About Community Virtual Ward
The Community Virtual Ward was created to prevent unnecessary hospital admissions by providing at-home care for patients, particularly those with respiratory diseases, frailty, and heart failure.
Patients accepted onto the Community Virtual Ward will be provided with a remote monitoring kit that will allow blood pressure, temperature, pulse, and respiratory observations to be transmitted to the dedicated Community Virtual Ward Hub.
Our services include point of care testing, ECGs, blood pathology, holistic assessments, regular observations, clinical reviews, medication management, IV medication administration, fluid support, and palliative care support.
We also have access to social and therapy support through our co-location with the NEAT team, and maintain close relationships with UCCH, 111, EEAST, and acute SDECs, ED, and OPED services. Our goal is to keep patients safe at home.
Rest is key to recovery really and we all know that you don't get much rest in hospital, you don't get much peace and quiet. Staying at home made everything that much easier.
It just meant that I got that extra supervision, that extra monitoring that you would get in hospital, but I was able to stay at home. It made the world of difference to me.
Jennie - Community Virtual Ward patient
Overarching Criteria
Inclusion Criteria
- A deteriorating health condition that can be managed in a predetermined step-up pathway.
- A deteriorating health condition that can be safely managed in the community setting.
- Patients referred by a registered health care professional or professional advocate following a formal assessment.
- Patients in any community setting including community hospitals, residential care homes and nursing homes.
- Where patients choose to remain in their normal place of residence to prevent hospital admission.
Exclusion Criteria
- Patients under the age of 18 (Patients aged 16 and over can be accepted if they are currently under the care of an adult-care Consultant such as Virtual Ward step-down patients).
- Patients not consenting to treatment under Virtual Ward.
- Patients with no place of safety to reside while admitted to virtual ward.
- Patients with a presenting condition that requires acute assessment or admission and deemed unsafe to remain in a community setting, (unless refusal to be conveyed to acute trust).
- Patients with an advanced cognitive condition who does not have the continuous support of family or carers.
- Patients requiring intravenous therapy with a recent history of illicit intravenous drug misuse.
- Patients currently residing in a place of detention.
Frailty Pathway Criteria
Inclusion Criteria
- Any person over 18 who has been assessed to be living with frailty and is in a crisis that requires acute level care.
- An informed and capacious decision of the patient or carer/family member where appropriate, who wants to have their treatment at home.
- Where a person is living with dementia, this should not exclude admission to the Hospital at Home service.
- Expected required treatment time is short-term intervention of 1 to 14 days.
Exclusion Criteria
- Severe injury, for example non-ambulatory fractures requiring urgent orthopaedic opinion.
- Is experiencing a mental health crisis and requires referral/assessment by a specialist.
- mental health team that cannot be supported in the community.
- Needs acute/complex diagnostics and/or clinical intervention that can only be offered in hospital.
- This can become a shared risk with the patient if they do not wish to be admitted.
- For safeguarding reasons, it is not safe for a person to remain in their home or usual place of residence.
Respiratory Pathway
Inclusion Criteria
- Inclusion and exclusion criteria will vary between local systems and virtual wards, depending on what is available and how long services have been established.
Exclusion Criteria
- Severe or life-threatening presentations of pneumonia, asthma or COPD – but remembering that patients may receive end of life care at home if that is their preferred place.
- Unstable or worsening clinical trajectory, e.g. saturations <93% unless confirmed baseline and/or NEWS2 ≥5
- Suspected sepsis.
- Chest pain that is concerning for a serious cause requiring immediate hospital transfer, e.g. acute coronary syndrome.
- Pregnant women with saturations of ≤94%
- Where urgent oxygen is required in less than 4 hours of urgent delivery.
Heart Failure Pathway
Inclusion Criteria
- ≥ 18 years, needing acute level care.
- Can be safely & effectively managed in community.
- Current HF diagnosis confirmed by a HF specialist.
- High risk of deterioration or admission to hospital or could step down from HF admission for early supported discharge.
- Would otherwise remain in a secondary care bed.
- Discussed with and/or reviewed by a HF specialist at the time of onboarding.
- Referred by the HF MDT.
- Can benefit from daily remote monitoring, regular clinical re-assessment and are suitable for remote treatment by a HF specialist team, including home visits where required.
- Have made an informed decision and consented to be on a virtual ward based on their needs and preferences, and carer support where appropriate at the patient’s best interest.
- Are expected to be in the service in the short term (usually managed within 14 days).
Exclusion Criteria
- Clinical presentations, co-morbidities or psychosocial problems which can only be investigated, treated, or care coordination that can only be achieved with a hospital admission. The definition of each of these exclusion criteria should be developed with HF specialists and be robustly considered by each ICB co-ordinating their own virtual ward programme.
- Acute pulmonary oedema should not be a reason for heart failure virtual ward admission unless supporting patients as part of an end-of-life care at home pathway.
- For safeguarding reasons, where it is not safe for a person to remain in their home or usual place of residence.
Operating Hours and Timeframe for Visit Following Referral
Patients are monitored by the Hub from 8am to 8pm, 7 days a week including bank holidays.
Your referral will be managed by our dedicated team and triaged by a clinician. Referrals made by 5.30pm can usually be seen on the same day with clinician agreement.
Your attention and treatment prevented the need for me to be hospitalised and I'm sure being able to stay at home has been a big part in my recovery. Your regular visits, understanding, and kind care were a real boost to me.
It was a joy to help to use the new kit you now have. My daughter was able to keep you up to date with the daily stats with the pack left with me.
Mike - Community Virtual Ward patient
What Happens When Treatment Ends?
The patient will be assessed by our team for clinical suitability before being discharged. Onward referrals to specialist services will be made if required.
A discharge summary will be sent to the patient and their GP explaining what care has been received while under the care of Community Virtual Ward. The discharge summary will clearly document any changes to the patient's medication.
The Community Virtual Ward team will coordinate arrangements to collect any monitoring equipment provided to patients.