Stage 4: treatment, assessment and monitoring
Our guidance can help you deliver evidence-based care within the virtual ward setting.
Patient experience in adult NHS services
1.5 Enabling patients to actively participate in their care.
Intermediate care including reablement
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.
Multimorbidity: clinical assessment and management
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.
Falls in older people: assessing risk and prevention
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.
Medicines optimisation
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.
Shared decision making
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.
Chronic heart failure in adults: diagnosis and management
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.
Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use
All recommendations from 1.1.23 to 1.1.39 implementation of local antimicrobial guidelines and recognise their importance for antimicrobial stewardship.