PEOPLE FIRST in action

Page last updated: 16 May 2023

Improving patient outcomes with virtual frailty wards and urgent community response teams.

Frimley Health NHS Trust


Frimley Health NHS Trust have trialled some of the recommendations from PEOPLE FIRST as part of their 2023-2025 strategy . Through use of virtual frailty wards and urgent community response (UCR) teams, they have:

  • improved patient outcomes
  • reduced hospital admissions
  • decreased the length of hospital stays for some patients
  • increased patient satisfaction.

About the UCR and Virtual Frailty Ward service

The service aims to offer people the same level of care at home as they would receive if they were admitted to hospital.

It is equipped to deal with frailty related incidents, including:

  • falls
  • reduced mobility
  • acute confusion
  • acute infections
  • issues caused by chronic diseases, such as heart failure or chronic obstructive pulmonary disease (COPD).

How the service works

A consultant geriatrician leads the team. It consists of:

  • advanced nurse practitioners
  • registered nurses
  • therapists
  • pharmacists
  • administrative support.

The service operates seven days a week, from 8am to 8pm, and the team can respond within two hours of receiving a referral.

Referrals can come from a variety of sources, including:

  • GPs
  • 999 and NHS 111 call operators
  • care homes and other social care teams
  • therapists
  • paramedics
  • community nurses.

When they receive the referral, the urgent community response team visit the person in their home. They assess and care for the patient.

At this point, a treatment escalation plan (including a ReSPECT form if appropriate) is completed for each patient.

If the patient requires ongoing care at home, the team will admit them to the virtual frailty ward. But, if patients need more support than this, the team can also refer them to:

  • a community rehabilitation hospital
  • the frailty Same Day Emergency Care team (or other SDEC services) 
  • a specialist service in the hospital.

These alternative pathways help to further reduce demand for emergency departments in acute hospitals.

Once enrolled, each patient in the virtual frailty ward receives:

  • virtual multi-disciplinary team (MDT) assessments, twice a day
  • in-person visits from nurses and therapists, once a day.

During these visits, the nurses and therapists can further assess the patient and provide treatment.

The team discharge the patient when their treatment is complete. The patient may receive ongoing support from other community services if needed.

Equipment and resources used

The team have access to:

  • the patient’s GP records
  • shared care records
  • acute hospital notes.

They also have:

  • a point of care machine that gives blood results within minutes. This helps the onsite team to make treatment decisions and prescribe safely. 
  • an ECG machine
  • a bladder scanner
  • a nebuliser.

This set-up enables the team to administer intravenous antibiotics, fluids, diuretics, nebulisers. They also carry oral medications for common acute medical emergencies.

Results and benefits

From April to October 2022 the team cared for 861 patients. Of these cases:

  • 90% of referrals received a response within 2 hours
  • 85% of cases avoided hospital admission
  • The average stay on the virtual ward was 3.4 days. This is much shorter than the 9-day average for an acute hospital stay
  • 100% of patients said they would like treatment at home again in the future, and would recommend the service to others.

The team also observed that patients:

  • are more likely to recover quickly at home
  • are less likely to experience deconditioning and hospital related harm (such as falls, healthcare acquired infection, medication errors or delirium)
  • avoid long waits for discharge prescriptions (TTOs), transport and care packages that can cause delayed discharge from a hospital setting.

In addition, the trust’s acute hospitals can now transfer patients to the virtual ward for ongoing care. This means in-patients can also leave hospital earlier. This benefits patients, but also reduces pressure on acute hospitals by improving patient flow.

Future plans

The team has an ongoing communications strategy that helps them to raise awareness and share information about the virtual ward with GP practices, 999 and NHS 111 providers.

The service currently manages up to 15 patients every day, with plans further to expand capacity in the future.