Virtual Care for Long-term Condition Management
How do you use virtual care for long-term condition management?
Dr. Matt Wilkes, Director of Clinical Affairs at Current Health, interviewed Alison Chadwick and Dr. Abdul Ashish from Wrightington, Wigan & Leigh NHS Foundation Trust (WWL). WWL has a unique, innovative virtual ward model that focuses on a step-up and step-down pathway, providing care for various long-term conditions. In a recent webinar, hosted by HETT, Chadwick and Ashish shared how they have overcome challenges with their virtual ward, such as gaining confidence among general practice nurses (GPs) to make virtual care a primary protocol, and the benefits of the virtual ward as a platform to safely manage patients needing stepped-up care outside of a traditional hospital setting.
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Virtual Ward Coverage and Capacity
WWL’s virtual ward operates daily, providing care to patients from early morning until late at night. The central hub has 100 beds, and is staffed by 40 nurses that manage patient monitoring during 12.5-hour shifts. Overnight, patients are safety-netted, with few returning to A&E (accident & emergency) or requiring readmission.
She describes their differentiator, saying, “Our virtual ward patients are what we call monitoring-at-home-patients. They have continuous monitoring with the Current Health RPM kit, so they’re monitored 24 hours a day. For patients without the kit, we can reduce that to intermittent monitoring or just provisioning a blood pressure monitor or an oximeter, depending on what’s right for the patient.”
Integrating Virtual Wards with Primary Care
General practitioners are encouraged to consider the virtual ward for patients who are not in life-threatening situations but need a higher level of care. The virtual ward integrates with primary care, and Dr. Ashish shared some of the successes and challenges they’ve had within that effort.
“We’ve had several network primary care meetings with colleagues explaining the pathway,” Dr. Ashish says. “The teams are having one-on-one sessions at individual practices. But we’re still in the process of gaining confidence because it’s a cultural change from what GPs are used to doing, but so far, good, and they’re very pleased with the results.”
The support from the rapid response team, Community React Teams (CRT) teams and district nurses adds to the success of the virtual ward, replicating hospital care while enabling patients to be managed safely in the community. This initiative helps reduce hospital admissions and facilitate patient discharge with proper follow-up care and monitoring in place.
“The most important thing is that once a GP refers the patient, the responsibility sits with us. So we look after the patient just as you would have a discharge summary from the hospital. They get notified when they’re onboarded and when the patient is discharged. So they get the whole package and know that the patient will be well looked after and has backing from the secondary care colleagues.”Dr Abdul Ashish, Consultant Respiratory Physician, Wrightington, Wigan & Leigh NHS Foundation Trust
Getting Buy-in from Colleagues
“Introducing this idea of virtual wards to the GPs was met with a bit of trepidation,” he says. “It’s not something that was accepted with open arms, but piecemeal by one colleague at a time, referring or sharing the experience with the primary care colleagues.”
Despite the challenge of changing established practices, the response has been positive, with the virtual ward becoming a path of least resistance for managing patients outside of traditional secondary care.
“There’s no haggling or arguing, which you sometimes have to do with several gatekeepers on the secondary case,” Dr. Ashish says. “It’s difficult to get a new practice established and embedded as the first go-to, and we are on this journey where we are winning hearts and minds. I think it will take a little bit longer for this to become the first protocol rather than being any secondary care, which most colleagues are used to during their training years, as they grow as GPs, but this is the new thing they’re getting used to. And so far, the response has been quite positive, because we have put the system in a way that 1) is easier, and 2) the responsibility largely sits with us.”
To encourage acceptance of the virtual ward and make it easier for GPs to identify suitable patients, Chadwick advises listening to feedback from GP meetings and individual surgeries, and creating patient stories to showcase successful outcomes and interventions. Then, combine rigorous evidence-based medicine with relatable stories to gain wider acceptance.
“To bring it into life for them, we started creating patient stories about the types of patients that have been stepped up from GPs, the experience and journey they took, how we intervened with them, and their outcomes based on feedback from the patient, the family, and the carers,” she says.
How to Approach Clinical Pathways
A key recommendation Chadwick stresses for establishing a virtual ward is using a simple approach to clinical pathways, defining them by escalation criteria.
“We started with a very detailed model, a step down from the acute model, and focused on individual pathways. At the outset, we had about 90 to 100 pathways, so we decided to scale back. We’ve gone back to a step up and step down pathway for medicine, and a step down pathway for surgery.”Alison Chadwick, Clinical Quality Lead – Virtual Care, Wrightington, Wigan & Leigh NHS Foundation Trust
With this radically simple foundation, the virtual ward team is now exploring additional pathways in collaboration with other specialties. They are analyzing data on frequent attenders to A&E and frequent admissions, especially for COPD cases, to assess the virtual ward’s potential role in reducing hospital visits.
“Looking at that data, we’re evaluating the previous month’s frequent attenders and whether there was something that might have reduced the number of attendances to see whether the virtual ward has a role to play there,” Chadwick explained.
Digital Exclusion of Elderly Patients
The virtual ward has successfully managed very elderly patients with appropriate support and technology. Chadwick and Ashish agree that the main challenge lies in staff overcoming their biases and being more inclusive when offering the virtual ward to patients of all ages and backgrounds.
“We’ve had several patients over age 90 who have successfully managed the kit and the technology,” Chadwick says, “but I think the biggest barrier is ourselves. So we’ve challenged our staff, because they tended to be the people making that decision instead of allowing the patient to.”
Return on Investment for Technology in Virtual Wards
Reducing the length of hospital stays through the virtual ward has resulted in a great return on investment (ROI) in terms of significant bed day savings and improved patient care.
“As a healthcare industry, if you look anywhere, the current problems are overcrowding, not having enough space, patient movement, and all of this in some measure can be addressed if the patients were only staying the optimal duration in the hospital,” Dr. Ashish explains. “We have seen around 1500 patients since inception, and saved 4,000 to 5,000 bed days. You can do the math on that, but it’s a significant savings.”