Frailty virtual ward service

Key information

Your clinical team can be contacted 24 hours a day, 7 days a week on 0333 405 3000.

Go to your nearest A&E immediately or call 999 if:

  • You’re so breathless that you’re unable to say short sentences when resting
  • Your breathing has suddenly got worse
  • You cough up blood
  • You feel cold and sweaty with pale or blotchy skin
  • You develop a rash that looks like small bruises or bleeding under the skin and does not fade when you roll a glass over it
  • You cough up blood and/or develop acute bleeding
  • You have sudden chest pain
  • You’ve had a fall with significant head injury
  • You experience profuse vomiting and/or severe abdominal pain
  • You suddenly become very drowsy

Good signs and readings that show you are improving:

  • Gradual improvement
  • Fully mobile, able to manage stairs (if this is normal for you)
  • Not confused
  • Normal eating and drinking
  • Observation readings are within normal ranges for you (as agreed with your nurse/doctor)
  • Improvement in mobility

We welcome your feedback

If you have any questions, feedback, compliments, concerns, or complaints about Virtual Hospital, you can contact the Patient Advice and Liaison Service (PALS) on 0300 131 1000 or you can email CCS-TR.PALS@nhs.net

We will also send you a short survey to fill out at the end of your treatment. Please fill this out and let us know what went well with your experience, and what could be improved to make Virtual Hospital the best it can be.

What is a virtual ward?

A Virtual Ward, also known as Hospital at Home, is a service designed to provide NHS care in the comfort of your own home, for up to 14 days. The primary aim of this service is to support acutely unwell patients over the age of 65 years living with frailty, providing care in their own home as an alternative to hospital admission.

We know that being in familiar and comfortable surroundings – where you can see friends, family and pets – is much better for your physical health, mental wellbeing and overall recovery.

We would like to treat your condition at home to allow for quicker recovery that is more comfortable.

While on the virtual ward, a senior doctor and nurse will oversee your care through a joint team of hospital and community staff. You will have a personalised care plan, tailored to your specific needs, with healthcare professionals monitoring and caring for you. You may also be started on intravenous treatment if required. Do not worry, you will have regular contact with the team who will call or visit to check how you are progressing.

You might be given some easy-to-use devices to use at home to monitor things like your blood pressure or your oxygen levels. These readings will be sent back to the virtual ward staff who will monitor them. If needed, changes can be made to your care plan. Our aim is to give you a hospital level treatment at home and speed up your recovery process avoiding hospitalisation.

If you have any questions, please speak to a member of your healthcare team.

What will happen on the virtual ward?

1. Patient Assessment

What to expect:

Your healthcare clinician will first assess whether your condition can be managed at home from a virtual ward team. Your care team will then work with you, your family or carer (if you want them to be involved) to decide whether you are suitable to be treated through the service. A member of the team will explain how the service works and why they think it would be the best option for you. If you and your carer consent to this, they will refer you into the virtual ward.

We will look at:

  • Your preferences
  • Your health condition(s)
  • The type of treatment you need
  • Your ability to use equipment, on your own or with a carer
  • Your ability to understand decisions
  • Support available from your family and carer(s)

What you need to do:

  • Be honest about how you feel and any concerns you have. This will help to make sure your treatment is right for you.
  • Make sure you and your family or carer have your say in the discussion about whether you are cared for at home.

2. Creating a Care Plan

What to expect:

Once admitted to the virtual ward you remain under the care of the team. A personalised care plan will be discussed between you, your carer, and your healthcare team. This identifies what matters to you to ensure that the support you receive is designed and coordinated around your needs.

At home, your care will continue to be reviewed by the team who might include nurses, physiotherapists, occupational therapists, carers and doctors. They will contact you regularly – this could be an in person checkup, a telephone or video call. They will also explain what to do if you suddenly become unwell – please contact us immediately or ring 999 in an emergency.

If you need any additional care or treatment to support you at home, your team will contact care services to set this up. Family members or friends looking after you at home can be given support as well. If you don’t need any additional support immediately, this can still be discussed later if you find you need help.

What you need to do:

  • Be honest about how you feel and any worries you have. This will help to make sure you receive treatment that is right for you.

3. Health Monitoring at Home

What to expect:

If you need to have things like your blood pressure or oxygen levels monitored, you will be loaned a device(s) that can take readings at home. These readings are easily sent from these devices back to the virtual ward team.

The clinical team will show you how to use the device(s). If a family member or friend is looking after you, they will also get this information. You will be able to try the equipment yourself and ask any questions you may have.

If you need help setting up the device, someone will come to your home to help you.

What you need to do:

  • You and any family member or friend taking care of you should ask questions and make sure you are comfortable with the device(s) and how to use it.
  • Ask for help if you aren’t sure how to use the equipment at home.

4. Your Care and Treatment

What to expect:

Once at home, the Virtual Ward team will check-in with you regularly via phone or video call, or a home visit if needed. How often you speak to the team will be based on your needs.

If you have any monitoring devices it is important that you use them, so your readings can be monitored.

If you need extra support, a home visit from a community-based team can be arranged. Sometimes you may need to attend the hospital for more specialist investigations or more intensive treatment – the virtual ward team will help organise this for you.

Your care will be discussed with you, so you know how you are progressing.

You can get in touch with the Virtual Ward team by phone or through the provided tablet device. Operating hours and contact details are on the front of this leaflet.

What you need to do:

  • Make sure you talk to your care team about how you are feeling, any problems you have or any support you might need.
  • This also applies to any family or friends looking after you – there is support available for them.
  • If you are asked to use equipment or do exercises, please follow this advice and be really honest about any challenges you have.

5. Responsive Care – what to do if your health changes

What to expect:

A care plan will be developed at the start of your care. This will explain what to do if you become unwell at home. If you have a family member or a friend looking after you, the care plan will be shared with them as well.

The virtual ward team will be alerted if your readings worsen or you are not responding to treatment as expected.

Changes to your care plan can then be made by your clinical team without you having to go to hospital. For example, arranging medication, providing additional equipment, or visiting you at home.

What you need to do:

  • Make sure you have read your care plan and know what to do if you become unwell.
  • If your health gets worse, contact your team or the people you have been asked to contact as soon as possible.
  • Make sure anyone who helps look after you knows when and how to do this.

6. Leaving the Virtual Ward

What to expect:

You will be reviewed by the team before being discharged.

Most people are on the virtual ward for between 1 and 14 days. You should be given an expected date of discharge when you join.

When you are discharged from the service, the team will make sure you are referred to any other services you need. Then we will send a discharge letter to your GP explaining what care you have received and any medication changes that have taken place.

The team will talk to you about what happens after you are discharged. This will be based on what you need.

Doccla will arrange collection of any monitoring devices you used.

You may be asked about your experience to help improve the service. If a family member or friend is looking after you, they may also be asked for feedback.

What you need to do:

  • Return any equipment you have been loaned; you will be contacted by the team for this.
  • Please tell us about your experience, what worked and what didn’t. This will help us understand what is working and what isn’t so that services can be improved.

7. Frequently Asked Questions

What if I have COVID-19?

If you have symptoms of COVID-19 you should follow national guidance on staying well at home and isolating.

To reduce a high temperature it can help to:

  • Get lots of rest
  • Drink plenty of fluids (water is best) to avoid dehydration – drink enough so your pee is light yellow and clear
  • Take paracetamol if you feel uncomfortable.

If you live alone, ask a friend, family member or neighbour to check up on you.

Is there support for my family or carer while I am on the Virtual Ward?

Yes, speak to your virtual ward team to discuss what support you and your carer(s) might need. If there is anything specific you are struggling with it is important to let your clinical team know.

In addition, Carers UK have published some helpful advice on their website.