Implementing the Primary and Community Services District Nursing Service Review and creation of a care planning approach within emerging Integrated Care Teams

The Virtual Ward planning process

Project Leads
Cath Hemingway
Integrated Care Team Service Manager, Primary and Community Care Group Services, Health and Wellbeing
NHS Project Team
Emma Backhouse
Community Matron, North Locality
Sally Burton
Integrated Care Team Leader, HASC Locality
Sue Gavelle
District Nurse Team Leader, HASC Locality
Dr Sally Fowler Davies
Dr Tony Smith 
Additional knowledge exchange activity
Dr Sarah Salway
Health Inequalities team
Dr Jill Thompson
PPI team

Aim of the project
The innovation in commissioning theme sought to recruit and support service re-design using two complementary approaches; appreciative enquiry and whole systems thinking. South Yorkshire CLAHRC partnered with a service manager and engaged closely with a team within the NHS, including commissioners and planners to discuss the wider research and critical issues associated with the service re-design. Using a service improvement methodology, a number of senior academic's offered guidance to achieve a clear plan for the innovation.

The co-ordination of a series of 'whole system's meetings and the further co-production of an implementation plan was achieved through a number of meetings over a 4 month period and included the support of the Sheffield CCG and 'Right First Time' initiative along with the engagement of several GP practices and the selection of a specific GP practice to pilot the virtual ward initiative. The pilot began in May 2013 with a 3 months re-configuration of professional services towards the delivery of a virtual ward.

Background to the project
The white Paper (2012), Caring for our future: reforming care and support, sets out a new vision for a reformed care and support system within the NHS by promoting wellbeing and independence at all stages to reduce the risk of people reaching crisis point, and so improve their lives.

Stronger co-ordination and collaboration between the primary, community and social care sectors is regarded as essential for the provision of high quality, safe and effective services to people living with complex, long term health and social care needs. (Lewis et al 2011)

The Virtual Ward model aims to integrate primary, community and social care at micro (clinical) level and explore the cost effectiveness of this type of integrated, multidisciplinary care management in reducing emergency hospital admissions for patients at moderate to high predictive risk. 

The virtual ward was initially identified in the District Nursing service review (Cantrill 2012) and as part of the review of community nursing, the Matrons developed a model of the virtual ward, in collaboration with district nursing management, to allow a more responsive service fully utilising the matron's skills in the management of acute conditions for those with long term illnesses. The Community Matron role, the proposed lead for the virtual ward, has been assigned to them in an acknowledgement of their clinical skills knowledge and experience. 

The community matrons and district nursing teams will have limited effect on the outcome of the patients admitted to the virtual ward, without wider collaboration and active involvement with other health and social care practitioners. 

In parallel to the District Nursing Review, the "Right First Time Programme" set up 'Project 1' to focus on the establishment of Integrated Care Teams. This includes the use of risk stratification tools to identify those patients most at risk of admission. The virtual ward model is consistent with the emerging thinking of the role and focus of the Integrated Care Team.

Following a search and review of Virtual wards nationally, the Croydon virtual ward model has been adapted by the project group, supported by the stakeholder group in November 2012.

Definition and Principles of the Virtual Ward
Virtual wards copy the strengths of Hospital wards: the virtual ward team shares a common set of notes, meets daily, and has its own ward clerk who can take messages and assist with coordinating actions identified to support patients. 

The term virtual is used because there is no physical ward building, patients are cared for in their own home. 

The virtual ward will be proactive and coordinated in identifying At Risk vulnerable people and then coordinating and managing their care in partnership with the patient and carers using a multi-professional approach which will support self-care, self-management and enable independence where possible. 

This proactive approach to care for patients at risk of hospital admission will enable the community matron and district nursing team to lead, coordinate and organise complex care packages to support personalised care plans being delivered efficiently, effectively, and to the highest quality standard ensuring the desired outcome is achieved. (DOH, 2005 Long Term Conditions)This approach is strongly recommended in the Francis Report, arising from the care concerns in mid Staffordshire. (Francis Report, 2013). Furthermore, it dovetails with the drive from the Right First Time programme to deliver services within a process of mutual collaboration with patients and utilising a care planning approach.
The ability to develop care packages will be dependent on the resources available to the team. One of the advantages of trialling the model will be to complete a resource gap analysis on the effectiveness of the team within the available resources. (See below)
By continually monitoring the care provided to patients, the Virtual ward will ensure that patients who are at risk of deterioration will be provided with diagnostics, management of acute conditions and provide future management planning for recurring exacerbation of long term conditions before they reach crisis.

The virtual ward will work closely at the secondary care interface to facilitate supported discharge for patients from inpatient care. This will be achieved by liaising with Front Door Response team (FDRT) and accessing discharge data, through Transfer of Care Team.

The virtual ward will target patients at moderate to high risk of Hospital admission with a combined predictive score of 50 and above.

Trialing the model
A 'whole systems' stakeholder group in November 2012, facilitated by CLARHC Innovation in Commissioning leads and attended by social care leads, NHS commissioning, local Authority commissioning, GP's, Nurse Practitioner, Geriatrician and community nursing, it was agreed that the Integrated Care service Manager for Community nursing lead a project group to develop a model that could be trialled in the City. Using the data analysis from the Public Health paper 'Outputs from the population need for emergency hospital beds in Sheffield modelling' (Rutter, 2012) it was noted that the incidence of ambulatory care admissions was prevalent in the Mosborough and Birley areas of Sheffield. The stakeholder group agreed to support a trial of the virtual ward model in these areas with the GP Practices and District Nursing Teams. Both GP practices and District Nurse Teams are engaged with the proposal.

It is proposed that the trial will be conducted for 3 months, commencing 1st May 2013.

Whole systems planning
The methodology promoted by the CLAHRC was designed to include a range of practitioners and agencies in the design of the virtual ward and particularly to support the interface between primary care and community care.

By using appreciative enquiry, each element of the service across the health economy could challenge and engage with the re-design in-order to build up a coherent operational plan based on evidence and expert knowledge within the health system.

Project meetings included the following:

Meeting 1 - initial scope and goal setting with extended CLAHRC team and commissioning representatives
Meeting 2 - systems re-design and planning, patient selection
Meeting 3 - whole systems event
Meeting 4 -key performance indicators and measures
Meeting 5 - operational planning
Meeting 6 - PPI engagement and evaluation planning
Meeting 7 - whole systems follow up

The ward clerk post for £14k pro rata for 6 months was a successful business case.

The pilot of the virtual ward for 15 patients began on May 6th 2013