community matron (case manager), district nurses, a ward clerk, pharmacist, social worker, physiotherapist, occupational therapist, mental health professional and a representative from the voluntary sector. Virtual ward staff receive a prompt when the patient’s name drops below the 100 people with highest predicted risk in that virtual ward’s catchment area according to the Combined Model
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