Dr Natasha Bradley, Research Fellow in Realist Evaluation, Centre for Health & Clinical Research
Background
Virtual wards (VWs) rounds deliver multidisciplinary care to people with fluctuating health conditions such as frailty, within their own homes or usual place of residence. The aim can be to prevent hospital admission and to support self-management. Existing evidence showed there were different types of VWs in operation in the UK, and that results appeared inconsistent.
We used realist methods to provide complementary evidence to existing systematic reviews and randomised controlled trials, by shedding light on the different contexts and mechanisms that enable VWs to work effectively.
This project investigated how and why VWs could work for people with frailty. We carried out a type of literature review called a rapid realist review, asking ‘what works for whom, under what circumstances, how and why?’.
Aims
First, we aimed to summarise the different types of VWs for people with frailty. Second, we considered how and why VWs might work by exploring interactions between the context, mechanisms, and outcomes. The knowledge gained in this process could then be applied to help VWs work more effectively.
Methods
Literature synthesis
We searched for academic publications and other online sources of information (‘grey lit’) to gather evidence on VWs for frailty in the UK and ROI. In total, 28 documents were included. We began to extract causal insights and bring them together, informed by rapid realist review methods. In this case, we initially worked with ‘if-then-because’ statements and then gradually synthesized into preliminary context-mechanism-outcome configurations.
Patient and public involvement
To assist us in this process, we had input from people who had lived experience of frailty.
We met with public contributors on two occasions: two people on 28th February 2022, and five people on 15th June 2022. In each meeting, we presented what we thought were important aspects of VWs and invited their discussion. The first conversation helped to refine our initial ideas and the second conversation gave feedback on our findings from the literature synthesis. Alongside these meetings, we also met several times with three clinicians who were experts in frailty VWs.
Findings
Two main types of frailty Virtual Ward models were identified: longer-term proactive care to prevent a frailty crisis and short-term acute care for those in-crisis, both intended to reduce acute hospital admissions. Current NHS England policy is directed towards short-term VWs, but longer-term VWs may also be beneficial within a whole system approach to frailty.
Minimum requirements for VWs are common standards agreements, information sharing processes, and an appropriate multidisciplinary team that is able to meet regularly. Pertinent mechanisms include the motivation and capability of the different stakeholders to work together, so that VWs can function as a forum for the integration of care and timely multidisciplinary decision-making.
The patient pathway involves their selection into the VW, comprehensive assessment including medication review, integrated case management, and in some cases proactive or anticipatory care. Important components for patients and caregivers are their communication with the VW and their experience of being at home instead of hospital.
We developed evidence-based theories for how and why different parts of frailty VWs may be important for implementation, for the patient pathway, and for patient and caregiver experience. Our review indicates that existing work has overlooked the potential impact of transfers of care on entering and leaving the VW, and the caregiver’s role in the VW intervention.
Next Steps
The rapid realist review is now complete. Our findings help to explain how and why the contexts of the local healthcare system, the VW team, and the patient are influential to the effectiveness of VWs. A manuscript is under preparation for the peer-reviewed journal ‘Age & Aging’ and we will be submitting our evidence to NHS England for their guidance on VWs for people with frailty.
Innovations in service design for people with frailty remains high-profile in 2023. The insights gained from this review could inform implementation or evaluation of VWs for frailty. A combination of acute and longer-term VWs may be required within a whole system approach. We will be submitting our evidence to NHS England, so that it can have an impact on their guidance for VWs.
See more: Can virtual wards help treat people with frailty in their own homes and avoid them going to hospital? A rapid realist review – ARC West (nihr.ac.uk)
