Bringing hospital care home: Virtual Wards and Hospital at Home for older people
This document summarises the current landscape of Virtual Wards from the perspective of healthcare for older people, and provides advice to BGS members looking to set up such services for older people living with frailty.
In recent years, healthcare professionals have been considering new ways to respond to the acute care needs of older people with frailty and other long-term conditions. Urgent care is needed but hospitals bring risks for older people as well as benefits, and community-based alternatives are increasingly being explored. This has resulted in a shift in focus within the NHS and internationally towards providing hospital-level care in a person’s home environment.
2. About Virtual Wards
We have heard from BGS members that there is a great deal of confusion around Virtual Wards and that the term means different things in different parts of the country. This section will endeavour to provide an explanation of the terms currently in use by different healthcare providers.
Four nations context
NHS England5 have identified nine principles upon which a Virtual Ward should be built. These principles state that Virtual Wards should:
The Scottish Government has recently announced additional investment of £3.6 million with the aim of doubling Hospital at Home capacity by the end of 2022. The Scottish Government has invested £8.1 million in Hospital at Home services since 2020.6 Health Boards in Scotland are required to provide Hospital at Home services and many services have been operational for several years. BGS members in Scotland have suggested that the majority of the successful Hospital at Home services are operating in cities and urban areas. Providing Hospital at Home for Scotland’s significant rural and island population is a greater challenge. The ambition of doubling capacity by the end of 2022 may not be realistic.
Hospital at Home and Virtual Ward services have been operational in Wales for several years but are not as widespread as in other parts of the UK. There is also no central support from Government to increase the provision of hospital care closer to home. The RCP have called for additional investment in Welsh health and care services closer to home.4
Hospital at Home services have been operating in Northern Ireland for some time with the Department of Health hosting and chairing a project conducting quarterly reviews of regional activity such as patient numbers and time to assessment by Hospital at Home teams. This aims to support a common approach to language and metrics and enable the sharing of progress and good practice.
3. What is the evidence?
A recent rapid synthesis7 of existing systematic reviews identified 32 papers relating to Virtual Wards, Hospital at Home or remote monitoring as alternatives to inpatient care or admission. While these reviews were not limited to studies of people with frailty, many participants in the included primary studies were older and/or had one or more chronic conditions. The most mature evidence base to inform design of Virtual Wards is from reviews of Hospital at Home.
There is a substantial evidence base on the clinical effectiveness of Hospital at Home – both admission avoidance and early supported discharge models. Multiple Cochrane reviews exist which suggest that most outcomes, including mortality, are probably at least equivalent to those of inpatient care, while subsequent admissions to residential care may be lower. The evidence on length of stay is mixed, with some studies showing that step up models of care can increase length of stay. This is likely to indicate identification of unmet need in patients who otherwise would have received less comprehensive care, and it should not necessarily be seen as a negative. While systematic reviews of COVID-19 Hospital at Home services exist, these primarily focussed on respiratory and mortality outcomes. Because of the very specific context of COVID-19 care, these should not be conflated or combined with the broader literature on Hospital at Home for older people with frailty.
Recent evidence syntheses identified aspects of patient selection as important factors in the success of care involving remote monitoring at home, but also elements of organisational and staffing structures and provision. The review also highlighted the need for guidance on multiple aspects of service design and provision, including staff competencies and data protection. These factors are reflected in, and supported by, research on staff views of Hospital at Home, where concerns centred on unclear and underdeveloped workflows, difficulties identifying patients who would be suitable for Hospital at Home, and increased staff burden.
It is important to recognise that all studies of Hospital at Home have used clinician judgement to select patients for the service. The choice of selection criteria has not been extensively researched and further evidence will be required around this if services are to be delivered in a consistent and effective way. Hospital at Home services which were simple and easy to use, relevant to the patient, and which supported patients’ self-management were more likely to be successful. Co-development of remote interventions with patient groups was identified as a factor in success, while reviews in COVID-19 patients identified use of telephone-based interventions as more inclusive for people who lacked internet access or digital literacy.
4. Top tips for getting started
Understand your local population and geography
Be clear about the care you provide and for whom
- Drink – can they get a drink on their own, or do they have someone who can get it for them?
- Once a day – can they cope with a visit from the team only once a day?
- Toilet – can they get to the toilet on their own, or do they have someone who can help them?
If a patient meets all three of these criteria, they are more likely to be suitable for Hospital at Home care.
It is also important that patients and families are not pressured into receiving care at home if this is not their preference. BGS members tell us that when a patient is admitted to the Hospital at Home service and they or their family are not happy about this, they may call an ambulance once the team has left the house. This can be avoided through honest communication with patients and families about how the service works and what to do if the patient’s condition deteriorates. If a patient does need to be admitted to hospital after assessment by a Hospital at Home team, this may assist staff at the hospital as a Comprehensive Geriatric Assessment and diagnostics may already have been carried out.
Visit other services
Services providing hospital-level care to people in their own homes have been operating successfully for several years in parts of the country. In establishing your own service, there is no need to reinvent the wheel. You may find it helpful to make contact with colleagues elsewhere who are already delivering the type of service you are aiming for. You could visit other services to help you understand how you might want to develop your local model. The UK Hospital at Home Society (www.hospitalathome.org.uk) will be able to put you in touch with an appropriate service who would be happy to host visitors and share business cases.
Start small and learn as you go
For services struggling to start providing a Virtual Ward, it may be easier to begin with a limited service, such as providing support to enable people to be discharged from hospital earlier rather than launching a full Hospital at Home service from the outset. This will still have an impact on patient experience as patients will be able to recover in their own homes with the support of the hospital team. It will also help to relieve pressure on hospitals as beds will be freed up sooner.
NHS England guidance advises Virtual Wards to provide a service 12 hours a day (8am until 8pm), seven days a week. This may not be achievable for many services, at least to start with, and some may prefer to start with a 9am-5pm service, moving to longer hours once established. Virtual Wards do not tend to be a 24-hour service and it will be important to ensure there are clear processes for patients who require support outside of the normal hours of the service. This is likely to be through routine out-of-hours GP services or advice to contact 111 or 999 services. Treatment escalation plans and advance care planning conversations are an important aspect of Virtual Wards, to help ensure the right decisions are made if a patient deteriorates out of hours.
Build on and integrate with the services and workforce you already have
Consider the services that you already have before trying to implement something new. It may be that you have an existing rapid response service that could form the basis of a Virtual Ward or Hospital at Home service.
Workforce will be a key consideration and it will be important to understand whether a Virtual Ward can be staffed by those already in post or whether you will need to recruit to new roles. The available workforce (or funding, if new roles need to be recruited) will play a big role in determining the level of service you can offer.
The NHS is experiencing a workforce crisis and it is understandable that the workforce requirements of providing hospital-level care at home may seem daunting to those who are struggling to fill rotas in hospitals. In order for systems to provide hospital-level care at home for older people with frailty, it will be important to invest in the skillset of the community workforce and to enable senior clinicians to remain in clinical roles as they progress rather than being obliged to move into purely management positions. Advanced Clinical Practitioners (including both nurses and allied health professionals) should be included in workforce models to ensure that services have capacity at a senior decision-making level.
Many healthcare professionals are accustomed to working in relatively predictable environments such as hospitals or clinics where they have direct support and supervision from colleagues. Going into someone’s home, perhaps alone, is a different experience as one can never predict what one will find. Virtual Wards teams should be supported to develop the confidence to work in this setting. Indeed many teams benefit from clinicians with prior experience in community and primary care.
The evidence around optimal workforce for Virtual Wards is still evolving. However, NHS England have published five good practice recommendations2 for Virtual Ward workforce models:
- Appropriate clinical leadership and governance in place.
- A competency-based approach, avoiding assumptions about professional boundaries and early investment in workforce development and training.
- Integrated working across health and social care.
- Appropriate use of technology with training and supervision.
- An incremental approach to improvement and growth.
Develop good relationships
The success of providing hospital-level care at home will depend on strong relationships between services to ensure that patients receive the best care for them in the most appropriate setting. Some patients may be admitted to a Virtual Ward service and deteriorate, necessitating admission to hospital. Systems must be in place to enable this to happen quickly without hospital admission being seen as a failure by any party. Good relationships between services and with social care providers will be essential and these will take time to develop and build.
Invest in leadership and governance
Guidance from NHS England states that Virtual Wards must have appropriate clinical leadership and governance and should be clinically led by a named registered consultant practitioner. This individual can be a doctor, nurse or allied health professional and they should have knowledge and capabilities in the relevant specialty or model of care. When planning Virtual Wards it will be important to establish where the governance and accountability lies. In some areas Virtual Wards may be led by and report through the acute hospital while in other areas they may be led and governed through community services.
Explore technology-enabled care
Part of the appeal of the Virtual Ward model is the ability to monitor patients remotely using day-to-day technologies and wearables. Healthcare professionals could monitor patients and provide advice without visiting them (if no other processes of care are required in person) without the need for patients to attend a hospital or clinic.
However, in contrast to the evidence for remote monitoring of chronic conditions, evidence on how best to implement remote monitoring for acutely ill patients at home or in care homes is currently lacking. It may be that the use of technology in Virtual Wards is greater among younger patients with acute respiratory illness. Many BGS members who have delivered hospital-level care at home for some years have told us that the use of remote monitoring for older people with frailty and other complex conditions is limited. While patients may be issued with a pulse oximeter or asked to monitor their weight, other remote monitoring devices are not routinely used in this population.
It is important to ensure that older people with frailty who may not be confident using technology are not excluded from using technology likely to be beneficial to their care. While many patients on a Virtual Ward may have help from family or formal carers, some will not, and it is important that this group is not excluded. Ideally, equipment should be simple enough for patients to use independently, without the help of healthcare professionals, family members or carers. Consideration should also be given to those with cognitive, hearing or visual impairments and tools should be developed with this group in mind.
Clarity on what technology is available and for what purpose will be essential if services are to be successful. It is also important to ensure services have ongoing funding for this equipment and that the supply is stable.
† The DOT acronym was created by Dr Patricia Cantley and is reproduced here with her consent.
The BGS welcomes the focus across the UK on providing hospital-level care for older people at home. We know that many BGS members have been providing these services for years with good outcomes. We also know that many patients speak very highly of the care they have received in these services and are very grateful to have been able to stay at home rather than be admitted to hospital. Sustained increased funding for older people’s care closer to home can only be a good thing.
- British Geriatrics Society (2021). Right time, right place: Urgent community-based care for older people. Available at: www.bgs.org.uk/righttimerightplace (accessed 6 July 2022)
- NHS England (2022). Enablers for success: virtual wards including hospital at home: Supporting information for ICS leads. Available at: www.england.nhs.uk/publication/enablers-for-success-virtual-wards (accessed 17 June 2022)
- UK Hospital at Home Society (2022). What is Hospital at Home? Available at: www.hospitalathome.org.uk/whatis (accessed 6 July 2022)
- Royal College of Physicians Wales (2022). No place like home: Using virtual wards and ‘hospital at home’ services to tackle the pressures on urgent and emergency care. Available at: www.rcplondon.ac.uk/news/rcp-cymru-wales-calls-investment-hospital-home-services-and-social-care-keep-patients-home (accessed 16 June 2022)
- NHS England (2022). Virtual ward including Hospital at Home: Supporting information. Available at: www.england.nhs.uk/wp-content/uploads/2021/12/B1478-supporting-guidance-virtual-ward-including-hospital-at-home-march-2022-update.pdf (accessed 17 June 2022)
- Scottish Government (2022). Hospital at Home. Available at: www.gov.scot/news/hospital-at-home-1 (accessed 16 June 2022)
- Norman, G, Bennett, P, Vardy, E (2022). Virtual wards: A rapid evidence synthesis and implications for the care of older people. (preprint) https://doi.org/10.1101/2022.06.24.22276864
- British Geriatrics Society (2021). Timely Discharge Blog Series. Available at: www.bgs.org.uk/timelydischarge (accessed 4 August 2022)
- Dr Firdaus Adenwalla, Consultant Geriatrician, Abertawe Bro Morgannwg Health Board
- Dr Michael Azad, Chair, England Council, BGS; Consultant Geriatrician, Nottingham University Hospitals NHS Trust
- Dr Clare Bostock, Consultant Geriatrician, NHS Grampian
- Dr Eileen Burns, National Specialty Adviser for Older People and Integrated Person-Centred Care, NHS England & Improvement; Consultant Geriatrician, Leeds Teaching Hospitals NHS Trust
- Dr Jennifer Burns, President, BGS; Consultant Geriatrician, Glasgow Royal Infirmary
- Dr Patricia Cantley, Consultant Geriatrician, NHS Borders
- Dr Esther Clift, Chair, Nurse and AHP Council, BGS; Professional Adviser, NHS England & Improvement; Consultant Practitioner in Frailty, Southern Health NHS Foundation Trust
- Rob Coster, Delivery and Policy Lead, Community Transformation (Virtual Wards), NHS England & Improvement
- Maria Espasandin, Nurse Consultant for Older People, Frimley Park Hospital
- Professor Adam Gordon, President Elect, BGS; Professor of Care of Older People, University of Nottingham; Consultant Geriatrician, University Hospitals of Derby and Burton NHS Foundation Trust
- Sally Greenbrook, Policy Manager, BGS
- Professor Anne Hendry, Honorary Secretary, BGS; Honorary Professor, University of the West of Scotland
- Professor Dan Lasserson, President, UK Hospital at Home Society; Professor of Acute Ambulatory Care, University of Warwick; Clinical Lead, Acute Hospital at Home, Oxford University Hospitals NHS Foundation Trust
- Sarah Mistry, Chief Executive, BGS
- Dr Gill Norman, Research Fellow, NIHR Applied Research Collaboration Greater Manchester, University
- Dr Natalie Offord, Consultant Geriatrician, Chesterfield Royal Hospital NHS Foundation Trust
- Dr Shelagh O’Riordan, Professional Adviser, NHS England and Improvement; Consultant Community Geriatrician, Kent Community Trust
- Dr Jan Ritchie, Consultant Geriatrician, Belfast Health and Social Care Trust
- Dr Mark Roberts, Consultant Geriatrician, Southern Health and Social Care Trust
- Jane Sproat, Assistant Director, Digital Community Health Services, NHS England and Improvement
- Professor Emma Vardy, Consultant Geriatrician, Salford Care Organisation, Northern Care Alliance NHS Foundation Trust; Honorary Clinical Chair, School of Health Sciences and NIHR Applied Research Collaboration Greater Manchester, University of Manchester