South Devon and Torbay care planning/co-ordination process

This content relates to the following topics:

Part of Co-ordinated care for people with complex chronic conditions

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. This organogram illustrates the care planning/co-ordination process.

South Devon and Torbay care planning process


Step 1: The predictive risk report

Each month the Devon Predictive Model (DPM) monthly report is generated. This includes patients who are already being case managed on the virtual ward and those flagged by the DPM as high risk. The ward co-ordinator or practice representative accesses this report from a web portal and the information is shared with relevant practice staff.

Step 2: Shortlisting patients for the virtual ward meeting

Before each meeting, the GP or practice nurse meets with the virtual ward co-ordinator to discuss the predictive report and shortlist patients who may be suitable for admission to the virtual ward. The co-ordinator obtains any additional background information for each patient on their physical and mental health needs and social care requirements by accessing electronic records in primary care or the social care systems.

Step 3: Virtual ward meeting

The virtual ward team at each practice meet once a month to review the current status of patients on the virtual ward. Each case is assigned a traffic light (red/amber/green) which is adjusted based on information provided by their case manager on the level of input required.

The team also discusses potential admissions identified from the predictive risk report and any other cases identified by staff at the meeting. Approximately 80 per cent of the patients on the ward are identified from the predictive risk report, with the remaining 20 per cent referred in by the MDT directly. New admissions are assigned a case manager, based on their prevailing needs, or to a professional with a pre-existing relationship with them.

Step 4: Patient assessment

Once the practice and the rest of the virtual ward agrees to admit a new patient, the assigned case manager gets as much information on the patient as they can from other care professionals. If they do not know the patient, the case manager will be introduced to the patient by another professional who is known to them, and they seek their consent to perform an initial assessment.

The case manager assesses the person’s physical health, psychological wellbeing, environmental, social, personal and spiritual needs. They identify potential gaps in care, vulnerable areas and issues for review to ascertain whether any measures can be put in place as a ‘safety net’ to prevent subsequent deterioration which might result in a hospital admission.

Step 5: Ongoing multidisciplinary, proactive case management

Case management is delivered in a variety of ways according to the specific need of the patient. Some patients are managed through regular telephone calls. Other patients may require daily face-to-face contact with their case manager during a period of crisis. The level of intervention is tailored to the needs of the patient and the complexity of their health and social care requirements. The role of the case manager is to co-ordinate their care plan, which may involve providing direct care as well as liaising with other professionals. They also act as the contact point for the patient and family where possible.

The case manager can refer to a checklist of ongoing actions including:

  • ensuring the patient is provided with contact details for the case manager and relevant carers/support workers
  • ensuring the patient is contacted regularly as determined by their traffic light status and ongoing needs
  • monitoring the patient’s wellbeing and regularly reviewing their goals, quality of care, access to services and equipment
  • documenting all reviews, changes to treatment plans or goals in the appropriate electronic record.

Step 6: Review and discharge from the virtual ward

Patients on the virtual ward are assigned a status using the red/amber/green flagging system. These are reviewed regularly to determine whether any patients are ready to be discharged. In preparation for discharge, the case manager assesses the patient’s readiness to manage in their future environment and ensures that contingency plans are in place in case their health status begins to deteriorate. Each ward has a set capacity and patients are discharged from the virtual ward when the goals set in their case management plan have been fully met, the virtual ward approach no longer adds value to the patient’s situation or the patient no longer wants to participate.

Once discharged, the virtual ward team agrees on a planned ‘outpatient review’ at regular intervals by the original case manager to provide input if required. Patients can be readmitted to the virtual ward at a later date if their situation requires further multidisciplinary input.