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Supporting more care at home through digitally-enabled information sharing

Support a COVID virtual ward in East Lancashire by improving speed and quality of information sharing between NWAS and the Intermediate Care Assessment Team by designing and testing digitally-enabled referrals.

  • Proposal
  • 2020

Meet the team


  • Jay Bullock
  • Adele Markland
  • Jane Clayton
  • Caroline Hargreaves
  • Alex Townsend
  • Lisa Kay
  • Jessica McKeown
  • Sarah Foster
  • Cheryl Whittaker

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

In East Lancashire, NWAS refer adults with sub-acute/intermediate care to East Lancashire Integrated Care Assessment Team (ICAT). Referrals are predominantly older people. Referrals are made for patients who are experiencing a deterioration in their health or care needs such as falls, chest infections, urine infections, cellulitis, heart failure and pain.  During the April 2020 COVID peak, NWAS clinicians supported 35.5% of patients in East Lancashire to stay at home following a face-to-face assessment (See & Treat), 35 of these patients were referred to ICAT. NWAS See & Treat in East Lancashire dropped to 28.6% in September 2020 and ICAT referrals are 25 per month, on average.  ICAT have created a COVID Virtual Ward which aims to provide rapid, initial remote assessment of COVID positive patients to support their management at home. ICAT are working with NWAS both to increase the number of referrals made by improving clinician decision-making confidence to conduct an initial remote assessment.

What does your project aim to achieve?

The project aims to develop and test digitally-enabled information sharing between NWAS clinicans and East Lancashire ICAT to support the ICAT virtual assessment of patients. Information is currently shared between the organisations via telephone with handwritten paperwork.  Digitalising part of the process aims to enhance the quality of information shared and support confidence in virtual assessment of patients because a written record of a full face-to-face clinical assessment will be readily available. The project will explore how technology can support a joined up assessment. The aim is to increase the number of patients that NWAS refers to ICAT, thereby reducing the number of patients conveyed to a hospital setting and enable rapid community intervention. ICAT also hope to increase the number of patients that they are able to assess remotely which will reduce close contact, benefitting both the patient and NHS clinician by supporting safer assessments during the COVID pandemic.

How will the project be delivered?

Delivery will involve collaboration between NWAS Quality Improvement, Digital Innovation, Informatics teams and the East Lancashire ICAT. Specialist software development expertise will be purchased and our plan is to facilitate face-to-face or virtual design workshops to agree an information sharing platform. We aim to achieve a digital electronic information sharing process which will be compliant with Data Protection Impact Assessments (DPIA) and the Interoperability Tool Kit (ITK). Once created, we would then perform small scale testing with a limited number of NWAS clinicians with periodic evaluation and adaptation. Impact will be measured through referral numbers, admission avoidance rates and monitoring of patient outcome. The data sharing risks would be managed through the DPIA and ITK. The project will provide testing and evaluation on a small scale to create a minimum viable product that can then be scaled up across the area with potential for regional adoption.

How is your project going to share learning?


Learning and progress throughout the project will be shared via Twitter and Facebook. The project team will actively participate in Q Exchange and Q Community activities and events. A written evaluation will be provided at the end of the project to summarise methodology, measurements and learning.

Internal (NWAS)

This work links into existing programmes of work to reduce avoidable conveyance to hospital and increase community referral pathways. NWAS is currently recruiting to an evaluation post, based within the Quality Directorate. This role could design a simple evaluation framework that could run alongside this project. There is an ongoing improvement programme ‘Treat Half at Home’, supported by an active Improvement Network, which aims to increase clinician confidence making decisions not to convey patients. Learning from this project will be shared internally within the Improvement Network and as part of Treat Half at Home.

How you can contribute

  • Please share your own experiences with us.
  • Comment on our proposal and suggest different approaches that might help us to see alternative solutions.
  • Have you been involved in a similar improvement project before? It would really help us if you could share your learning so we can avoid pitfalls or adopt and adapt brilliant ideas.
  • Share our idea. We want to get comments and feedback from as many people as possible.

Plan timeline

1 Apr 2021 Engagement with projects teams to confirm roles and meeting dates
8 Apr 2021 Develop communications and stakeholder engagement plan
3 May 2021 2 hour virtual session – COVID collaborations learning and improvement methodology
10 May 2021 Virtual design workshop 1
24 May 2021 Virtual design workshop 2
31 May 2021 Share progress and learning with Q community
14 Jun 2021 DPIA creation and agreement
12 Jul 2021 Software prototype developed
23 Jul 2021 Small scale testing of referrals 1 complete
30 Jul 2021 Evaluation using PDSA cycles
20 Aug 2021 Small scale testing of referrals 2 complete
10 Sep 2021 Videos of progress made for stakeholder engagement
24 Sep 2021 Small scale testing of referrals 3 complete
8 Oct 2021 Share progress and learning with Q community
22 Oct 2021 Approval confirmed from senior leads for larger scale testing
5 Nov 2021 Larger scale testing complete
19 Nov 2021 Feedback to senior leads
19 Nov 2021 Share Learning with Q Community

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