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Virtual Care

Virtual Care

Insight: long-term conditions
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Dr David Hegarty
Chairman – Dudley Clinical Commissioning Group

 

We are seeing an increase in people with long-term conditions (LTCs) in the UK – some as a result of lifestyle choices; others are simply due to age. Irrespective of the cause, they represent a pressure the NHS has to address.

The management of LTC and preventing admissions into secondary care are a priority for emerging clinical commissioning groups (CCGs).

Dr David Hegarty
Chairman – Dudley Clinical Commissioning Group

 

We are seeing an increase in people with long-term conditions (LTCs) in the UK – some as a result of lifestyle choices; others are simply due to age. Irrespective of the cause, they represent a pressure the NHS has to address.

The management of LTC and preventing admissions into secondary care are a priority for emerging clinical commissioning groups (CCGs).

Here at Dudley CCG, we are committed to facing this challenge head on. Through the introduction of a 'Virtual Ward', we are focusing on a whole system change to improve patient care and reduce costs to the whole health economy.

Jointly with our NHS provider and social care colleagues, we recognised a need for a shift in focus from acute care to self-care, particularly for patients with LTCs.

With 5% of inpatients accounting for 42% of acute admissions – most of which are related to LTC care – we knew we could provide more clinical and cost-effective care for the majority of these patients in the community.(1) We also recognised that by focusing our efforts on some of the most vulnerable patients in the community, we could prevent unnecessary hospital admissions.

Virtual Wards use risk stratification to identify patients at risk of admission to secondary care. The concept began its development in Croydon, London in May 2006.2 Many commissioners have since turned to 'predictive risk modelling' in order to identify their most at-risk patients.

A Virtual Ward is modelled on a hospital ward with a fixed number of beds. Patients are admitted to and discharged from such beds as they would be in hospital. The model is known as a Virtual Ward because a patient receives care while remaining in their own home rather than being in a physical hospital bed.
We used elements from the Croydon Virtual Ward project and applied them to a Virtual Ward pilot site.

The predictive modelling tool uses sophisticated algorithms and data from secondary care providers. Data are also extracted from GP practice systems to predict the patients who are likely to consume the most secondary care resource in the following 12 months. The algorithm reviews patterns of care, LTC diagnosis, prescribing and demographic data to generate a risk score. The higher the score, the greater the likely future use of the health environment.

We use the list of high-risk patients generated by the tool to initiate clinical conversations between members of the multidisciplinary Virtual Ward team to ensure the highest risk patients who are most likely to benefit from the Virtual Ward style of intervention are selected for a place on the ward.

Dudley CCG ran a pilot of the Virtual Ward from September 2009 to August 2010. The aims were to co-ordinate and optimise the social, medical and psychological health of our patients in the community with a particular focus on the management of their LTCs. 

We found that signing up to monthly data submissions through the BUPA risk stratification tool was essential to the success of the project.

Forty-eight out of 54 practices within the Dudley Borough were signed up by the start of the project go-live in December 2010. Throughout the pilot, we reviewed Virtual Ward patients who were admitted into secondary care daily in order to facilitate an early appropriate discharge back into the community. 

As patients' care was optimised and stabilised, we discharged them from the care of the Virtual Ward to the most appropriate available ongoing management.

The pilot demonstrated a sustained reduction in both emergency secondary care admissions and excess bed days. Patients had shown a decrease of 35.48% in non-elective hospital admissions. We also saw 30% fewer home visits.
Although the pilot numbers were small, Dudley CCG felt this model proved itself for potential use across the whole of Dudley by the health economy, and we made the decision to rapidly roll out the Virtual Ward.

As the pilot drew to a close, the Dudley Urgent Care Programme Board recognised the need to address the approaching winter pressures. While there was merit in expanding the size and demography of the pilot, Dudley CCG had a vision for delivering a patient-centred service and seized upon an opportunity to deliver an innovative and personalised care pathway for individuals. 

We chose to take the high-risk/reward option in pursuit of maximum improvement and we rolled out the project across the borough. 

Dudley Virtual Ward integrates health and social care services as well as secondary care, the voluntary sector and patients themselves in the care pathway. We recognised early on that effective partnership working was the most proactive way to increase focus on delivery. We agreed clear objectives with our partners from the outset, with built-in flexibility for the necessary compromises that partnering brings with it. 
The roll-out was a considerable success for our CCG. We moved from inception to the roll-out of eight wards in the space of four months.

During this time we also implemented a complete service redesign. This comprised of a whole system analysis to map the Dudley health economy and identify demand, capacity and patient flow of high-risk patients. 

The eight wards each cover an identified group of practices with an identified caseload size. Based on a ward size of 200 patients, the top 150 eligible risk stratified patients per ward are automatically admitted after initial screening, with the remaining 50 patients having been identified at some point by the risk stratification tool and clinical ward round acknowledging a clinical need.

A large proportion of community health nurses have now taken on the role of Virtual Ward nurse, enabling the preventative work they carry out to continue with those who are identified as being of the highest risk.

Our Virtual Ward ethos is to put the patient at the 
centre of care delivery, regardless of their location. If a patient is high-risk and a resident in a nursing home, the team will still identify what measures can be put in place to mitigate that risk.

Calculating savings-related admission reduction requires a number of assumptions and accurate base lining to be carried out. If we assume costs will increase comparably to the increase seen in the previous year, the admission profile will be similar in the future.

For example, in Dudley 10.5% of the annual admission patient cost relates to short-stay admissions, while 27.6% of total admissions relate to short-stay admissions.

"In the last four months my life has got better, and although I have been poorly it could have been a lot worse," said one patient of the Virtual Ward. "It also made me feel like a person and not a number. I made a phone call on one day and they were here the next day talking to me and discussing what was best for me."

Although not an initial measure, the wards were at 75% capacity within six months of the start of the project.
It had long been acknowledged within Dudley that not every practice had been able to utilise their case manager effectively.

However, the new design means that each practice can now access a proactive multidisciplinary team of nurses focused on optimising the quality and effectiveness of patient care and preventing unnecessary admissions.

We believe this innovative service has shown promising indications that a change in the method of case management for complex conditions can reduce secondary-care usage.
We have seen a reduction in excess bed days and, through improved proactive management of these patients, we are expecting to see an ongoing reduction in unscheduled admissions. 

We are working with partners including the acute trusts, the ambulance service and other unscheduled care providers to enable our case managers to intervene and avoid admission or facilitate rapid discharge.

Dudley CCG set CQUIN (Commissioning for Quality and Innovation) targets of admission reduction targets of 20% for long-stay admissions and 30% reduction on short-stay for Virtual Ward patients. Although it is still early to give an accurate representation of performance, the potential financial savings, along with the host of associated benefits, make this a worthwhile proposition and others should consider exploring this further.

Initial data – Virtual Ward potential savings targets
Predicted costs of patients as at July 2011:
Cost of top 1,600 risk score patients (most complex conditions): £9,819,451
Cost for patients above risk score of 6 (likely to be easier to affect): £5,504,758
Results from pilot:
Reduction in non-elective long-stay admissions: 30%
Reduction in non-elective short-stay admissions: 45%

References
1. Department of Health. Supporting People with Long Term Conditions. London: DH; 2007. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
2. Lewis G et al. Do 'virtual wards' reduce rates of unplanned hospital admissions, and at what cost? A research protocol using propensity matched controls. Int J Integr Care 2011. Published online. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178802/

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