This case study is part of a research project undertaken by The King’s Fund and funded by Aetna and the Aetna Foundation in the United States to compare five successful UK-based models of care co-ordination.
What does the model aim to do?
South Devon and Torbay CCG uses proactive case management and community virtual wards to identify people at risk of an unnecessary hospital admission in the next 12 months. Each month, the multidisciplinary team, including professionals from health, social care and the voluntary sector, identifies and addresses patients’ needs across health and social care to put in place a case management plan to prevent crises from occurring.
How is the model structured?
Predictive modelling is used to support proactive case management of patients by risk-stratifying a population and identifying patients with complex chronic needs who require multidisciplinary input.
The Devon Predictive Model (DPM) combines primary and secondary care data to provide each GP practice with a list of its top 0.5 and 5 per cent of patients most at risk of an emergency admission in the next 12 months. This list is reviewed in the practice by a multidisciplinary team to choose patients deemed suitable for proactive case management on a virtual ward. Those requiring multidisciplinary input are admitted to the ward, where patients receive intensive assessment and care co-ordination from staff in the team – which is led by a case manager – who provide ongoing care and support in their home. Once their condition has stabilised they are discharged from the virtual ward and continue to receive ‘usual’ care.
What is distinctive compared to the standard practice of care?
Unlike many other models of care co-ordination, community virtual wards are based within GP practices. This enables the GP or practice nurse to bring their knowledge of patients into the process of identifying people who might benefit from proactive case management. Each virtual ward has a co-ordinator who provides administrative and management support to the team, downloading the predictive risk report and accessing electronic records from the integrated community health and social care system to ensure that the virtual ward team can build up a complete picture of the person’s health and care needs.
What are the key lessons?
- Predictive risk modelling and risk stratification
Using a predictive risk model to stratify the patient population uses data from primary and secondary care to identify those at risk of a hospital admission more accurately, targeting the intervention at patients who would benefit most from proactive case management.
- Locality working
The virtual wards are hosted by GP practices and in many cases were initiated using an existing multidisciplinary meeting of health and social care professionals. This approach has strengthened the focus on the local population, with the GP practice team and virtual ward co-ordinator ensuring that information from their records are combined with data held in other systems. The virtual wards harness existing good working relationships between care professionals across health, social care and voluntary sector, and their knowledge of locally available services.
- Holistic care assessment and a personalised case management plan
Conducting a holisitic assessment of patients’ needs reduces duplication and provides the case manager with a detailed understanding of the needs of the patient and carer. Developing a personal case management plan ensures that all members of the virtual ward team are kept aware of any developments and can provide cover for the case manager if needed.
- Dedicated care co-ordination
The case manager holds accountability for co-ordinating care, supporting the patient to make decisions and self-manage, as well as liaising with other professionals where needed. This role provides continuity of care for the patient and a point of contact for other members of the virtual ward team or out-of-hours care.
Contact details for more information about the model
For more information about community virtual wards in South Devon and Torbay, please contact Solveig Sansom, Senior Commissioning Manager for Integration, South Devon and Torbay Clinical Commissioning Group, on email@example.com
No. of pages: 32
See more of our work on co-ordinated care
- Watch our video to find out more about South Devon and Torbay's approach to care co-ordination
- View our organogram showing South Devon and Torbay's care planning/co-ordination process
- Read patient stories from South Devon and Torbay
- Find out more about the project: Co-ordinated care for people with complex chronic conditions