PALLIATIVE CARE
Extending virtual wards to palliative care delivered in the community Brian Nyatanga
Brian Nyatanga, Senior Lecturer in Allied Professional Studies and Lead for The Centre for Palliative Care, University of Worcester Email: [email protected]
328
which patients should be offered telephone-based health coaching and advice. Elsewhere, as in Worcestershire, the model has been used to identify patients who are offered multidisciplinary integrated care without coming into hospital—hence the idea of a virtual ward. It is clear that the tool is multi-purposed and is a welcome addition to community activities.
The predictive risk model This model was introduced by Lewis (2006). The list below details some of the key characteristics necessary for VWs to be successful: w Patients identified by a predictive risk model as being at high risk of a future emergency hospital admission are offered ‘admission’ to a VW w VWs use the systems, staffing and daily routines of a hospital ward. However, there is no physical ward building w VW patients receive multidisciplinary preventive care at home through a combination of home visits and telephone-based care w Each VW has a fixed number of ‘beds’. Once these ‘beds’ are full, no more patients can be admitted to the VW until a bed becomes available w Each VW should be linked to a specific GP practice w Specialist staff may work across several VWs w The composition of the VW multidisciplinary team will vary according to the needs of local high-risk patients. It may include a community matron, district nurses, a ward clerk, pharmacist, social worker, physiotherapist, occupational therapist, mental health professional and a representative from the voluntary sector w Medical input comes from the duty doctor at each constituent GP practice, as well as from the patient’s usual GP w The role of the administrator (‘ward clerk’) is seen as being pivotal in supporting and coordinating members of the VW staff w The VW team uses a shared medical record system w Systems are put in place to notify local hospitals, the
© 2014 MA Healthcare Ltd
A
study by the Nuffield Trust (Blunt et al, 2010) .concluded that around 35% of all hospital admissions in the NHS between 2004/05 and 2008/09 were classified as emergency admissions with an estimated cost of £11 billion a year. These figures have been rising year on year, with reasons cited including people living longer, increases in chronic disease (of which cancer is arguably one), and increasing economic constraints on health-care budgets (Blunt et al, 2010).There is now a drive to prevent such unplanned admissions and to allow people to remain in their own homes. Although there is currently no clear evidence to show that preventative measures to stop emergency admissions are cheaper than admitting patients to hospital, a number of preventative measures are in place and some others are being piloted. For example, in Worcestershire, community teams use virtual wards (VWs) as a means of keeping patients at home as much as possible. VWs aim to quickly identify patients at high risk of being rushed into hospital at short notice, and to prevent such admissions. The article by Joanne Jones and Andrea Carroll on p.330 details the work of the Enhanced Care Team in Wyre Forest, Worcestershire implementing VWs and its impact on reducing unplanned hospital admissions. One question to be considered is whether VWs integrate the work of primary, community and social care at the three different levels of service provision often viewed as important for providing palliative care: macro (policy and organisational input); meso (clinical multidisciplinary working) and micro (individual Enhanced Care Team involvement with the patient). A further question then arises regarding the impact of VWs and whether they serve their purpose of reducing avoidable emergency admissions into hospital for all patients identified as being at high risk. VWs use a predictive risk model (Wennberg et al, 2006) to assess whether patients are at high risk of emergency admission. However, Wennberg et al (2006) note that the ways in which this model is used by community healthcare professionals varies across the country. For example, the model has been used to identify patients for community matrons to support, and in some instances to select
British Journal of Community Nursing July 2014 Vol 19, No 7
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 23, 2015. For personal use only. No other uses without permission. . All rights re
PALLIATIVE CARE local ambulance trust and GP out-of-hours cooperatives about which patients are being cared for on each VW. This information is used to alert VW staff automatically should a VW patient present to any of these services (e.g. to a local A&E department). Thus, VWs seek to improve integration through a number of strategies, including shared record-keeping, multidisciplinary team meetings and, more importantly, an automated alert system for informing VW staff when a patient accesses another care service, such as attending a local emergency department. While the ideas presented in the model are welcome, we need to be certain that when the model is translated into reality/practice, it does serve its original purpose—to prevent avoidable emergency admissions. The article by Joanne Jones and Andrea Carroll on the next page highlights the successes of virtual wards in a small locality of Wyre Forest in Worcestershire. The challenges encountered and benefits of using virtual wards are discussed in some detail. Given that most palliative care patients prefer to die at home, but often end up being rushed into hospital as emergency admissions, the practice of virtual wards can be extended to palliative care in the community.
Conclusion The potential for VWs to prevent unnecessary and avoidable hospital admissions of patients makes the concept very persuasive. However, a key consideration is the effectiveness of the predictive risk assessment tools available, and one example is given by Jones et al in this issue of BJCN. However, the real point to consider is that any model is only as good as the people using it. Although we know that most people want to die at home, one of the key drivers to keeping patients at home is the cost implication for the NHS. While initiatives such as VWs can help prevent emergency admissions, cut down on hospital costs, respect preferred pace of care by patients, we also need to be sure that the costs incurred in preventative initiatives and projects are in fact less than having patients admitted into hospital. The overarching aim should be achieving the best care for all patients. BJCN Blunt I, Bardsley M, Dixon J (2010) Trends in Emergency Admissions in England 2004–2009: Is Greater Efficiency Breeding Inefficiency? Nuffield Trust. http:// tinyurl.com/luas2rc (accessed 17 May 2014) Lewis GH (2006) Case study: virtual wards at Croydon Primary Care Trust. King’s Fund. http://tinyurl.com/pr5sjxa (accessed 17 May 2014) Wennberg D, Siegel M, Darin B, Filipova N, Russell R, Kenney L (2006) Combined Predictive Model: Final Report and Technical Documentation. Health Dialog/King’s Fund/New York University. http://tinyurl.com/pmq9v5s (accessed 17 May 2014)
BREAKING NEWS: Community nurses, join in the conversation online Keep up to date with the news, views, debate, policy and best practice ideas for district and primary care nurses through BJCN’s social media channels.
Find out what’s coming up in future issues of the journal, connect with other community nurses and industry leaders and find out about BJCN events and promotions.
‘Like’ us on Facebook (www.facebook.com/communitynursing) Join our community nurses group on LinkedIn (www.linkedin.com, then search British Journal of Community Nursing)
© 2014 MA Healthcare Ltd
Follow us on Twitter (@BJCommunityNurs) and stay in contact with us with your views or ideas ([email protected])
Keep your ear to the ground and your finger on the pulse wherever you are in the community
British Journal of Community Nursing July 2014 Vol 19, No 7
www.bjcn.co.uk 329
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 23, 2015. For personal use only. No other uses without permission. . All rights re
Extending virtual wards to palliative care delivered in the community Brian Nyatanga
Brian Nyatanga, Senior Lecturer in Allied Professional Studies and Lead for The Centre for Palliative Care, University of Worcester Email: [email protected]
328
which patients should be offered telephone-based health coaching and advice. Elsewhere, as in Worcestershire, the model has been used to identify patients who are offered multidisciplinary integrated care without coming into hospital—hence the idea of a virtual ward. It is clear that the tool is multi-purposed and is a welcome addition to community activities.
The predictive risk model This model was introduced by Lewis (2006). The list below details some of the key characteristics necessary for VWs to be successful: w Patients identified by a predictive risk model as being at high risk of a future emergency hospital admission are offered ‘admission’ to a VW w VWs use the systems, staffing and daily routines of a hospital ward. However, there is no physical ward building w VW patients receive multidisciplinary preventive care at home through a combination of home visits and telephone-based care w Each VW has a fixed number of ‘beds’. Once these ‘beds’ are full, no more patients can be admitted to the VW until a bed becomes available w Each VW should be linked to a specific GP practice w Specialist staff may work across several VWs w The composition of the VW multidisciplinary team will vary according to the needs of local high-risk patients. It may include a community matron, district nurses, a ward clerk, pharmacist, social worker, physiotherapist, occupational therapist, mental health professional and a representative from the voluntary sector w Medical input comes from the duty doctor at each constituent GP practice, as well as from the patient’s usual GP w The role of the administrator (‘ward clerk’) is seen as being pivotal in supporting and coordinating members of the VW staff w The VW team uses a shared medical record system w Systems are put in place to notify local hospitals, the
© 2014 MA Healthcare Ltd
A
study by the Nuffield Trust (Blunt et al, 2010) .concluded that around 35% of all hospital admissions in the NHS between 2004/05 and 2008/09 were classified as emergency admissions with an estimated cost of £11 billion a year. These figures have been rising year on year, with reasons cited including people living longer, increases in chronic disease (of which cancer is arguably one), and increasing economic constraints on health-care budgets (Blunt et al, 2010).There is now a drive to prevent such unplanned admissions and to allow people to remain in their own homes. Although there is currently no clear evidence to show that preventative measures to stop emergency admissions are cheaper than admitting patients to hospital, a number of preventative measures are in place and some others are being piloted. For example, in Worcestershire, community teams use virtual wards (VWs) as a means of keeping patients at home as much as possible. VWs aim to quickly identify patients at high risk of being rushed into hospital at short notice, and to prevent such admissions. The article by Joanne Jones and Andrea Carroll on p.330 details the work of the Enhanced Care Team in Wyre Forest, Worcestershire implementing VWs and its impact on reducing unplanned hospital admissions. One question to be considered is whether VWs integrate the work of primary, community and social care at the three different levels of service provision often viewed as important for providing palliative care: macro (policy and organisational input); meso (clinical multidisciplinary working) and micro (individual Enhanced Care Team involvement with the patient). A further question then arises regarding the impact of VWs and whether they serve their purpose of reducing avoidable emergency admissions into hospital for all patients identified as being at high risk. VWs use a predictive risk model (Wennberg et al, 2006) to assess whether patients are at high risk of emergency admission. However, Wennberg et al (2006) note that the ways in which this model is used by community healthcare professionals varies across the country. For example, the model has been used to identify patients for community matrons to support, and in some instances to select
British Journal of Community Nursing July 2014 Vol 19, No 7
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 23, 2015. For personal use only. No other uses without permission. . All rights re
PALLIATIVE CARE local ambulance trust and GP out-of-hours cooperatives about which patients are being cared for on each VW. This information is used to alert VW staff automatically should a VW patient present to any of these services (e.g. to a local A&E department). Thus, VWs seek to improve integration through a number of strategies, including shared record-keeping, multidisciplinary team meetings and, more importantly, an automated alert system for informing VW staff when a patient accesses another care service, such as attending a local emergency department. While the ideas presented in the model are welcome, we need to be certain that when the model is translated into reality/practice, it does serve its original purpose—to prevent avoidable emergency admissions. The article by Joanne Jones and Andrea Carroll on the next page highlights the successes of virtual wards in a small locality of Wyre Forest in Worcestershire. The challenges encountered and benefits of using virtual wards are discussed in some detail. Given that most palliative care patients prefer to die at home, but often end up being rushed into hospital as emergency admissions, the practice of virtual wards can be extended to palliative care in the community.
Conclusion The potential for VWs to prevent unnecessary and avoidable hospital admissions of patients makes the concept very persuasive. However, a key consideration is the effectiveness of the predictive risk assessment tools available, and one example is given by Jones et al in this issue of BJCN. However, the real point to consider is that any model is only as good as the people using it. Although we know that most people want to die at home, one of the key drivers to keeping patients at home is the cost implication for the NHS. While initiatives such as VWs can help prevent emergency admissions, cut down on hospital costs, respect preferred pace of care by patients, we also need to be sure that the costs incurred in preventative initiatives and projects are in fact less than having patients admitted into hospital. The overarching aim should be achieving the best care for all patients. BJCN Blunt I, Bardsley M, Dixon J (2010) Trends in Emergency Admissions in England 2004–2009: Is Greater Efficiency Breeding Inefficiency? Nuffield Trust. http:// tinyurl.com/luas2rc (accessed 17 May 2014) Lewis GH (2006) Case study: virtual wards at Croydon Primary Care Trust. King’s Fund. http://tinyurl.com/pr5sjxa (accessed 17 May 2014) Wennberg D, Siegel M, Darin B, Filipova N, Russell R, Kenney L (2006) Combined Predictive Model: Final Report and Technical Documentation. Health Dialog/King’s Fund/New York University. http://tinyurl.com/pmq9v5s (accessed 17 May 2014)
BREAKING NEWS: Community nurses, join in the conversation online Keep up to date with the news, views, debate, policy and best practice ideas for district and primary care nurses through BJCN’s social media channels.
Find out what’s coming up in future issues of the journal, connect with other community nurses and industry leaders and find out about BJCN events and promotions.
‘Like’ us on Facebook (www.facebook.com/communitynursing) Join our community nurses group on LinkedIn (www.linkedin.com, then search British Journal of Community Nursing)
© 2014 MA Healthcare Ltd
Follow us on Twitter (@BJCommunityNurs) and stay in contact with us with your views or ideas ([email protected])
Keep your ear to the ground and your finger on the pulse wherever you are in the community
British Journal of Community Nursing July 2014 Vol 19, No 7
www.bjcn.co.uk 329
Journal of Community Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 23, 2015. For personal use only. No other uses without permission. . All rights re
