Bradford Teaching hospitals and its partners have developed an innovative and ambitious project to move care closer to home, whilst also enabling more patient-centred care. The Bradford Virtual Ward began in 2012 as a discharge-to-assess model, relying from the outset on working together across organisational boundaries of health and social care teams. The team is multidisciplinary, comprising therapists, qualified nurses, advanced nurse practitioners, rehabilitation support workers, local authority colleagues and consultant geriatrician input. In 2015 we developed an integrated hub with partners, and new pathways taking direct referrals from community matrons, general practitioners and local ambulance services.
Within hours, on any day of the week, the hub can escalate community support, initiate rehabilitation-at-home, or directly admit to community hospital rehabilitation or a nursing home flexi-bed. Multiple hospital admissions have been entirely prevented, and length of stay in hospital further reduced. Bradford Teaching Hospitals is now in the top 5% of trusts across the country for shortest length of stay. More importantly we have also demonstrated significant improvements in patient quality of life and high rates of patient satisfaction. We proudly present this model, which champions integrated delivery of high quality seamless services to our patients. These embody key principles of the NHS Five Year Forward View, in a replicable way.
Challenges
- Unprecedented demand for acute care admissions was overwhelming resources for inpatient services, and this was predicted to increase.
- the occupation of acute Hospital beds by patients with sub-acute illness whilst awaiting social care enablement had become a major obstacle to efficient patient flow.
- the local population is ageing and, consequently, the number of people living with age-related chronic conditions and Frailty is markedly increasing.
- We identified a critical gap: to enable Co-ordinated working We needed a better interface between community support, Hospital medical teams, voluntary and social care.
- primary care services on their own were unsuited to the needs of frail older people.
Actions
- To develop a collaborative team working with 3 core partners: the elderly admissions unit; an established community support team run by the then primary care trust; and the local voluntary sector.
- To change the culture and ethos of the community team to become more dynamic and pro-active in empowering patient independence at home.
- To build stronger links with GP practices using the primary care electronic health record to enable daily dialogue and shared care between hospital and primary care.
- To develop a hub-and-spoke model with the hub easily and directly accessible to 3 complex care community teams across Bradford, each led by a community-matron.
- To prioritise immediate enablement therapy in a familiar environment straight away with therapy from day of discharge, 7 days-a-week.
Results
- Improved Quality of Life for elderly patients as measured by EQ5D (Euro-Quality of Life Score in 5 Domains) before and after the virtual ward intervention. There were improvements measured in all 5 domains: symptoms of anxiety/ depression; mobility; reduction in pain/ discomfort; improvement in ability to self-care; and completion of usual activities.
- Reduction in bed occupancy in elderly care at Bradford during this time period, despite an increase in admission rate.
- Reduction of length of stay reversing a general increase over preceding years: a significantly greater reduction than that witnessed in other departments.
- Patient satisfaction was high as measured by the PREM patient questionnaires and this has improved further during evolution of the service.
- Re-admission rates have not increased for this frail cohort of patients despite the marked reduction in length of stay.
Value
- Length of Stay: Since 2012, average length of stay of elderly patients at Bradford has reduced from 6.2 to 4.9 days, despite an admission rate increase from 5,874 to 6,449 patients per year.
- Cost savings: Comparison of financial years 2014/2015 to 2015/16 reveals a total of 4,612 bed days saved, at a cost of £400 per bed day. This is equivalent to a cost saving of £1.85 million compared to the previous year.
- The initiation of virtual ward step-up services have been followed by a reduction in the number of GP emergency admissions. (See attachment: HSJ2016_Improving Value in the Care of Frail Older Patients_Efficiency Outcomes).
- Assessment of the health status of patients before and after virtual ward, demonstrated marked reductions in average level of symptoms of extreme anxiety/ depression (29%), pain and discomfort (66%), and improvements in resolution of mobility problems (75% no longer had problems), self-care ( 46% no longer had problems), and performance of usual activities ( 76% no longer had problems).
- Patient satisfaction was high: 94% agreed/ strongly agreed that overall quality of care was very good, 98% felt they were always treated with dignity and respect.
In detail
1. Ambition
(a) Rationale for the project:
i. Between 2012 to 2015, emergency admissions grew by 7.7% (NHS England, April 2015) and in this period alone, the number of people over 65 increased by 7.6%, with those over 85 increasing by 9.1%.
ii. With ageing come increased long term conditions, frailty, dementia, increased dependency and social isolation. People over 75 require person-centred, multi-agency care, as opposed to silo pathways of care, traditionally offered in the acute and primary care sectors.
iii. If frail older people are assessed using comprehensive geriatric assessment there is a greater potential for identifying the underlying cause of frailty and taking action to regain that person’s independence.
iv. A single point of assessment, with a range of “wrap around” support at home, across both the health and social care economy, could ensure that the frail older person gets the right service at the right time with patient-centred care planning.
(b) Aims:
i. Provision of one single point of access for referral to intermediate/ rehabilitation care: available “24-7” with signposting, assessment and screening to ensure appropriate person-centred care pathways, a range of step up and step down intermediate care services, including crisis response, at home or in the community.
ii. An expanded, integrated virtual ward multi-disciplinary team (MDT) with fully developed shared care pathways enabling an interface between GPs, consultants, the intermediate care hub, advanced practitioners and integrated community teams (ICTs).
iii. Integrated health and social care records with connectable information technology support to facilitate good communication and sharing of key information to support effective care delivery.
(c) The design and method was inspired by the following:
i. Calderdale Framework (http://www.calderdaleframework.com/): for the cross-development of skills in nursing and therapy to deliver shared knowledge and tools to carry out assessment and proactively support patient choice and patient decision-making and to deliver care in the right setting.
ii. NHS England 5 year forward plan: following these principles to offer a more seamless, person centred journey through intermediate care services with the minimum of ‘hand offs’ that delivers the right care, in the right place, first time.
iii. Interface Geriatrics (King’s Fund Report) (https://www.kingsfund.org.uk/sites/files/kf/media/leeds-interface-geriatrician-service-kingsfund-oct14.pdf): these methods helped support patients, family and carers more proactively, with early simple interventions.
2. Outcome
i. The reduction in length of stay has enabled the elderly care department at Bradford Teaching Hospitals to initiate other innovative new care models.
ii. One example is the redesign of orthogeriatric care at Bradford. Previously patients with hip fractures were managed on an orthopaediac ward with geriatricians delivering in-reach advice.
iii. With a bed base available as a result of the virtual ward, we were able to take over the care for elderly patients with hip fracture onto our elderly care bed base.
iv. We now provide geriatrician-led, peri-operative, multidisciplinary-team (MDT) care delivering comprehensive geriatric assessment for patients, with orthopaedics providing in-reach for the operation itself.
v. This simple system change has led to improvements in care for older people presenting with hip fracture, including reductions in time to surgery (52% within 36 hours before we introduced the virtual ward, 80% after, versus 72% nationally); time to geriatric assessment (74% within 72 hours before, and 99% after, versus 85% nationally). The trust’s achievement of best practice tariff improved from 20% in 2011/12 to 81% after.
3. Spread
i. Closer working with our colleagues in the community, in social care and in primary care through the virtual ward has been the catalyst for other developments in cross boundary working.
ii. The Foundation Trust is exploring a potential arrangement with our Local Authority to provide additional capacity in Social Care to ease the discharge process. Our investment would guarantee that suitably trained personnel are available to conduct discharge assessments within 24 hours. It is planned that by introducing this proposal we will reduce length of stay by between 1 and 3 days per referral. Given there are approximately 80 referrals to the Local Authority per month, this equates to a saving in bed occupancy of between 960 and 2,880 days p.a. or between 3 and 8 beds.
iii. Following the success in elderly care, our aspiration ultimately is for the trust to develop virtual wards in all specialties, to move more care closer to the patient’s home, and reduce the potential harm, inconvenience and expense of unnecessarily hospital stays. This award would help us inspire interest in other departments by celebrating the success in elderly care.
4. Value
i. There have been significant reductions in length of stay and emergency GP referrals (See attachment: HSJ2016_Improving Value in the Care of Frail Older Patients_Efficiency Outcomes). This has translated to significant cost savings for the trust.
ii. The virtual ward has demonstrated high rates of satisfaction, and improvement in quality of life outcomes which are higher than community population means. (See attachment: HSJ2016_Improving Value in the Care of Frail Older Patients_Paitent Satisfaction, HSJ2016_Improving Value in the Care of Frail Older Patients_Quality of Life).
5. Involvement
i. The idea for the Bradford Virtual Ward was generated by clinicians at the Foundation Trust, and a full range of stakeholders was consulted as part of the development process.
ii. We consulted with patients and their families both before the introduction of the virtual ward and after its implementation to obtain feedback on the service.
iii. We also consulted and designed the service with community colleagues and our partners within primary and social care.
iv. Internally, Foundation Trust management and key business functions were consulted, along with our experts in patient safety and clinical governance. The advice of other interdependent specialties was also sought.
v. Excellent relationships have been developed as a result of the Bradford virtual ward and the Foundation Trust is exploring opportunities to invest in social care to allow the Local Authority to provide greater capacity to assess patients for care packages promptly to expedite discharge.
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