Community-Based Care and Rehabilitation as a Hospital Alternative
Service Overview:
The virtual ward, provide a safe alternative to hospital for adults with an acute exacerbation of a frailty-related condition. Our ward is designed for adults with underlying long term health conditions (including dementia), or those who may be experiencing physical weakness/frailty and who may need treatment and recovery support for an illness or recent worsening of long-term conditions.
Eligibility Criteria:
Adults aged over 65 (discussion on a case-to-case basis if under 65) with a Clinical Frailty Score 4 or more.
Patients who have urgent or emergent care needs for higher acuity care to manage intercurrent illness/frailty syndrome/exacerbation in underlying long-term condition. Patient requires daily monitoring and support for recovery and may have intensive rehabilitation needs.
Any patient registered with an in-area GP that requires admission avoidance and can be supported within their own home.
Patients admitted and treated within the acute hospital, seen in the emergency department, short stay inpatient assessment wards or by UCRT and identified for early supported discharge.
High degree of prognostic uncertainty (person might be deemed to be within last 12 months of life – end of life) and needs a period of ongoing support and monitoring to establish preferences and personalised advanced care planning goals before transition to palliative and end of life care services.
Clinical judgement should be used where a person is living with dementia or has limited capacity including a learning disability, this should not exclude admission to the service.
Not Eligible:
Any patient who requires emergency care interventions/has treatment escalation needs, necessitating acute/complex diagnostics and/or clinical interventions that can only be offered in a secondary care hospital environment (and these are appropriate for and wanted by the patient).
Experiencing a mental health crisis and requires referral/assessment by a specialist mental health team that cannot be supported in the community.
Our Team:
The service consists of multidisciplinary teams of experienced staff including consultant geriatrician, physiotherapists, nurses, occupational therapists, doctors, rehabilitation support workers and volunteers equipped to support patients on their care journey. We assess, manage, and deliver care in service users’ homes. The ward has medical oversight by the consultant geriatrician.
Hours of operation:
Hub hours for referrals are Monday – Friday 8.30am – 4.30pm. 01245 397700.
Service Delivery 7.30am – 10pm 7 days a week.
Contact Us
If you are registered with SystmOnline you will be able to view your own Electronic Medical Record (EMR), manage your appointments, request repeat medication, update contact details and message your healthcare service. There is also a SystmOnline app available for Apple and Android devices.
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