[Skip to content]

Enter search here...
Wyre Forest Clinical Commissioning Group

Virtual Ward

The Admission Prevention Team (APT)

Emergency admissions and subsequent re-admissions of people with chronic disease are a major source of costs within the overall Wyre Forest budget.

Wyre Forest spent £18.2 million in 2009/10 on emergency admissions, equating to 40% of the localities total spend. The high cost nature of this activity provides potential for large financial savings with only a small reduction in activity. 

Wyre Forest Clinical Commissioning Group (WFCCG) Board considers reducing avoidable emergency admissions and re-admissions as a priority to improve patient outcomes and reduce the costs of unscheduled care.

It has been agreed by the WFCCG Board that one way of doing this is with the implementation of a ‘Virtual Ward’ model in the Wyre Forest. 

What is a Virtual Ward?

The Virtual Ward aims to reduce hospital admissions by identifying patients who are at high risk of admission and managing them more effectively in the community.

The core team supporting these patients consists of GPs and Community Nursing/Therapists. They will do daily/weekly/monthly ‘ward rounds’ and weekly Multi-Disciplinary Team (MDT) meetings, where all appropriate community health professionals will be invited, including the District Nurses, Specialist Nurses, Social Workers, Pharmacist etc. Information from these meetings would then be communicated directly to the patient’s registered GP by updating their clinical notes.

The Community Virtual Ward reproduces the strengths of a hospital ward in the community by using a multi-disciplinary team approach in healthcare provision. It is called "virtual" because the ward does not exist physically and patients remain in their home.

Community virtual wards have been running across the UK since 2006.

How are patients identified for the Ward?

Admission to a virtual ward is determined both by predictive modeling and by clinical decision making by the ‘Virtual Ward’ team and the patient's doctor. This ensures that the patients admitted to a virtual ward are truly those who will benefit the most, i.e. those most at risk of unplanned hospital admission.

The predictive model (BUPA Risk Stratification tool)rates patients' risk by taking into account inpatient, outpatient and GP data, demographics, geographical factors and census data. Those identified as being at risk will be reviewed by the GP and the Community Matron re their suitability to be admitted onto the Ward. GPs/Community Matron will use the predictive tool and their clinical judgment when making a decision to admit a patient.

All Patients admitted to the Ward will have a Care Plan developed by the GP and the Community Matron. 

How will this work in Wyre Forest?

This new way of working will be delivered by a team made up of an integration of the Community Matrons, Care Managers, Intermediate Care Team and a (soon to be) Rapid Response Nurse and Social Worker.

This new team will be co-located together in A Block at Kidderminster Treatment Centre and will manage all patients at risk of admission.

The team has chosen to be called The Admission Prevention Team (APT) and not ‘Virtual Ward’ – as they felt the term ‘virtual ward’ would be too confusing for patients.

This team will look after the patients identified by the BUPA Risk Stratification tool as well as patients from the Single Point of Access (SPA) and Worcestershire Acute Hospitals Trust (WAHT) facilitated discharge patients.

The team will look to proactively manage about 300 patients identified by the BUPA Risk Stratification tool.

Wyre Forest Oval Diagram

Referral Pathways for the Admission Prevention Team (APT)

The practice will identify patients to be proactively managed by this team (using the BUPA Risk Stratification tool) with an aim to avoid an unnecessary admission.

Any patient not admitted for proactive management but still requiring some support for a patient will go through the Single Point of Access (SPA). See referral pathways diagram below:

Wyre Forest Flow Chart

Who do I contact if I want to find out more?

You can contact any member of the Admission Prevention Team. Tel: 01562 513264 or

Dr Tony de Cothi (Clinical Lead)

Email: tonydecothi@nhs.net This e-mail address is being protected from spambots. You need JavaScript enabled to view it.


Heather Macdonald 

Email: Heather.macdonald@worcestershire.nhs.uk This e-mail address is being protected from spambots. You need JavaScript enabled to view it.

Tel: 07501483696