Summary
The diabetes virtual ward (DVW) pathway allows patients to receive the care and support they need at home, safely and conveniently, rather than in the hospital. The ward offers different approaches to care, narrowing the gap between demand and capacity for secondary care beds, offering an alternative to admission or early discharge. It also presents educational opportunities for the team supporting people living with diabetes. This pathway demonstrates optimisation of care, positive patient feedback and continued investment for growth. Finally, DVW supports collaborative working across the patient pathway in primary and secondary care within Leicester, Leicestershire and Rutland.
Innovation
Unplanned attendances at emergency departments (EDs) and readmissions of people with diabetes soon after discharge are disadvantageous to patients and healthcare systems. For some patients and carers, lack of support on discharge can be detrimental to managing recovery at home and can increase the need for readmission. Existing national guidance recommends that people with diabetes (PWD) are not discharged until their clinical condition is stable. Discharge plans need to consider the level of care and support that can be provided once the patient is discharged. While there are recommendations regarding input from MDTs and opportunities for home-based care, there is no mention of virtual wards or the value they could offer patients. VWs involve healthcare and social care teams identifying high-risk patients who may be destabilising, resulting in admission to hospital. In the longer term, VW MDTs would offer care working jointly with primary, secondary care and community care providers. The benefits include limiting disruption for PLWD and reduced costs to the NHS trust. There is increasing pressure to provide same-day emergency care (SDEC) services. A review of avoided admission data (defined as seen in ED or GP assessment unit or seen in ED and asked to return for a diabetes review), showed 45 would have been eligible to move into a VW over a three-month period. NHS teams are encouraged to use digital technology to deliver care closer to home, offering individualised care, no admissions and early discharge of patients. This pathway was created to offer PWD appropriate follow up and support after being admitted or attending the ED. The DVW is defined as similar to hospital care provided by an interdisciplinary team, delivered at home, via telephone or video consultation along with telemonitoring. Patients have clear MDT oversight. The pathway uses diabetes technology and digital health monitoring along with Spirit Health’s ClinitouchVie app to connect patients and clinicians. The patient completes daily health questions, with data reviewed daily alongside remote continuous glucose monitoring (CGM) (Libre 2) and connected insulin pens (where applicable). If necessary, changes are made to treatment plans, with face-to-face support available. Key components include: predictive risk modelling and risk stratification; locality working; holistic care assessment and personalised case management plan, plus dedicated care coordination.
Equality, Diversity and Variation
The online platform is user friendly and can be used by all ages. Data can be entered by carers on behalf of patients and there is a multiple language interface. This is a hospital-level DVW accessible to all patients and all UHL staff involved have completed equality and diversity training. Onboarding and supply of equipment is personalised to every patient, regardless of background. Enabling patients to be monitored and treated in their own homes maintains their individuality and independence. Socially deprived patients without smart phones are provided with electronic tablets to ensure digital inclusion; disabled patients use the service either with carer support or by tailoring the daily tasks to their needs. All patients with diabetes are eligible, regardless of their age (16+), sex, race, gender or social background. Leicester’s cultural diversity contributes to the city having 10% of residents diagnosed with diabetes. Over two thirds of the Leicester population live in the most deprived 40% of areas nationally. Health education is an integral part of the service and prolonged remote monitoring includes advice on lifestyle and improved management of blood glucose levels. An audit highlighted a need to improve access to CGM technology for all, including staff. Improvements in mobile compatibility increased uptake from 38% to 43%.
Results
Since December 2021, 357 patients have experienced this DVW pathway. Of these, 153 were classed as avoided admissions, with step down of early discharges 62 and likely readmission 36. Those likely to have returned to SDEC services totalled 15. Since the introduction of this pathway there has been a reduction in admissions from ED where diabetes is included in the diagnosis. Monthly data collection includes referral areas, patient satisfaction and reduction in symptoms. Follow-up offers referral to GP, community DSN team, or a secondary care consultant, with most returning to their normal care provider. ED attendances have reduced from 62% to 57%. The current pathway capacity is 15, with average length of stay 11 days. The team bid for an Advanced Nurse Practitioner as lead, Band 7 DSN, two Band 6 DSN, two Band 3 support staff and one administrator. Staff recruitment was difficult. The team has been encouraged to expand this pathway to take direct referrals from EMAS and primary care, but funding and staff need to be secured. Funding for the DVW is secure for the next 18 months and it is anticipated that this will continue after full evaluation.
User Feedback
Patient feedback is collected electronically or by telephone. Patients were included during the design stage and most were very happy with the service. Areas for improvement, such as limited cover over weekends and bank holidays, are being reviewed.
Dissemination and Sustainability
The local diabetes delivery group and ICB receive updates bi-monthly, with weekly reports on numbers and delivery. Technology support email daily to support on any challenges the team may have. This is also fed back to the speciality within the Trust for wider appreciation of the ward. Kent and Derby have shown interest in the Leicester model. It is part of the GIRFT pilot for VW pathways, demonstrating that other trusts would be able to implement it.
