Lessons learned from Toronto's virtual ward

I recently had the opportunity to visit the Toronto virtual ward as part of my Management Fellowship role working with researchers at the Nuffield Trust who are evaluating the costs and benefits of the virtual wards in Croydon, Devon and Wandsworth.

The virtual wards work just like hospital wards, using the same staffing, systems and daily routines, except that the people being cared for stay in their own homes throughout.

The purpose of my visit was to understand the model deployed in Toronto and to consider any useful lessons for the UK – particularly in relation to any QIPP benefits.

The issues to be addressed in Toronto, the provincial capital of Ontario, were:

• Most ‘acute illnesses’ are actually exacerbations of chronic disease, so patients do not leave hospital in a state of perfect health;
• Hospital admissions have become shorter – patients are sicker at discharge;
• There has been a reduction in the intensity of care following discharge from hospital;
• Readmissions are common with 10-25% of patients readmitted within 30 days;
• Unplanned readmissions cost about $700 million per year in Ontario.

The virtual ward is a collaborative project between several Toronto hospitals and the community care provider. Most of the staff are employed by the community care provider. The hospital provides space and infrastructure support, along with a part-time nurse. Unlike most doctors in Canada, the virtual ward doctors are paid a daily per diem.

I observed the 8.30-9.30 am daily ward round with the core team on each day of my visit, with members of the wider multidisciplinary team also attending on certain days of the week. The focus of the ward round was on sharing information between members of the team regarding each patient’s current position, issues, a plan for action, and a review date.

The thing that struck me most about this virtual ward was the level of collaboration and communication that takes place – both within the virtual ward and across all the organisations and professionals involved in patients’ care. So much so that it was possible on one occasion to see the safety net preventing a tricky situation becoming a crisis. This was integrated care in action.

Patients are encouraged to contact the virtual ward if they are worried – support, reassurance, a visit or an appointment with the doctor can be arranged relatively quickly with the aim of dealing with any emerging problems to prevent a crisis.

Hospital admissions for exacerbations often result in changes to a patient’s medications or new prescriptions. The potential for medication errors following these changes is high, and the role of the pharmacist was crucial in educating the patient around the changes made.

I was particularly interested to learn that the case managers could be a nurse, social worker, physiotherapist or an occupational therapist; however they all received the same training to be case managers.

Most of the case managers that I met had a social work background – I wondered how much this influenced the way they approached their work. What I observed was an approach that focussed on patient concerns, for example getting better, bathing, falling, getting to the shops, and the ability to get a meal. This was less clinical than I had expected.

At the first post-discharge home visit, the case manager completes a mandated assessment process called the Resident Assessment Instrument (RAI). A care and support package is then developed, addressing the needs according to the patients’ identified goals and priorities.

My overall impressions of this virtual ward were that it is well structured with clear processes for communication and collaboration across health and social care. From the patient’s perspective, this constituted a seamless service.

A randomised control trial of this virtual ward is being conducted and will be completed by 2013, and it is at that stage we will learn what effect, if any, the virtual ward has had on reducing unplanned hospital admissions within 30 days of discharge.

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.'