The Concept of a Virtual Ward needs some explaining. In Seaham in County Durham we identified the most vulnerable and elderly patients through predictive risk modelling and developed a service which would improve their clinical outcomes, improve their experience, reduce costs through reducing use of unplanned care, and improve working lives. Although this only ran for 12 months in pilot form, it has since been extended across 170,000 patients in Easington and Sedgefield in County Durham

1. Virtual Ward Pilot - Easington
Hugo Minney for the Easington CCG
team
Tuesday 20th December 2011

2. Programme of preventive care to reduce the
need for hospital admissions (promote
confidence to cope with exacerbations at
home)
• Identify patients using a Predictive Risk tool such as
Combined Predictive Model
• “Admit” these patients (those most likely to benefit) to
a multi-disciplinary team co-ordinated by an
administrator and senior community nurse
• Frequent case reviews and intensive support, co-
ordinated across the team
• Discharge to make room when higher risk people are
identified
What is it?

3. Identify
• Predictive Risk Modelling
Diagnose
• Multiple conditions, bio-psycho-social complications
Manage
• Frequent case reviews. Multi-disciplinary including specialists
• Intensive support avoiding duplication of effort & confusion
Discharge
• When higher risk patient identified
Standard Clinical Protocol

4. Red Flag Inclusion Criteria
Target at risk
patients
(CPM)
A fall
Not coping
at home
urgent care
service issue
Untreated
medical problem
eg atrial
fibrillation
Iatrogenic disease
(complication of Px
medicine)
Intercurrent
illness eg
chest infection,
D&V, UTI
Poor
control of
LTC

5. • Those already on Case Management? –
unless this co-ordination will make a
material difference
• Frequent fliers whose needs are best met
in hospital – this programme may not help
them and they would naturally reduce their
hospital attendance after one intensive 12
months
Exclusion Criteria

6. Multi-Disciplinary Team
Patient
Community
team
GP team
Co-ordinator
Specialists
(hospital and
community)
Social care
And other
Local Autho-
Father Christmas

7. • 2 GP practices for pilot (Murton, Deneside
the Avenue)
• Registered patients roughly 11,600
• To mimic the Croydon model, this means a
Community Ward of roughly 30 pts; roughly:
• 2 requiring MDT Case Review Daily
• 9 requiring MDT Case Review Weekly
• 19 requiring MDT Case
Review Monthly
Numbers
Case
Management
Disease
Management
Supported Self Care
Prevention & Wellness
programmes

8. Team Time Commitment
Community (Community Matron,
District Nurses, Co-ordinator –
CDDFT)
District Nurses will provide day-to-day
care. Co-ordinate all case reviews
(avg 5 per day plus new arrivals)
Urgent Care Centre/ Walk-in
Centre and OOH
Attend appropriate case reviews (by
telephone). Aim for half of above
Local Authority (Social Care team) Attend appropriate case reviews,
where patient is on their case load or
Community Matron believes it relevant
GP & Primary Care Team Attend (by telephone) Case Reviews,
option to change depending on results
as pilot progresses
Specialist Nurses & Community
Consultants (note GP is already
involved)
Attend depending on requirements of
patients being reviewed. Co-ordinator
to ensure effective attendance
(schedule)
Hospital specialists and
consultants
Attend appropriate case reviews (tel)
Staffing

9. • Numbers of each category of patients, length of time in
the pilot, numbers through
• Numbers of hospital/ outside network use of
healthcare by this group whilst in care, compared to
previous 12 months (admissions, length of stay)
• Patient satisfaction and Quality of Life
• Reduction in overall emergency admissions, A&E
attend and urgent care/ WIC attend
• Actual costs of staffing for network and reviews from
each provider (inc GP)
• Duplicate activity avoided, use of telehealth
Evaluation

10. • What criteria do we have for risk-scoring
patients? CPM model? PARR+ model? Our
own? How will scoring be done?
• Who will decide whether to admit a patient to
the network? GP? Risk Tool?
• Who is ultimately responsible for the patient?
• Who will discharge? Will the main criterion be
resources, or will these be flexible?
• What needs to be in place in order to start?
Discussion

11. Action Responsib-
ility
Done by
Identify GP practices/ patient
population
Easington
CCG team
Completed
Engagement with Social
Services, Specialist Nurses,
other parties
CDDFT
Community
Matron
Risk Modelling tool running &
patients identified
Easington
CCG team
Date for first MDT review of
“admissions”
GPs/ Comm
Matrons
First admissions GPs/ Comm
Matrons
1 working
day later
Action Plan