Supporting the health and care system to implement virtual wards

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• 1.5.14 Explore the patient's preferences about the level and type of information they want. Based on this, give the patient (and their family members and/or carers if appropriate) clear, consistent, evidence-based, tailored information throughout all stages of their care. This should include, but not be limited to, information on their condition (or conditions) and any treatment options, where they will be seen, who will undertake their care, expected waiting times for consultations, investigations and treatments.

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• 1.1.1 Ensure that intermediate care practitioners: develop goals in a collaborative way that optimises independence and wellbeing adopt a person-centred approach, taking into account cultural differences and preferences.
• 1.1.2 At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and: other agencies people using the service and their families and carers.
• 1.1.3 Intermediate care practitioners should: work in partnership with the person to find out what they want to achieve and understand what motivates them to focus on the person's own strengths and help them realise their potential to regain independence build the person's knowledge, skills, resilience and confidence learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack support positive risk-taking.
• 1.4 Referral into intermediate care. People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

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• 1.1.5 Provide nurse-led support in the community for people at increased risk of hospital admission or readmission. The nursing team should work with the team providing specialist care.
• 1.1.6 Provide multidisciplinary intermediate care as an alternative to hospital care to prevent admission and promote early discharge. Ensure the benefits and risks of various types of intermediate care are discussed with the person and their family or carer.

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• 1.1 Ensuring care is person centred.
• 1.1.1 Ensure services support the aspirations, goals and priorities of each person, rather than providing 'one size fits all' services.
• 1.1.2 Ensure support focuses on what people can or would like to do to maintain their independence, not only on what they cannot do. Recognise: that people have preferences, aspirations and potential throughout their lives and that people with cognitive impairment and those living alone might be at higher risk of having unmet social care‑related quality of life needs or worse psychological outcomes.
• 1.1.3 Ensure people using home care services and their carers are treated with empathy, courtesy, respect and in a dignified way by: involving people and their carers in discussions and decisions about their care and support. Agreeing mutual expectations. Always respecting confidentiality and privacy. Providing a reliable service that people and their carers can trust. Regularly seeking feedback (both positive and negative) about the quality and suitability of care from people using the service, including those who do not have a carer or advocate.
• 1.1.6 Ensure the person using the service, and their carers (if the person has involved them in their care), can direct the way home care is delivered. This is so that the person's safety, comfort, independence and sense of security are always promoted.

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• 1.1.5 People with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised. Timing of discharge should take into account the wishes of the person and their family or carer, and the level of care and support that can be provided in the community.

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• 1.3.4 Use an approach to care that takes account of multimorbidity for adults of any age who are prescribed 15 or more regular medicines, because they are likely to be at higher risk of adverse events and drug interactions.
• 1.3.5 Consider an approach to care that takes account of multimorbidity for adults of any age who: are prescribed 10 to 14 regular medicines,are prescribed fewer than 10 regular medicines but are at particular risk of adverse events.

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• 1.1 Preventing falls in older people.
• 1.1.1 Case/Risk identification.
• 1.1.1.1 Older people in contact with healthcare professional should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s.
• 1.1.1.2 Older people reporting a fall or considered at risk should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance.
• 1.1.2 Multifactorial falls risk assessment.
• 1.1.2.1 Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention.
• 1.1.2.2 Multifactorial assessment may include the following: identification of falls history,assessment of gait, balance and mobility, and muscle weakness, assessment of osteoporosis risk, assessment of the older person's perceived functional ability and fear relating to falling, assessment of visual impairment, assessment of cognitive impairment and neurological examination, assessment of urinary incontinence, assessment of home hazards, cardiovascular examination and medication review.
• 1.1.6 Home hazard and safety intervention.
• 1.1.6.1 Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer and appropriate members of the health care team.
• 1.1.6.2 Home hazard assessment is shown to be effective only in conjunction with follow up and intervention, not in isolation.

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• 1.5 Enabling patients to actively participate in their care.

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• 1.1.1 Ensure that intermediate care practitioners: develop goals in a collaborative way that optimises independence and wellbeing adopt a person-centred approach, taking into account cultural differences and preferences.
• 1.1.2 At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and: other agencies people using the service and their families and carers.
• 1.1.3 Intermediate care practitioners should: work in partnership with the person to find out what they want to achieve and understand what motivates them to focus on the person's own strengths and help them realise their potential to regain independence build the person's knowledge, skills, resilience and confidence learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack support positive risk-taking.
• 1.3 Assessment of need for intermediate care.

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• 1.1.5 Provide nurse-led support in the community for people at increased risk of hospital admission or readmission. The nursing team should work with the team providing specialist care.
• 1.1.6 Provide multidisciplinary intermediate care as an alternative to hospital care to prevent admission and promote early discharge. Ensure the benefits and risks of various types of intermediate care are discussed with the person and their family or carer.

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• 1.1 Ensuring care is person centred.
• 1.1.1 Ensure services support the aspirations, goals and priorities of each person, rather than providing 'one size fits all' services.
• 1.1.2 Ensure support focuses on what people can or would like to do to maintain their independence, not only on what they cannot do. Recognise: that people have preferences, aspirations and potential throughout their lives and that people with cognitive impairment and those living alone might be at higher risk of having unmet social care‑related quality of life needs or worse psychological outcomes.

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• 1.1.1 Ensure that intermediate care practitioners: develop goals in a collaborative way that optimises independence and wellbeing adopt a person-centred approach, taking into account cultural differences and preferences.
• 1.1.2 At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and: other agencies people using the service and their families and carers.
• 1.1.3 Intermediate care practitioners should: work in partnership with the person to find out what they want to achieve and understand what motivates them to focus on the person's own strengths and help them realise their potential to regain independence build the person's knowledge, skills, resilience and confidence learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack support positive risk-taking.
• 1.1.4 Ensure that the person using intermediate care and their family and carers know who to speak to if they have any questions or concerns about the service, and how to contact them.
• 1.1.5 Offer the person the information they need to make decisions about their care and support, and to get the most out of the intermediate care service. Offer this information in a range of accessible formats, for example: verbally, in written format, in other accessible formats, translated to other languages, provided by a trained, qualified interpreter.
• 1.5 Entering Intermediate Care.

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• 1.5.14 Explore the patient's preferences about the level and type of information they want. Based on this, give the patient (and their family members and/or carers if appropriate) clear, consistent, evidence-based, tailored information throughout all stages of their care. This should include, but not be limited to, information on: their condition (or conditions) and any treatment options. Where they will be seen. Who will undertake their care. Expected waiting times for consultations, investigations and treatments.

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• 1.5.2 Ensure staff in contact with older people are aware of the importance of maintaining and improving their independence and mental wellbeing.

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• 1.1 Ensuring care is person centred.
• 1.1.1 Ensure services support the aspirations, goals and priorities of each person, rather than providing 'one size fits all' services.
• 1.1.2 Ensure support focuses on what people can or would like to do to maintain their independence, not only on what they cannot do. Recognise: that people have preferences, aspirations and potential throughout their lives and that people with cognitive impairment and those living alone might be at higher risk of having unmet social care‑related quality of life needs or worse psychological outcomes.

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• 1.2 Medicines-related communication systems when moving from one care setting to another.
• 1.31 In an acute setting, accurately list all of the person's medicines (including prescribed, over‑the‑counter and complementary medicines) and carry out medicines reconciliation within 24 hours or sooner if clinically necessary, when the person moves from one care setting to another – for example, if they are admitted to hospital.
• 1.5 Self-management plans.
• 1.8.2 Organisations should involve a pharmacist with relevant clinical knowledge and skills when making strategic decisions about medicines use or when developing care pathways that involve medicines use.

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• 1.1 Overarching principles of care and support during transition.
• 1.3.7 As soon as the person is admitted to hospital, identify staff to form the hospital‑based multidisciplinary team that will support them. The composition of the team should reflect the person's needs and circumstances.
• 1.5.25 Ensure that older people with identified social care needs are offered early supported discharge with a home care and rehabilitation package.
• 1.5.26 Consider early supported discharge with a home care and rehabilitation package provided by a community‑based multidisciplinary team for adults with identified social care needs.

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• 1.1.6 Home hazard and safety intervention.
• 1.1.6.1 Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer and appropriate members of the health care team.
• 1.1.6.2 Home hazard assessment is shown to be effective only in conjunction with follow up and intervention, not in isolation.

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• 1.4 Communicating risks, benefits and consequences.
• 1.4.1 Discuss risks, benefits and consequences in the context of each person's life and what matters to them. Be aware that risk communication can often be supported by using good-quality patient decision aids or graphical presentations such as pictographs (see recommendations 1.3.1 to 1.3.3).
• 1.4.2 Personalise information on risks, benefits and consequences as much as possible. Make it clear to people how the information you are providing applies to them personally and how much uncertainty is associated with it. For more on dealing with uncertainty, see the General Medical Council's guidance on decision making and consent.
• 1.4.3 Organisations should ensure that staff presenting information about risks, benefits and consequences to people have a good understanding of that information and how to apply and explain it clearly (see recommendations 1.1.12 and 1.1.13).
• 1.4.4 If information on risks, benefits and consequences specific to the person is not available, continue to use the shared decision making principles outlined in this guideline.

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• 1.5 Enabling patients to actively participate in their care.

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• 1.1.1 Ensure that intermediate care practitioners: develop goals in a collaborative way that optimises independence and wellbeing adopt a person-centred approach, taking into account cultural differences and preferences.
• 1.1.2 At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and: other agencies people using the service and their families and carers.
• 1.1.3 Intermediate care practitioners should: work in partnership with the person to find out what they want to achieve and understand what motivates them to focus on the person's own strengths and help them realise their potential to regain independence build the person's knowledge, skills, resilience and confidence learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack support positive risk-taking.
• 1.1.4 Ensure that the person using intermediate care and their family and carers know who to speak to if they have any questions or concerns about the service, and how to contact them.
• 1.1.5 Offer the person the information they need to make decisions about their care and support, and to get the most out of the intermediate care service. Offer this information in a range of accessible formats, for example: verbally, in written format, in other accessible formats, translated to other languages, provided by a trained, qualified interpreter.
• 1.6 Delivering intermediate care.

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• 1.2 Taking account of multimorbidity in tailoring the approach to care.
• 1.2.1 Consider an approach to care that takes account of multimorbidity if the person requests it or if any of the following apply: they find it difficult to manage their treatments or day-to-day activities, they receive care and support from multiple services and need additional services, they have both long-term physical and mental health conditions they have frailty (see section 1.4) or falls, they frequently seek unplanned or emergency care, they are prescribed multiple regular medicines.
• 1.4 How to assess frailty.
• 1.4.1 Consider assessing frailty in people with multimorbidity.
• 1.4.2 Be cautious about assessing frailty in a person who is acutely unwell.
• 1.4.3 Do not use physical performance tool to assess frailty in a person who is acutely unwell.
• 1.4.5 When assessing frailty in hospital outpatient settings, consider using 1 of the following.
• 1.5 Principles of an approach to care that takes account of multimorbidity.
• 1.5.2 Follow these steps when delivering an approach to care that takes account of multimorbidity: Discuss the purpose of an approach to care that takes account of multimorbidity (see recommendation 1.6.2). Establish disease and treatment burden (see recommendations 1.6.3 to 1.6.5). Establish patient goals, values and priorities (see recommendations 1.6.6 to 1.6.8). Review medicines and other treatments taking into account evidence of likely benefits and harms for the individual patient and outcomes important to the person (see recommendations 1.6.9 to 1.6.16). Agree an individualised management plan with the person (see recommendation 1.6.17), including: goals and plans for future care (including advance care planning). Who is responsible for coordination of care. How the individualised management plan and the responsibility for coordination of care is communicated to all professionals and services involved. Timing of follow-up and how to access urgent care.
• 1.6 Delivering an approach to care that takes account of multimorbidity, discussing the purpose of an approach to care that takes account of multimorbidity, establishing disease and treatment burden, establishing patient goals, values and priorities, reviewing medicines and other treatments, and Agreeing individualised management plan.

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• 1.1.2 Multifactorial falls risk assessment.
• 1.1.2.1 Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention.
• 1.1.2.2 Multifactorial assessment may include the following: identification of falls history,assessment of gait, balance and mobility, and muscle weakness, assessment of osteoporosis risk, assessment of the older person's perceived functional ability and fear relating to falling, assessment of visual impairment, assessment of cognitive impairment and neurological examination, assessment of urinary incontinence, assessment of home hazards, cardiovascular examination and medication review.
• 1.1.3 Multifactorial Interventions.
• 1.1.3.1 All older people with recurrent falls or assessed as being as being at increased risk of falling should be considered for an individualised multifactorial intervention.
• 1.1.9 Encouraging the participation of older people in falls prevention programmes.
• 1.1.10 Education and information giving.

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• 1.8.2 Organisations should involve a pharmacist with relevant clinical knowledge and skills when making strategic decisions about medicines use or when developing care pathways that involve medicines use.

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• 1.4 Communicating risks, benefits and consequences.
• 1.4.1 Discuss risks, benefits and consequences in the context of each person's life and what matters to them. Be aware that risk communication can often be supported by using good-quality patient decision aids or graphical presentations such as pictographs (see recommendations 1.3.1 to 1.3.3).
• 1.4.2 Personalise information on risks, benefits and consequences as much as possible. Make it clear to people how the information you are providing applies to them personally and how much uncertainty is associated with it. For more on dealing with uncertainty, see the General Medical Council's guidance on decision making and consent.
• 1.4.3 Organisations should ensure that staff presenting information about risks, benefits and consequences to people have a good understanding of that information and how to apply and explain it clearly (see recommendations 1.1.12 and 1.1.13).
• 1.4.4 If information on risks, benefits and consequences specific to the person is not available, continue to use the shared decision making principles outlined in this guideline.

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• 1.7.3 The frequency of monitoring should depend on the clinical status and stability of the person. The monitoring interval should be short (days to 2 weeks) if the clinical condition or medication has changed, but is needed at least 6-monthly for stable people with proven heart failure. 
• 1.7.4 People with heart failure who wish to be involved in monitoring of their condition should be provided with sufficient education and support from their healthcare professional to do this, with clear guidelines as to what to do in the event of deterioration.

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• All recommendations from 1.1.23 to 1.1.39 implementation of local antimicrobial guidelines and recognise their importance for antimicrobial stewardship.

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• 1.1.5 People with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised. Timing of discharge should take into account the wishes of the person and their family or carer, and the level of care and support that can be provided in the community.
• 1.9.1 Offer people with heart failure a personalised, evidence based cardiac rehabilitation programme, unless their condition is unstable.  

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• 1.1.6 Home hazard and safety intervention.
• 1.1.6.1 Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer and appropriate members of the health care team.
• 1.1.6.2 Home hazard assessment is shown to be effective only in conjunction with follow up and intervention, not in isolation.

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• 1.1.1 Ensure that intermediate care practitioners: develop goals in a collaborative way that optimises independence and wellbeing adopt a person-centred approach, taking into account cultural differences and preferences.
• 1.1.2 At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and: other agencies people using the service and their families and carers.
• 1.1.3 Intermediate care practitioners should: work in partnership with the person to find out what they want to achieve and understand what motivates them to focus on the person's own strengths and help them realise their potential to regain independence build the person's knowledge, skills, resilience and confidence learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack support positive risk-taking.
• 1.7 Transition from intermediate care.

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• 1.5.2 Ensure staff in contact with older people are aware of the importance of maintaining and improving their independence and mental wellbeing.
• 1.5.3 Ensure staff in contact with older people can identify those most at risk of a decline in their independence and mental wellbeing. This includes being aware that certain life events or circumstances are more likely to increase the risk of decline. For example, older people whose partner has died in the past 2 years are at risk. Others at risk include those who: are carers, live alone and have little opportunity to socialise, have recently separated or divorced, have recently retired, were unemployed in later life, have low income, have recently experienced or developed a health problem, have had to give up driving, Have an age related disability, are aged 80 or older.

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• 1.1 Ensuring care is person centred.
• 1.1.1 Ensure services support the aspirations, goals and priorities of each person, rather than providing 'one size fits all' services.
• 1.1.2 Ensure support focuses on what people can or would like to do to maintain their independence, not only on what they cannot do. Recognise: that people have preferences, aspirations and potential throughout their lives and that people with cognitive impairment and those living alone might be at higher risk of having unmet social care‑related quality of life needs or worse psychological outcomes.

Read the full guidance

• 1.2 Medicines-related communication systems when moving from one care setting to another.
• 1.5 Self-management plans.
• 1.8.2 Organisations should involve a pharmacist with relevant clinical knowledge and skills when making strategic decisions about medicines use or when developing care pathways that involve medicines use.

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• 1.1 Overarching principles of care and support during transition.
• 1.5.25 Ensure that older people with identified social care needs are offered early supported discharge with a home care and rehabilitation package.
• 1.5.26 Consider early supported discharge with a home care and rehabilitation package provided by a community based multidisciplinary team for adults with identified social care needs.