Acute GP service
Cornwall
This is a site intended for clinicians - all guidelines must be interpreted in the context of clinical risk assessment
Virtual Wards
A primary care allied service for increased monitoring in the community, sitting between self-management and admission/palliation. This is a CFT nurse-led service, which often may need the support of the referring GP at times (eg establishing COPD baseline, discharge of the anxious patient, etc).
Referral is via SERF
Virtual Ward Telephone Line: 01726 873400 (7 days a week 0900 -1700)
The Virtual Ward Service offers:
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Who - People whose acute respiratory or frailty condition could be managed in their preferred place of care as an alternative to hospital
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What - An enhanced healthcare at home package including a bespoke remote monitoring plan alongside an ongoing co-ordination of care during a person’s acute period of illness.
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When - Admission avoidance, early supported discharge, escalation from the Virtual Care Ward or as part of an integrated arrangement of interventions.
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Why - Better patient experience and outcomes. Improved patient flow by reducing admissions and length of stay. Reduced nosocomial transmission of infections including COVID-19. Shared decision-making for patients.
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How - Monitored service with early deterioration recognition and clinical input. Patient and carer empowerment to self-monitor and escalate. Working in partnership with the wider community teams
Please note:
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Clinical judgement remains paramount for all assessments, particularly for people at higher risk of serious illness, with a learning disability or living with serious mental health.
Exclusion Criteria for Virtual Wards:
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Need acute / complex diagnostics and / or clinical intervention that can only be offered in hospital. This can become a shared risk with the individual if they do not wish to be admitted to bedded care.
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Those experiencing a mental health crisis and requiring referral / assessment by a specialist mental health team that cannot be supported in the community.
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For safeguarding reasons, it is not safe for a person to remain in their home or usual place of residence.
Specifically 'Covid Oximetry at Home'
This is a service currently being taken within the 'Virtual Ward' service above. Referral through Virtual Ward is possible, as is direct referral as below.
Patient referred by Emailing this form to cft.nhsathome@nhs.net
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GP/ED/CATU/Community Hospital/MIU/OOH Services GP can all refer
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Patient consented they are happy with patient contact
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Referrer provides information pack including pulse oximeter to patient (packs held at GP practices/ED/MIU/111 and Community Hospitals)
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Patient to be advised by referrer will be contacted by the CO@H team in <2hrs
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Referrer notified of referral outcome at this time and 111 special note made for patient
They will refer to the relevant virtual ward team, who will check the patient:
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has pulse oximeter and information
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is guided through Virtual support offer and safety netted
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knows how to take readings and at what times.
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takes readings three times daily
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if not deteriorating within 14 days of onset of symptoms is discharged with information and safetynetting
This team provides a virtual monitoring service 9am - 5pm, 7 days a week
In out of hours, care defaults to normal OOH provision
Covid Oximetry at Home team current monitoring protocol:
Covid Oximetry at Home email
Care Home outbreak coordinator
Louise Forbes - Care Home Programme Manager. Contact via Bodmin switchboard 01208 251300