Earlier this autumn, I had the opportunity to visit the Hospital2Home virtual ward project in New York. Like other virtual wards, this project aims to reduce the risk of unplanned hospital admission for people at high predicted risk of admission.
I was particularly interested to visit this project because it has strong partnerships with health care, social care and charitable organisations, and it cares for some of the most vulnerable people in the city.
The New York State Government uses a computerised algorithm similar to the PARR algorithm to identify Medicaid patients who are at high risk of a future hospital admission. A mandate is in place to provide these individuals with intensive care management aimed at improving their health and social care outcomes and reducing overall Medicaid expenditure.
The people identified by the predictive algorithm typically have complex health and social care needs. A high proportion may be abusing substances, have mental health problems, and are homeless, in temporary accommodation or staying with a succession of acquaintances.
Clients are asked to consent for Hospital2Home to communicate with other agencies including social care and charitable organisations, which is important given that so many different agencies may be involved in their care
Such unstable housing arrangements mean that clients often find it difficult to use primary care services. But it can also make it difficult for health care staff to contact clients.
To address these problems, clients are supplied with a very basic mobile phone for contacting services. This encourages – indeed empowers – clients to take more control of their lives. I found it positive to note that the vast majority of clients did not abuse this privilege.
Once a person has been identified by the algorithm and has agreed to participate in the Hospital2Home programme, they complete an incredibly detailed assessment. Much of this involves self-assessment, and the primary purpose is to establish the client’s goals.
The Hospital2Home team see it as their role to work on achieving these ambitions. Clients are asked to consent for Hospital2Home staff to communicate with other agencies including social care and charitable organisations, which is important given that so many different agencies may be involved in the care of any one client.
I was interested to learn that, unlike in the UK, the care managers in New York did not necessarily come from health or social care backgrounds. Instead, the main recruitment criterion was that case managers be highly experienced in working with vulnerable clients similar to those in the population identified.
The care managers are employed by Bellevue hospital and they share an office. This co-location seemed to support regular communication when the care managers meet each morning. Each care manager has a maximum caseload of 25 clients, with additional direct support for clients being provided by a social work supervisor and a primary care physician.
This project is currently being evaluated and the findings should be available towards the end of 2012, but what lessons have been learned so far which might be of benefit to the virtual ward scheme in the UK?
- A key advocate in a senior position is required at every organisation with which clients may come into contact: soup kitchens, shelters, probation services, criminal justice system, human resource agencies etc.
- The degree to which mental health, and in particular personality disorder, are present among patients was under-estimated at the start of the project, as was the extent to which these factors can complicate treatment,
- An information governance structure was required to enable inter-organisational sharing of information.
- Staff benefit from mental health support.
- More access to pharmacy is required.
My lasting memory, however, is how much I was touched by the empathy, warmth and kindness shown by the team to their clients. Simple gestures such as sending a birthday card or bereavement card helps the clients to see that someone does really care about them.
The Nuffield Trust is evaluating virtual wards in four sites in the UK. For further information, visit our dedicated project page or contact Geraint Lewis or Lorraine Wright. You can also sign up for updates on the Nuffield Trust’s work in this area (select the 'integrated care' and 'evaluation' options).
This project was funded by the National Institute for Health Research Service Delivery and Organisation (NIHR SDO) programme (project number 09/1816/1021).
Department of Health disclaimer: 'The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the SDO programme, NIHR, NHS or the Department of Health.'
Wright L (2011) ‘A virtual ward for some of the most vulnerable residents of New York’. Nuffield Trust comment, 9 December 2011. https://www.nuffieldtrust.org.uk/news-item/a-virtual-ward-for-some-of-the-most-vulnerable-residents-of-new-york