The RCP view: Hospital at Home and virtual wards

The terms ‘virtual ward’ and ‘Hospital at Home’ are often used interchangeably. In the current context, they describe coordinated healthcare for an acute health condition that can be managed in the patient’s home, which may traditionally have been managed in hospital. Virtual wards originally described preventive care for people at risk of hospital admission.

Virtual wards and Hospital at Home have been provided in some local healthcare systems in the UK for many years, and in some places for decades. There are multiple formats.

The term virtual ward refers to a specific group of patients managed at home by a clearly defined and consistent multiprofessional team working together for the patient, through the use of ‘ward routines’.

RCP supports the World Hospital at Home Congress consensus statement (2023):

‘Hospital at Home is an acute clinical service that takes staff, equipment, technologies, medication, and skills usually provided in hospitals and delivers that hospital care to selected people in their homes or in nursing homes. It substitutes for acute inpatient hospital care.

Hospital at Home IS:

• subject to regulatory and governance obligations
• care is hospital-directed by specialist physicians
• fully responsible for the patient, providing all medical, nursing and allied healthcare
• diagnostics, therapeutics and observation are delivered at home during the episode of care
• 24 hours a day, 7 days a week.

Hospital at Home is NOT:

• outpatient care (thus, not self-administered intravenous treatment, and not OPAT*)
• a hospital prevention programme
• a community-based chronic disease management programme
• solely virtual care or remote telemonitoring
• day facility-based treatment
• primary home care
• community nursing or standard skilled home healthcare.’

The increased availability of technology can provide diagnostics, monitoring and, where appropriate, remote consultation and connections between the patient and their care team. It therefore enables patients receiving Hospital at Home to be cared for on a virtual ward.

*The treatment of patients receiving Hospital at Home care might include intravenous antibiotics and this might be supported by an Outpatient Parenteral Antibiotic Therapy (OPAT) team. However, OPAT alone is not Hospital at Home.

The term ‘virtual ward bed’ is unhelpful, as it distorts thinking away from patient need. All patients have beds at home. What we can increasingly provide is clinical and personal care that enables them to stay at home during acute episodes of care. Digital technologies are helping this. There is a risk that the counting of ‘virtual ward beds’ will reduce the drive to increase the capacity of hospitals for acute care, which the population’s increasing health needs will require.

Benefits and risks of Hospital at Home and virtual wards

In England, a national programme for virtual wards incorporating Hospital at Home was established in 2022. This is led by NHS England, with clinical guidance from professional groups and aims to rapidly expand virtual wards and Hospital at Home. In Scotland, Hospital at Home services are more established and are adapting to use technology where appropriate. There is also policy to expand these. There are similar services in Wales and Northern Ireland. NHS England is investing considerably in the NHS England Virtual Ward Programme.

Many aspects of care that have traditionally been provided in hospital can be provided in the patient’s home, including:

• multiprofessional, consultant-led daily review of care
• blood and other diagnostic tests
• medication, including intravenous therapies
• oxygen therapy
• physiological monitoring throughout the day
• call and response systems for if the patient’s condition deteriorates.

These enable some acute care conditions to be managed in the patient’s home with rapid access to other specialist diagnostics, treatments and advice. They can enable whole episodes of care to be delivered in the patient’s home, or care that reduces the length of time the patient needs to be in hospital. It may be particularly appropriate for patients who are nearing the end of life.

The research that has been carried out for Hospital at Home and virtual wards can be difficult to interpret because it rarely examines a single model of care. It suggests that well-established Hospital at Home services have similar outcomes for patients as for this cohort of patients being cared for in hospital, and may cost less.1 There is clear evidence for the delivery of acute care at home for appropriate patients with chronic obstructive pulmonary disease (COPD), and for patients with heart failure.2,3 Patients often prefer to be cared for at home during acute care episodes when this is possible and safe, but they find the name ‘virtual ward’ unhelpful.4 They can be concerned that they may not have quick access to help when needed, and about the care burden placed on family members.5 Considerable further research and evaluation are needed for us to understand fully the benefits and risks of each type of care provision, and how best to provide these services.

The delivery of acute care at home, which would traditionally have been delivered in hospital, is most dependent on services having:

• the right staff with the right skills
• the capacity to manage all the patients who would benefit or require it
• the ability to deliver care 24 hours, 7 days a week
• the ability to escalate care as required.

The availability of electronic health records that can be accessed in all care settings has also enabled this care and is essential for the multiprofessional team.

Equality of access to Hospital at Home might be affected by both digital exclusion and the ability for a patient’s care needs to be met fully during an acute episode of illness.

Personal care needs and impact on families

For many patients with acute illness, particularly those who are older and frail, nursing and other personal care needs are a large part of what has been delivered in hospital. Unless these can be met consistently and in a timely way within the patient’s home every day, Hospital at Home cannot be delivered safely or consistently.

Assessment and provision of care needs within the person’s home is therefore essential for Hospital at Home. It may put additional responsibilities on informal carers, such as family members, so their needs and abilities to provide care must also be assessed.

Staffing and routines

Currently, in the NHS, the number of health and social care staff available is limiting the availability of care. This is unlikely to change quickly. Rapid expansion of Hospital at Home and virtual wards risks putting other acute services that are already short of staff under more strain.

The use of digital technologies will enable many more patients to be cared for at home during acute episodes of care. Remote consultation for some assessments reduces the frequency that staff need to travel to the patient’s home. This can also benefit environmental sustainability. Importantly, multiprofessional teams are able to work together using videoconferencing technologies to review and ensure the right care for the patient. This can create considerable efficiencies in the use of staff time and can ensure wide involvement of the right expertise for the patient.

There is, however, a risk that the emphasis on the use of new technologies will result in patients with less severe illness – those who would usually have been cared for at home – having additional monitoring, investigation and healthcare professional time that is not required or of benefit. This would also divert staff from the care of patients with greater need when staffing is already short. The potential of ‘performance’ drive for ‘numbers’ may exacerbate this risk.

While the term ‘virtual ward’ has recently been used to emphasise the use of technologies, this risks inadequate emphasis of the importance of ward routines and processes during acute episodes of care that would otherwise require hospitalisation.

Ward routines and processes that are required for acute episodes of care include:

• admission processes
• multiprofessional clinical assessment
• documentation and care planning
• risk assessments
• medicines management, including reconciliation, prescribing, monitoring and administration systems, and antibiotic stewardship
• board rounds, ward rounds and safety huddles
• patient monitoring, with the facility for appropriate escalation and response
• discharge and transfer processes.6

The ability to incorporate specialty assessments beyond the core team is also important.

Professional recommendations

The UK Hospital at Home Society 7 is a multiprofessional organisation that promotes acute hospital-level care in people’s home, in line with the World Congress on Hospital at Home consensus statement. It provides educational resources and guidance for those who work in these services and connects these professionals and policy makers. The RCP is pleased to recognise the work of the UK Hospital at Home Society and its importance for professionals working in these services. Examples of the type and acuity of care provided by Hospital at Home services is described on their website.

The British Geriatrics Society has published a position statement on virtual wards and Hospital at Home.8 They highlight the current situation with their delivery across the four nations of the UK for older people.

They note:

• that Hospital at Home services have been provided in the UK by geriatrician teams for a number of years
• that this must include comprehensive geriatric assessment for frail older people
• a substantial evidence base on the clinical effectiveness of Hospital at Home – both admission avoidance and early supported discharge models suggesting that most outcomes, including mortality, are probably at least equivalent to those of inpatient care
• greater patient satisfaction with Hospital at Home
• services will need to be locally designed as they are influenced by geography, need and workforce availability
• patient selection, consent and the right multidisciplinary team and leadership are key.

RCP Cymru Wales called for an expansion of virtual wards and Hospital at Home to provide specialist medical care.9 That report described the preventative virtual ward model for people at high risk of hospital admission, and short-term, intensive, senior clinician-led acute care at home with hospital-level diagnostics, as Hospital at Home. It gives examples of these models of care that are being delivered successfully in Wales and calls for more investment in the whole health and social care team to deliver these models of care.

The Society for Acute Medicine recognises that key elements of acute care that have been traditionally delivered in hospital can be provided in the patient’s home, supported by diagnostic interventions ‘at the bedside’.10 It states that Hospital at Home care requires the same clinical approach as acute medical care and can also facilitate early discharge in a wide range of conditions. It cautions that recruitment for virtual ward teams may reduce capacity for inpatient services, and cautions overuse of remote monitoring of patients at home.

The British Thoracic Society published guidelines on Hospital at Home for COPD in 2007. 11 This is a well-established model of care, though there are parts of the UK where it has not been fully implemented. National Institute for Health and Care Excellence (NICE) guidance recommends Hospital at Home and early supported discharge for appropriately selected people with COPD.12

The British Society for Heart Failure broadly supports the use of virtual wards for eligible patients with heart failure in units with sufficient heart failure expertise and specialist staffing, and for early supported discharge.13 It cautions that specialist care must not be diluted and must be available to deliver this care safely. There are multiple well-established services that provide this.

Training

Training healthcare professionals to deliver acute care at home is essential for today’s and tomorrow’s healthcare. Currently, there are limited training opportunities in Hospital at Home care for physicians and other members of the multiprofessional team. Resources and guidance are available from the UK Hospital at Home Society.7 Training is essential for fundamental standards of care to be delivered, and for the development of a wider workforce who can deliver this care. This will include a number of medical specialties including acute medicine, geriatrics, respiratory and cardiology. While this is recognised in a number of postgraduate curricula, a more systematic, career-long approach is required with adequate training opportunities and supervision.

The future

The current pressures in urgent and emergency services are a good stimulus to develop and expand modern and innovative models of care, but they are not a short-term ‘fix’.

Over the medium to longer term, the expansion of Hospital at Home services will help reduce the demand for hospital-based care, but it will take many years. In the meantime, the overall demand for acute care – both in hospital and at home – will continue to increase with the changes in population needs.

As we develop the evidence of how best to deliver acute care at home, increase its delivery and training, and the public develops confidence in and familiarity with these services, the terms ‘virtual wards’ and ‘Hospital at Home’ will become redundant. It will simply be recognised and accepted as part of how acute care is delivered for patients.

RCP position

The Royal College of Physicians (RCP) supports the acute care of people in their own homes using Hospital at Home models. Ward routines and processes should underpin this care. This care should be provided when:

• it is appropriate for the patient, and agreed with them
• the patient would otherwise have been in hospital
• the service can be provided over 7 days, including access to care overnight when required
• there is available and adequate care to meet the patient’s personal care needs
• there are staff with the right skills forming a multidisciplinary team that is consultant led
• there are agreed pathways of care in place to access this care, which describe the role of all health and care sectors, and rapidly access other services as required
• there is an integrated electronic care record accessible to the wider team
• clear ward-based processes are implemented
• there is close collaboration between the Hospital at Home service, acute medicine, acute services for older people, diagnostic services, and other specialty services with expertise around specific conditions, eg COPD and heart failure
• the pace of development does not destabilise other acute services
• there is a robust local clinical governance system
• services are evaluated for their effectiveness, efficiency and experience, including any unintended system effects.

Training of physicians and other healthcare professionals in Hospital at Home is essential.

References

1.  Norman G, Bennett P, Vardy ERLC. Virtual wards: A rapid evidence synthesis and implications for the care of older people. Age Ageing 2023;52:afac319 academic.oup.com/ageing/article/52/1/afac319/6974849
2.  Jeppesen E, Brurberg KG, Vist GE et al. Hospital at home for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2012;5:CD003573. pubmed.ncbi.nlm.nih.gov/22592692
3. Voudris KV, Silver MA. Home hospitalization for acute decompensated heart failure: opportunities and strategies for improved health outcome. Healthcare (Basel) 2018;6:31. pubmed.ncbi.nlm.nih.gov/29597247
4. Health Foundation. How do the public and NHS staff feel about virtual wards? 2023. www.health.org.uk/news-and-comment/charts-and-infographics/how-do-the-public-and-nhs-staff-feel-about-virtual-wards [Accessed 3 November 2023].
5. RCP Patient and Carer Network workshop on virtual wards, 2023.
6. Royal College of Physicians. Modern ward rounds. Good practice for multidisciplinary inpatient review. RCP, 2021. www.rcp.ac.uk/projects/outputs/modern-ward-rounds [Accessed 3 November 2023].
7. UK Hospital at Home Society. www.hospitalathome.org.uk/home [Accessed 3 November 2023].
8. British Geriatric Society. Bringing hospital care home: Virtual Wards and Hospital at Home for older people. BGS, 2022. www.bgs.org.uk/virtualwards [Accessed 3 November 2023].
9. Royal College of Physicians Cymru Wales. No place like home: using virtual wards and ‘hospital at home’ services to tackle the pressures on urgent and emergency care. RCP, 2022. www.rcp.ac.uk/guidelines-policy/no-place-home-using-virtual-wards-and-hospital-home-services-tackle-pressures-urgent-and-emergency [Accessed 3 November 2023].
10. Lasserson D, Cooksley T. Virtual wards: urgent care policy must follow the evidence. BMJ 2023;380:343. pubmed.ncbi.nlm.nih.gov/36801848
11. British Thoracic Society Guideline Development Group. Intermediate care – Hospital-at-Home in chronic obstructive pulmonary disease. Thorax 2007;63:200–10. https://thorax.bmj.com/content/62/3/200.long [Accessed 3 November 2023].
12. National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline [NG115], 2019. www.nice.org.uk/guidance/ng115 [Accessed 3 November 2023].
13. British Society for Heart Failure. Position Statement – Virtual wards, 2023. www.bsh.org.uk/position-statements [Accessed 3 November 2023].