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VAWAS Virtual Ward Pilot in Easington


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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

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VAWAS Virtual Ward Pilot in Easington

  1. 1. Virtual Ward Pilot - Easington Hugo Minney for the Easington CCG team Tuesday 20th December 2011
  2. 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. 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. 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. 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. 6. Multi-Disciplinary Team Patient Community team GP team Co-ordinator Specialists (hospital and community) Social care And other Local Autho- Father Christmas
  7. 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. 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. 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. 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. 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