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From Covid to Frailty; Virtual Ward implementation across the system

Virtual Ward models implemented as a result of Covid can faciliate collaborative, shared learning with models for monitoring and escalation in many other health areas

Read comments 6 Project updates 2
  • Winning idea
  • 2020

Meet the team


  • Des Gorman (Associate Director of QI and Transformation, GHCFT)

What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

The Covid-19 pandemic has resulted in rapid evolution of new models of care to support patients with confirmed or suspected Covid.  One such model has been a primary care based virtual ward, into which patients are enrolled at the point of diagnosis, following risk stratification and to enable monitoring and early detection of deterioration such that care can be escalated earlier in the course of disease.

This virtual ward model was achieved through rapid PDSA cycling and broad collaboration from commissioners, project managers, primary care practice staff, community NHS organisations and secondary care clinicians.  Central to the success of the model was close communication and collaborative problem solving and idea generation, facilitated by a dedicated project manager to ensure momentum was maintained and learning/action documented.

What does your project aim to achieve?

Better coordination of care has been identified as a key priority for a number of cohorts of vulnerable patient groups in our communities.

This proposal  recognises the potential for virtual ward models in diverse areas of healthcare, including frailty, supported discharge and chronic disease management.  There are barriers to implementation in all of these areas, not least time and collaborative facilitation between the teams, amongst whom there is appetite for the model.

We aim to collaboratively develop a virtual ward implementation framework for Gloucestershire, facilitated by project management time and learning through the experiences of Covid Virtual Ward implementation.  By working with other health areas with the appetite to do so, this framework can be tested and developed in a QI process to produce an evolving Virtual Ward framework and community of practice in Gloucestershire across a range of clinicians and specialties.

How will the project be delivered?

  • A core project team will comprise clinicians with experience of the Covid Virtual Ward development, multidisciplinary representation from acute and chronic disease areas, project management expertise to facilitate discussion and development.  We will also co-opt representation from adult social care and the voluntary/community sector.
  • The project team will canvas wider views with a series of virtual workshops to identify barriers and enablers, benefits and risks to virtual ward models in a range of settings.  This will overlap with the Q project “Improvers without Borders” (
  • Collaboration will enable development of a framework for implementation, which will be tested through PDSA cycles in two areas; Frailty and Respiratory Supported Discharge.
  • Learning over these cycles will inform the development of a Gloucestershire Virtual Ward Implementation framework to share learning and experience, enabling other settings across the county to make use of such models.

How is your project going to share learning?

  • Use of the QI network across Gloucestershire and the wider South West through Q, the AHSN and the Gloucestershire QI and Safety Academy
  • Open sharing of the framework on social media and through Clinical Networks and between PCNs
  • This project will co-ordinate with and enhance to broadening Population Health Management programme in Gloucestershire, which is being rolled out to Integrated Locality Partnerships.  The data from PHM will help develop virtual ward models, but also identify areas of need/priority to encourage adoption of the model across the system.

How you can contribute

  • What barriers to development of a framework do members anticipate?
  • What benefits to "sell" the model?
  • Are members aware of such frameworks in other regions?

Plan timeline

23 Feb 2021 Project team finalisation
31 Mar 2021 Identification of acute/community models to pilot
31 May 2021 Workshops (virtual) to develop models with identified teams
25 Jun 2021 Commence PDSA cycles (pre-clinical then clinical)
30 Sep 2021 Initial impact assessment

Project updates

  • 1 Oct 2021

    Project update (1 October 2021)

    The project was originally described as ‘From Covid to Frailty; Virtual Ward implementation across the system’ but has since been reframed as ‘Remote Models of Care – a spread of innovation collaborative’.

    This reflects the ambition that, rather than rolling out a programme of virtual wards based on this – very specific – experience, we want to use the opportunity to identify and amplify promising new ways of working across our system, aligned to our approach to integration and innovation.

    Aim and intentions

    We are working with four ICS teams (our adoption partners) to support and enable them to design, test and (where possible) implement innovative virtual models of care. Our adoption partners are working to:

    · Formalise the clinical pathway for Home IV Therapy and stratify the caseload to ensure that patients get the right care, in the right way, at the right time, be that in person or monitored and reviewed remotely (digitally or by phone).

    · Empower patients with Bronchiectasis to manage their own conditions ensuring that they have the appropriate clinical support, but also to co-design a (digitally enabled) system with patients that will support self-management and promote wellbeing.

    · Coordinate care for patients with Frailty, providing colleagues across the ICS with access to the right patient information at the right time to:

    • support case management of people with complex needs
    • support collaborative personalised care planning
    • establish an assets-based and resilience-promoting approach to self-management, care and support

    · Support colleagues working with Diabetes patients across the system to deliver the right care, in the right place, at the right time.

    In addition to the benefits for individual adoption partners in terms of patient care and quality improvement learning, we are looking to share experiences, identify common themes (e.g. right care, right way/place, right time – though we anticipate there will be others), spreading innovation, using a collaborative approach to create a best practice framework.


    Whilst we are using our QI knowledge and experience to support our adoption partners, we are keen to energise the collaborative part of our project by refreshing our thinking on the spread of innovation, including from NHS Horizons 7 Interconnected Principles of Spread, which elevates the active role of adopters in the transfer of new approaches. Our overall approach is using a dynamic co-design approach to scope, design, test and develop the framework with four key activities:

    · A best practice stimulus from the outcomes and learning of the COVID Virtual Ward project

    · An adoption partner cohort – selected from ICS clinical development projects with a common cause for achieving patient outcomes using remote and virtual working models, and colleagues.

    · A co-design hub for the Framework for Remote Models of Care Innovations

    · A structured Improvement Collaborative: supporting the adoption partners to delivery of their projects, whilst testing the Framework’s emerging principles and providing live feedback to the co-design hub.

    Outcomes (for patients & ICS projects)

    We firmly believe that our project must add useful value to the participating improvement teams (adoption partners) so that they can deliver tangible and measurable patient benefits.

    For example, better coordination of care (right place, right place, right time) has been identified as a key priority for a number of cohorts of vulnerable patient groups in our communities. Typically these may include people with frail health or those with complex or long-term health conditions living at home. High-level benefits could include:

    · Patients and carers – improved health and wellbeing, and independence

    · Staff – better use of clinical time (stratifying and segmenting), satisfaction, and co-working

    · System value – more productive use of team resources

    Outcomes (for system development and capability)

    Our project is also designed to build our system collaborative strength , to create Enabling Adaptive Spaces and further build system level improvement capability, building on our learning and joint commitment to deliver potential benefits* such as:

    · Evidence-based learning and implementation

    · Evaluation of system working

    · Building collaboration in action across ICS partners

    · Building models for spread of innovation

    · Supporting health management

    · Supporting admission and discharge

    · Focusing on addressing health inequalities

    * Note: until we have evaluated our work at the end of the project, these represent our hopes rather than our expectations in terms of outcomes.


    Our intention is to co-design an implementation framework that explores, develops and records some of the key recommendations for teams wanting to develop cross-system remote models of care. We feel it is likely that the recommendations could be structured around a number of key question, perspectives and components. The first iteration will be drawn from the learning of the COVID virtual ward project, and then progressively developed in collaboration with the adoption partners. The role of our adoption partners will be central to the development of the framework. There may be some significant diversity in project areas and it will be important for projects led by the adoption partners to have clearly set aims and objectives in their own right, but with a good commonality of purpose.

  • 19 Feb 2021

    The are really excited to be selected for Q funding.

    While the landscape has changed since the bid was written, our aspirations and methods have not.

    Since autumn we have rolled out a Respiratory remote supported discharge service (both Covid and non-Covid) using learning from the CCVW.  We have been able to share our experiences across the AHSN, hopefully to regional benefit.


  1. Hi Team Gloucestershire - good to hear the update and interested in the diabetes workstream - SW Regional diabetic foot pathway network is developing an improvement tool for antibiotic prescribing for diabetic foot infection within NICE pathway guidance and would be useful to learn about any aligned learning this project can share. If / when any do please loop me in with appropriate contact. Thanks - Elizabeth

  2. Well done on getting funding for this project! I've heard that virtual wards are a key part of NHS 'oximetry @ home' programme & pathways. So presumably oximetry will be a key part of your work - including real-time sharing of oximetry data?

    Also I'm interested in how virtual wards work with care homes. Will care home residents be included in your virtual wards? Are there different factors that need to be considered - eg working with care home manager?

    1. Thanks for your interest.

      While this has arisen from the oximetry at home and virtual ward model for Covid, oximetry may not be relevant for the models of remote monitoring/virtual wards to develop in other specialties.  The oximetry was very much a small part/enabler for the Covid models and each model much be developed for its own purpose.

      We had valuable learning from supporting care homes (both those with clinical staff and those without) in oximetry at home models and this will inform any toolkit/implementation framework that arises from the Q project.  We are looking at frailty models of patient monitoring/tracking on VW and care homes are likely to be a component of this.

  3. Hi - great idea and well-thought out. I'm working with the Health Foundation to highlight where there might be opportunities for collaboration across  Q Exchange.  There are quite a lot of virtual improvement projects suggested but there is one that might be of more interest to you - Delivering a Virtual Frailty Multidisciplinary Team service during COVID-19. It might be worth having a look to see if there is any possibility for cross-support or feedback on your ideas.  Similarly there is a digital special interest group which you could contact in Q to gain some feedback on how to use technology for quality improvement. Good luck with your idea, Emma

  4. I like the clear link to the health and social care system model, suggesting that if effective, adoption of the model into practice will be very feasible

  5. From my experience of working in the community as a GP, this 'virtual ward' idea is such a good idea. It will allow us to systematise care in the community around complex patients who need proactive care coordination between services, professions and organisations. It really lends itself to our future 'One Gloucestershire' ICS model of care based on collaboration. We already have some rich learning from our early 'Covid virtual ward' which we have been testing with a view to upscaling in the coming weeks to meet the rising cases of covid as we head into winter. Should we be successful in this bid, this will greatly support our work in safely keeping people in their own homes and escalating care to hospital in a responsive manner should they start to deteriorate. The key opportunity is to have a 'care coordinator' to help conduct the often complex care orchestra which will improve patient care by rationalising / co-ordinating care delivery.

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