In an East Midlands NHS trust, community and acute teams came together to look at a frailty pathway. To help scale up and digitise the pathway, they enabled remote patient monitoring using Spirit Health’s Clinitouch platform. The teams worked together to make a step up and step down frailty pathway live. Patients admitted to the virtual ward receive the support they need at home or their usual place of residence.

Aims & Objectives

• To provide patients with frailty in the community with clinical support and prevent hospital admissions
• To ensure patients with frailty are safely discharged from hospital to home and reduce re-admissions
• To avoid patients with frailty deteriorating while in hospital by being safely discharged

What is a step up and step down pathway?

• Step up - Used for admission avoidance. Patients with frailty are monitored remotely in a community setting which helps to reduce hospital admissions and supports patient wellbeing.
• Step down - Used for assisted discharge. Patients are safely discharged from hospital and remotely monitored at home, supporting patients with frailty and reduces re-admissions.

How does it work?

• Patient - answers specific frailty questions and records observations on Clinitouch with the equipment provided. Observations include oxygen levels, temperature, blood pressure and pulse reading.
• Clinitouch - the platform has unique algorithms that automatically analyse and risk-score the data. It will highlight when any patient moves outside the agreed parameters.
• Clinician - community team monitor the Clinitouch dashboard which features a prioritised patient list with a red, amber, green rating to highlight where action may be required.

Dr Noel O'Kelly, Medical Director, Spirit Health, comments:

"Implementing the frailty pathways has meant vulnerable patients with frailty can be supported in familiar surroundings and kept out of hospital."

"The remote monitoring reassures patients whilst empowering clinicians with the information they need to better support patient care and experience."