Virtual wards milestone sees thousands of patients cared for at home

More than 12,000 patients have now been supported by Swansea Bay’s virtual wards service.

The service was initially set up as a pilot project in November 2021 but proved so successful that it was later rolled out with a virtual ward now running within all eight Local Cluster Collaboratives.

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

Rather than a ward being made up of hospital beds, the patient’s own bed becomes part of a virtual ward, meaning they still receive face-to-face care but in the comfort of their homes.

Pictured: Members of staff from the Bay Health and City Health Local Cluster Collaborative’s virtual wards.

A multi-disciplinary team made up of health and care professionals, such as doctors, nurses, pharmacists and therapists, discuss how to plan and manage each patient’s care, ensuring face-to-face assessment and intervention is completed.

Digital technology is used to pull the large teams together virtually, making communication and care planning more efficient and effective.

GPs and other community services can refer to the service, which also has a hospital in-reach team that works with hospital staff to identify patients who can go home under the care of the virtual ward, instead of being admitted.

This creates bed space for other patients and prevents the deconditioning associated with hospital stays for this group of patients.

It also ensures a patient’s health is optimised before handing them to the care of their GP.

So far, the virtual wards service has prevented approximately 4,000 hospital admissions (an approximate figure due to complexities around predicting admissions).

Neil Hapgood, service improvement manager for Swansea Bay’s virtual wards, said: “The service acts as an essential bridge between primary care, secondary care and community services by bringing together staff from across the health and care system to collaborate on the planning and delivery of care.

“This seamless approach prevents delays, allows high quality care to be delivered as prudently as possible and ensures Swansea Bay is moving in the direction of national policy.

“As well as treating the patient’s primary problem, virtual wards also carry out a full comprehensive geriatric assessment to optimise the patient’s care and their ability to live well at home.

“This can include falls prevention work, advanced care planning and medication reviews.

“Patients that leave hospital under the care of virtual wards are 70 per cent less likely to be readmitted than those that don’t, showing the value in this holistic approach.”

Data collected by the service showed that 98 per cent of patients were confident the virtual wards met their needs at home, and 98 per cent also felt they were involved in discussions about their care.

Dr May Li, virtual wards GP, has been involved in the service since its conception.

She said: “I am immensely proud of the wraparound service it provides to a very vulnerable cohort of patients in our community.

“It is one of the few services which provides a seamless link between our primary care and secondary care interface which is an incredible asset for our health board.”

In more recent years, the service has continued to develop and has introduced a number of different initiatives to help improve patient experience.

“We became aware that patients who had suffered a fracture, such as a fragility fracture for example, were having a longer than average hospital stay,” Neil added.

“As a result, we developed a Fracture Discharge Service which is delivered by teams from the virtual wards, Older Persons Assessment Service, Trauma and Orthopaedics and Early Supported Discharge.

“Patients with certain fractures are identified and a same day, or earlier discharge, is facilitated.

“This allows the patients to undertake their rehabilitation work at home which improves recovery outcomes and helps to create more hospital beds.”

The health board also ran a pilot with Welsh Government to enable patients to use devices to check their blood pressure, pulse and temperature at home as part of the virtual ward service.

The home device project, in partnership with Welsh Government-funded Technology Enabled Care Cymru, allowed staff to access more regular patient observations as results were logged on a smartphone or tablet via Bluetooth, allowing clinicians to view them.

Dr Elizabeth Davies, Clinical Director for Swansea Bay’s Care of the Elderly, said: “Reaching 12,000 admissions is a significant milestone for our virtual wards — a reflection not just of scale, but of the trust so many have placed in us.

“It speaks to the compassion, skill, and dedication of colleagues delivering the service across the health board.

“Together, we’ve helped thousands of people stay well, maintain their independence, and remain close to their families and communities.

“This is modern healthcare at its best: proactive, joined-up, and shaped around people’s lives — not just their conditions or the institutions that serve them.

“I’m proud to be a consultant for the virtual ward, and as we look to the future, we’ll keep building on its strengths, improving integration and responsiveness, so even more people can be safely and confidently supported at home.”