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Services transform to improve care in the community and help reduce hospital admissions for frail individuals

By 22nd July 2020 No Comments

A new service has been introduced in North Somerset to enable frail people to be supported in the comfort of their own homes, away from hospital.

In response to challenges posed by coronavirus, clinicians and key workers from all relevant aspects of health and social care have come together to implement the Integrated Acute Frailty Virtual Ward Round.

The new multi-agency initiative gives the opportunity on any weekday for GPs to refer frail individuals to a team of experts who will be able to assess their care needs away from hospital on the same day.

The outcome is a bespoke care plan for each person to support GPs or community teams to care for the individual in their own home, and in so doing improving patient care and reducing the need for people to be admitted to hospital.

The service has been operating since June, and supported 13 people in its first week in operation.

Dr Martin Jones, local GP and Medical Director for Bristol, North Somerset & South Gloucestershire CCG, said:

“This is a really positive initiative for an area that contains a high number of care homes and frail people, enabling them to continue to be cared for in their home environment where they have better long-term outcomes.

“We know that we cannot avoid all hospital admissions. However, through the virtual ward round we can enable a planned approach of care, where people will have a shortened length of stay and clear pathway out of hospital when medically well.”

Dr Holly Paris, GP for Pier Health Group, said:

“For the GP or community clinician utilising this service, being part of the Virtual Ward Round is a real privilege. It offers advice and guidance that’s not only extremely responsive, but invites you as a practitioner to be part of that multidisciplinary discussion and decision making.

“A key part of the virtual ward round is the involvement of social care, as so much of a person’s management plan hinges on their circumstances and this knowledge is not otherwise readily available. For me, I’ve also learned most from the approach of my mental health colleagues in managing dementia crises which has an impact on my day to day practice. It’s such a rich learning environment.”

Teresa Candfield, Associate Locality Director with Sirona care & health said: “We are delighted to be involved in the newly launched Integrated Acute Frailty Virtual Ward Round.

“Our community based services are crucial to helping reduce avoidable hospital admissions. The Virtual Ward Round consists of highly skilled multi-disciplinary professionals and is supporting our clinicians to help more service users receive the right care and support; it is also proving to be a useful sharing of information and learning environment for those involved. The service is already having a positive impact for service users and clinicians alike who are benefitting from enhanced joint decision making through the personalised care plans.

“We are looking forward to continuing to work with our system health and care partners and seeing how it evolves over the coming months.”

Dr Rachael Morris, clinical lead for the Geriatric Emergency Medicine Service (GEMS) at Weston General Hospital, part of University Hospitals Bristol and Weston NHS Foundation Trust said:

“It’s very exciting to be part of this innovative approach. Virtual ward rounds are a great example of health professionals across the NHS working together for the benefit of our patients. Older persons living with frailty have complex needs and it’s a privilege to care for them.

“It is well known that a holistic approach, considering health, psychological and social care needs offers the very best outcomes for older persons living with frailty and this is exactly the approach the virtual ward rounds take when delivering care. In addition, the specialist input from the GEMS team at Weston General Hospital also supports GPs and helps develop their knowledge caring for this group too.

“Of course we are still here if people need us, as being part of the virtual ward round provides a direct admission route to the GEMS unit at Weston, thereby avoiding the need to come through A&E.”

The service has been set up by, Pier Health Group, Avon and Wiltshire Mental Health Partnership, Sirona care & health, University Hospitals Bristol and Weston, North Somerset Council and Bristol, North Somerset and South Gloucestershire CCG.