Aberdeenshire’s virtual community wards

Hospital admissions reduce as multi-disciplinary teams collaborate to enable more patients able to stay at home

Thursday 30th May 2019

A new model of care in Aberdeenshire is offering an alternative to admitting vulnerable, predominately older, people to hospital.

Virtual community wards (VCWs) see a multi-disciplinary team organised around GP practices identify at risk people and provide them with the tailored support they need to stay at home.

A daily ten-minute ‘huddle’ brings together the GP, community nurse, care manager and occupational therapist where “anybody within that team can bring somebody you want to discuss,” says Iain Ramsay, a partnership manager at Aberdeenshire health & social care partnership.

Since starting in 2016, more than 4,500 people have been admitted and discharged from a virtual ward, avoiding 1,600 hospital admissions.

Staff say the more collaborative way of working avoids lengthy referral processes and helps them understand each other’s roles.

Speaking at the NHS Scotland 2019 event, Mr Ramsay explained: “We always felt there was a gap there in terms of people who had acute episodes getting resources and people around them quickly.”

A key aspect of the project’s success is the partnership’s homecare responder team that can step in to provide additional support at short notice, adds his colleague Kimberley Menzies, who manages two VCWs in Ellon and Pitmedden.

Personal and nursing care are the most common responses for people admitted to the virtual wards receive – it’s “not a medicalised model, we just want to support people whatever their need is,” Mr Ramsay adds.  

In one example, a carer notices an older lady is confused and reporting this to their care manager, who raises it at the daily huddle, leads them to discover she has an infection.

As a result, Mrs Smith is prescribed antibiotics by her GP and receives additional home care visits to check she is taking her medication at the correct time, rather than being admitted to hospital

Meanwhile, the homecare responder team is alerted to the change in needs, should extra overnight support be needed.

While it’s “taken a bit of time” for families to get used to the different way of thinking, communities are becoming more aware of the model and say they want to be at home.

The vast majority of patients stay in the virtual ward for five days or fewer – with a “clear focus not only on people being admitted and discharged, but discharged with the right package of support.”