Health care professionals' perceptions of a community based 'virtual ward' medicines management service: A qualitative study

Virtual wards for people with frailty: what works, for whom, how and why-a rapid realist review

BACKGROUND

Virtual wards (VWs) deliver multidisciplinary care at home to people with frailty who are at high risk of a crisis or in crisis, aiming to mitigate the risk of acute hospital admission. Different VW models exist, and evidence of effectiveness is inconsistent.

AIM

We conducted a rapid realist review to identify different VW models and to develop explanations for how and why VWs could deliver effective frailty management.

METHODS

We searched published and grey literature to identify evidence on multidisciplinary VWs. Information on how and why VWs might 'work' was extracted and synthesised into context-mechanism-outcome configurations with input from clinicians and patient/public contributors.

RESULTS

We included 17 peer-reviewed and 11 grey literature documents. VWs could be short-term and acute (1-21 days), or longer-term and preventative (typically 3-7 months). Effective VW operation requires common standards agreements, information sharing processes, an appropriate multidisciplinary team that plans patient care remotely, and good co-ordination. VWs may enable delivery of frailty interventions through appropriate selection of patients, comprehensive assessment including medication review, integrated case management and proactive care. Important components for patients and caregivers are good communication with the VW, their experience of care at home, and feeling involved, safe and empowered to manage their condition.

CONCLUSIONS

Insights gained from this review could inform implementation or evaluation of VWs for frailty. A combination of acute and longer-term VWs may be needed within a whole system approach. Proactive care is recommended to avoid frailty-related crises.

Length of stay and economic sustainability of virtual ward care in a medium-sized hospital of the UK: a retrospective longitudinal study

OBJECTIVE

To evaluate the length of stay difference and its economic implications between hospital patients and virtual ward patients.

DESIGN

Retrospective longitudinal study.

SETTING

Wrightington, Wigan and Leigh (WWL) Teaching Hospitals, National Health Service (NHS) Foundation Trust, a medium-sized NHS trust in the north-west of England.

PARTICIPANTS

Virtual ward patients (n=318) were matched 1:1 to 1:4, depending on matching characteristics, to all hospital patients (n=350). All patients were admitted to the hospital during the calendar year 2022.

OUTCOME MEASURES

The primary outcome is the length of stay as defined from the date of hospital admission to the date of discharge or death (hospital patients) and from the date of hospital admission to the date of admission in a virtual ward (virtual ward patients). The secondary outcome is the cost of a hospital bed day and the equivalent value of virtual ward savings in hospital bed days. Additional measures were 6-month readmission rates and survival rates at the follow-up date of 30 April 2023.

RISK FACTORS

Age, sex, comorbidities and the clinical frailty score (CFS) were used to evaluate the importance and effect of these factors on the main and secondary outcomes.

METHODS

Statistical analyses included logistic and binomial mixed models for the length of stay in the hospital and readmission rate outcomes, as well as a Cox proportional hazard model for the survival of the patients.

RESULTS

The virtual ward patients had a shorter stay in the hospital before being admitted to the virtual ward (2.89 days, 95% CI 2.1 to 3.9 days). Chronic kidney disease (CKD) and frailty were associated with a longer length of stay in the hospital (58%, 95% CI 22% to 100%) compared with patients without CKD, and 14% (95% CI 8% to 21%) compared with patients with one unit lower CFS. The frailty score was also associated with a higher rate of readmission within 6 months and lower survival. Being admitted to the virtual ward slightly improved survival, although when readmitted, survival deteriorated rapidly. The cost of a 24-hour period in a general hospital bed is £536. The cost of a day hospital saved by a virtual ward was £935.

CONCLUSION

The use of a 40-bed virtual ward was clinically effective in terms of survival for patients not needing readmission and allowed for the freeing of three hospital beds per day. However, the cost for each day freed from hospital stay was three-quarters larger than the one for a single-day hospital bed. This raises concerns about the deployment of large-scale virtual wards without the existence of policies and plans for their cost-effective management.

Interprofessional collaboration in a community virtual ward: A focus group study

BACKGROUND

The problem of a lack of nurses is expected to worsen in the future. With an ever-increasing number of elderly patients with multimorbidity and a shortage of healthcare professionals, primary care must innovatively organise their services to offer more sustainable healthcare services. Organising healthcare services in a community virtual ward has been found to improve the quality of life for vulnerable elderly populations.

AIM

The aim of the study was to explore healthcare professionals' experiences of interprofessional collaboration in care for patients with multimorbidity in a community virtual ward in the Norwegian context.

METHODS

Focus group interviews were conducted in this qualitative exploratory study. A purposive sample of 17 healthcare professionals working in a community virtual ward in Norway was interviewed. Data were analysed using thematic analysis.

RESULTS

The study results show that healthcare professionals recognise a need for patient involvement in the community virtual ward to offer more sustainable healthcare services at home. Furthermore, the results show how healthcare professionals experience the use of assessment tools and whiteboard meetings as useful tools for facilitating interprofessional collaboration. The study results also describe how interprofessional and holistic follow-up with patients with multimorbidity contributes to increased focus on health promotion in the community virtual ward.

CONCLUSION

We found that interprofessional collaboration in community virtual wards may be a sustainable way of organising healthcare services for patients with multimorbidity living at home. Interprofessional collaboration with a patient-centred and health promotion approach, seems to increase the quality of the follow-up for patients with multimorbidity living at home. Additionally, mutual interprofessional trust and respect seems to be essential for making use of the unique expertise of different professions in the follow-up for patients with multimorbidity. In the future, both the patient's voice and opinion of their next of kin should be considered in the development of more sustainable homecare services.

Access to cancer medication in public hospitals in a middle-income country: The view of stakeholder

BACKGROUND

Access to cancer medicines is a core component of comprehensive cancer care; as such, it is included in Mexico's public health insurance: Seguro Popular de Salud (SPS). Learning about stakeholders' experiences on processes and barriers influencing access to essential cancer medicines within healthcare facilities allows identifying needed policies to improve access to cancer care.

OBJECTIVE

The aim of this study was to obtain the insights of health professionals in public hospitals in Mexico on how SPS influences access to cancer medicines regarding medicine selection, financing, and procurement and supply systems. The purpose is to identify policy areas that need strengthening to improve access to cancer medicines.

METHODS

Semi-structured interviews were conducted with 67 health professionals from 21 public hospitals accredited by SPS across Mexico. A framework analysis was used with categories of analysis derived from the World Health Organization's Access framework.

RESULTS

Most stakeholders reported that the availability of listed cancer medicines was sufficient. However, cancer specialists reported that medicines coverage by SPS was restrictive covering only basic cancer care. Public hospitals followed SPS treatment protocols in selecting and prescribing cancer medicines but used different procurement procedures. When essential cancer medicines were unavailable (not listed or stocked-out), hospitals reported several strategies such as prescribing alternative therapies, resorting to direct purchases, and assisting patients in obtaining medicines elsewhere. Other reported barriers to access to treatment were: distance to health facilities, poor insurance coverage, and financial restrictions.

CONCLUSIONS

Health professionals have encountered benefits and challenges from the implementation of SPS influencing access to cancer medicines and care in Mexico, pointing to areas in which action is necessary. Finding the right balance between expanding the range and cost of cancer treatments covered by insurance and making basic cancer care available to all is a challenge faced by Mexico and other middle-income countries.