Review reveals how to achieve effective ‘virtual wards’

An NIHR funded report has explored how 'virtual wards' can work optimally to treat people at high risk of - or experiencing - a frailty crisis.

The report identifies key elements to be considered to implement ‘virtual wards’ effectively, including proactive care, a whole-system approach and operating as a ‘team-of-teams'.

Frailty is a health state in which people are unable to function fully. It is more often seen in older people. If you have severe frailty, a minor health problem such as an infection can become a frailty crisis. People with frailty may have reduced muscle strength and increased fatigue. 

Around 10% of people aged over 65 live with frailty. This figure rises to above 25% for those aged over 85. Yet living with frailty doesn’t mean a person is incapable of living a full and independent life.

When a person with severe frailty experiences a health problem such as sudden immobility they are often admitted to hospital. Collectively, these patients can place high demands on already busy hospitals. As the UK population ages and more people become frail the demand on hospital beds may become unsustainable. So it is important to look at alternative ways of caring for people with frailty who have a crisis or are close to a crisis. 

Virtual wards for people with frailty enable remote planning of individual patient care by a multidisciplinary team of professionals, with care delivered by community and primary care teams. They enable patients at high risk of or experiencing a frailty crisis to be cared for at home (where most people want to be). 

Researchers from the NIHR Applied Research Collaboration West (ARC West) undertook a rapid realist review to do two main things: 

  • Identify the different types of virtual wards operating in the UK. 
  • Determine what parts or processes help a virtual ward to work well and to understand how they best work, for whom and in what circumstances.

The team reviewed 17 relevant academic papers and 11 documents from other sources such as NHS websites. They also engaged with patients, caregivers and clinicians. 

Report findings  
They identified two virtual ward models for people with frailty, both intended to reduce acute hospital admissions:

  • Short-term, acute wards (1-21 days) for patients already experiencing a frailty crisis. 
  • Longer-term care wards (more than 3 weeks, typically 3-7 months) offering proactive preventative care to prevent a high-risk patient from reaching crisis.

The researchers suggest that optimising the implementation and delivery of frailty virtual wards could potentially improve quality of life for patients and caregivers, while alleviating resource demands of frailty management for the healthcare system.

The researchers looked at the factors influencing success of frailty virtual wards in each of these areas:

  • Setting up a virtual ward and underpinning effective operation
  • Delivering the patient pathway, including proactive care
  • Patient and caregiver experience and empowerment

The researchers suggest that in order to function well, virtual wards need to:

  • Operate as a ‘team-of-teams’
  • Have buy-in from the professionals on the team 
  • Think carefully about patient safety
  • Start small and take time to introduce formal agreements and learn new ways of working
  • Have good communication between patients, caregivers and staff

They found operating virtual wards may be more difficult if: 

  • The home environment is not safe
  • A patient has delirium
  • The caregivers or family members cannot cope

The researchers suggest a whole-system approach to frailty. Primary care and other place-based teams should be involved in selecting virtual ward patients and giving continuity of care after discharge. A combination of virtual ward models should be considered, offering both acute reactive care and proactive care. For example, red / amber / green wards within the one virtual ward, sharing the same staff and multidisciplinary team.

Dr. Maggie Westby, Senior Research Associate at ARC West and lead author of the paper, said: “Our rapid realist review is the first to look at what constitutes a virtual ward and how those elements come together under one ‘virtual roof’ to deliver frailty interventions. This is vital information as virtual wards are being adopted across the NHS. We found empowering patients and caregivers, and the value of preventative, whole-system approaches, were particularly important.

“With our ageing population, we need creative solutions to help people stay well at home for longer and reduce the impact on hospitals. Virtual wards are one possible solution, but how they are implemented and managed, and for whom, is key to delivering the benefits policymakers are hoping for.”

Virtual wards for people with frailty: what works, for whom, how and why – a rapid realist review was published in Age and Ageing.

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