Staff share expertise to help people keep well at home through virtual wards

November is COPD Awareness Month, dedicated to raising awareness of this chronic respiratory condition.

Chronic obstructive pulmonary disease is the collective name for a group of lung conditions that cause breathing difficulties.

During this month, we’ll be highlighting the services, self-management guidance and support available to people living with COPD.

People living with a chronic lung condition are being cared for at home rather than in hospital as part of Swansea Bay’s virtual wards.

These wards provide wraparound support in the community to people with complex health and social needs.

Rather than being in a ward being made up of hospital beds, the patient’s own bed becomes part of a virtual ward. This means they still receive the same level of care while still enjoying home comforts.

A multidisciplinary team, or MDT, comprising health and care professionals, such as doctors, nurses, pharmacists and therapists, discusses how to plan and manage each patient’s care, ensuring face-to-face assessment and intervention is carried out.

Virtual wards run within the health board’s Local Cluster Collaboratives (LCCs) – Afan, Bay Health, City Health, Cwmtawe, Llwchwr, Neath, Penderi and Upper Valleys – with one based in each.

Staff from the chronic obstructive pulmonary disease, or COPD, team already provide care for patients at home to help keep them out of hospital.

But they also sit within the virtual ward service to help provide any wider care patients may require.

Alison Lewis, the health board’s respiratory clinical lead, said: “It may be that a virtual ward patient is receiving care for another reason, but they are having an issue with COPD.

“The virtual ward team will bring us in to help support that patient.

“It could also be that our team is caring or a patient with COPD, but they have other issues that we feel requires a wider multidisciplinary approach.

“So the referrals are received both ways. We bridge that gap.”

The MDT meets to discuss how to plan and manage each patient’s care, with staff able to input based on their own areas of expertise.

“The patient may have multiple conditions, such as COPD, diabetes and heart failure,” Alison added.

“If the patient has more complex needs, they would benefit from the wraparound support provided by the virtual ward.

“We would retain their care as a COPD team but refer them into the virtual ward so they can benefit from the wider multidisciplinary approach and continue their care that way.”

The virtual ward funds two full-time roles from the COPD team as part of the service.

They sit within the MDT and use their knowledge and expertise to help identify what support would benefit patients the most.

Alison said: “We may feel the patient needs more complex care, which could involve an occupational therapist going out to assess them and their environment.

“We can identify patients who will benefit from different elements of the support available, as well as referring them into our service if needed.

“The nature of the service we provide as a COPD team means we flow between primary and secondary care. We help to prevent any barriers of communication between the two and provide seamless care.

“That is very relevant to our role within the virtual ward too.”

Dr May Li, virtual ward clinical lead, said: “The specialist COPD team provides an excellent service where our COPD patients in the community can be cared for in their own home.

“Their expert knowledge is invaluable to our virtual wards MDT meetings and allows us to provide the full wraparound care that our patients require to keep them well at home and prevent hospital admissions.”

Pictured (l-r): Community staff nurse David Nicol and clinical nurse specialists Sarah Jones, Jolly Thomas, Susan George, Sharon Davies, Louise Jenkins and Darren Phillips.