Care Coordination and 360 Referrals (Proof of Concept)
0.1.0 - proof-of-concept United Kingdom flag

Care Coordination and 360 Referrals (Proof of Concept) - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Virtual Wards (Hospital at Home)

A virtual ward (also known as hospital at home) is, in NHS England's words, "an acute clinical service with staff, equipment, technologies, medication and skills" that is "a substitute for acute inpatient hospital care". The patient is cared for at home, including in a care home. In interoperability terms a virtual ward is the same closed loop referral as an outpatient referral, with two additions: an inpatient-like stay at the patient's home and a shared care plan with monitoring.

References

Admission Routes

The operational framework describes two routes:

Route Framework Referral Initiator Code
Step-up "a patient becomes acutely unwell and is offered the choice between being treated at home or in hospital" Primary care, community care, care homes, NHS 111, 999, urgent community response (UCR), single point of access (SPoA), SDEC, ED, acute respiratory infection hubs step-up
Step-down "a virtual ward can facilitate an earlier discharge or transfer from an inpatient ward" Hospital ward (inpatient team) step-down

Both are a Referral Request [PCC-55] to the virtual ward service, with ServiceRequest.category = SNOMED CT 729021000000108 |Referral to virtual ward|.

Process

sequenceDiagram
    participant RI as Referral Initiator<br/>GP, community, 111/999, acute ward
    participant SPOA as Single Point of Access<br/>(optional)
    participant VW as Virtual Ward<br/>Referral Recipient
    participant PT as Patient at home<br/>devices / app
    participant GP as Patient's GP

    RI ->> SPOA: Referral Request [PCC-55]
    SPOA ->> VW: Referral Request [PCC-55] (forwarded)
    VW -->> RI: Accept / Decline [PCC-55]
    VW -->> VW: Admit - virtual ward stay (Encounter)
    VW ->> VW: Care plan: monitoring, visits, escalation [DCP]
    loop at least daily
        PT ->> VW: Observations (e.g. SpO2, NEWS2)
        VW -->> VW: Daily board round
    end
    opt Deterioration
        VW -->> VW: Escalate: home visit or hospital admission
    end
    VW ->> RI: Referral Outcome [PCC-57] - discharge report
    VW ->> GP: Discharge report (if the GP is not the referrer)
Step What happens Interaction FHIR
Refer Initiator refers, with the ward's eligibility form (Referral Forms); a single point of access may triage and forward PCC-55 Referral Request
Accept / decline Virtual ward team accepts, or declines (e.g. needs face-to-face hospital care) PCC-55, PCC-56 Referral Task
Admit The stay starts; the patient's home is the location HL7 v2 ADT A01 / A04 - To confirm which event trusts use Hospital Spell (location the patient's home)
Plan Monitoring, visits, medication and escalation plan, shared with the care team Dynamic Care Planning Care Plan
Monitor Readings from the patient or devices; at least daily review Device / remote monitoring platform; FHIR Observation Vital signs Observation
Update the referrer Optional interim note (e.g. escalation, change of plan) PCC-59 Clinical document (HDR section codes)
Prescribe Medicines for the patient at home EPS (secondary / community care) - To confirm current practice MedicationRequest
Discharge The stay ends; discharge report to the referrer and GP, medicines to the GP and community pharmacy PCC-57, HL7 v2 ADT A03 HL7 Europe HDR

Modelling the Stay

Question This guide Status
Is the stay an inpatient encounter? Yes - Encounter.class IMP, so the stay can end with an HL7 Europe Hospital Discharge Report (HDR only allows inpatient classes). The framework calls the service a "substitute for acute inpatient hospital care" and refers to "virtual ward admissions" To confirm against the Virtual Wards SitRep / Minimum Data Set and trust PAS practice
Where is the patient? Encounter.location = the patient's home (Location.type PTRES) -
Step-up or step-down? Encounter.hospitalization.admitSource from Virtual Ward Admission Route To confirm whether a national code set exists
Step-down - one spell or two? Encounter.partOf the acute stay, if the trust treats it as one spell Open
Which referral? Encounter.basedOn the referral -
Clinical responsibility Encounter.participant - the accountable consultant, consultant practitioner or GP -

Care Plan and Monitoring

The virtual ward care plan is the plan the whole team works to: who visits, what is monitored and how often, thresholds and escalation, medication. It is a CarePlan (Care Plan, from the HDR CarePlan) with category SNOMED CT 960751000000107 |Remote health monitoring care plan|, linked to the stay. Each activity references what carries it out: a referral (e.g. to community nursing), a Task, an Appointment or a monitoring ServiceRequest.

The operational framework requires "at least daily monitoring of patients using tools such as NEWS2" and says technology "should not be used to deliver virtual care where face-to-face care is required". Remote monitoring readings are vital signs Observations; the monitoring platform is out of scope here.

Records and Write Access

The framework asks for "access to information across all delivery partners" with "read/write functionality". This guide does not follow that as written: giving each partner write access to the others' records is not the general pattern, and it moves the responsibility for what is in a record away from the organisation that holds it. The general conventions are used instead:

Need General pattern Standard
Send results and observations to the GP or another provider Results messaging - the receiver's system files them HL7 v2 ORU^R01 (as for pathology and imaging); FHIR Message
Send the discharge report, clinic letter or interim note Clinical documents FHIR Document (HL7 Europe HDR) or CDA; HL7 v2 MDM^T02
Read another provider's record (e.g. the GP record when triaging) REST query APIs FHIR REST / IHE QEDm, IHE MHD, EU Health Data API; nationally GP Connect Access Record
Workflow between providers (accept, decline, outcome) Order status messages or shared Task 360X OSU^O51; FHIR Task (REST)
A plan the whole care team works to A shared care plan held by a Care Plan Service, which contributors update through its API - not by writing into each other's EPRs IHE Dynamic Care Planning

Supplier write interfaces such as IM1 may be used to file a received document or result, but they are an implementation detail inside the receiving organisation, not the interface between providers.

Example

A GP refers Sansa MANCHESTER (an NW GMSA test patient), who has an exacerbation of COPD, to the respiratory virtual ward instead of admitting her to hospital (step-up):

Step Example
Referral Request [PCC-55] GP to respiratory virtual ward
Accept [PCC-55] Virtual ward accepted
Virtual ward stay Encounter at the patient's home
Care plan Remote monitoring care plan
Monitoring SpO2 reading
Referral Outcome [PCC-57] Discharge report (HDR), completed

Data Collection

Virtual ward activity is collected through the Virtual Wards Situation Report; NHS England plans to "automate the flow of a new Minimum Data Set (MDS) via the Federated Data Platform (FDP)" (operational framework). The stay, its admission route and the discharge in this guide are the items such a data set would need - To confirm when the MDS is published.