When Thelma Barnes became unwell again with yet another infection, her daughter Deb couldn’t help but feel a sense of déjà vu.
“Mum had been in and out of hospital from about 2018 through to 2021,” Deb explains. “Every time she got an infection, it was straight back in. She was getting so fed up of it, and I could see it was wearing her down.”
After COVID, Thelma’s health became more fragile — but it was a visit from a practice nurse that changed everything.
“Catherine, the nurse, came to see us and said there’s a service called the virtual frailty ward. I’d never heard of it,” Deb recalls. “She explained how Mum could get care at home instead of going into hospital again. That’s how it all started.”
Care that comes to you
The virtual frailty ward is part of the Hospital at Home service — a way to deliver the kind of care patients would normally receive on a hospital ward, but safely and comfortably in their own home. It supports people living with frailty or long-term conditions, and aims to reduce avoidable admissions and the stress that often comes with them.
“It’s a massive relief. You know someone’s going to be there if we need them. It’s that peace of mind,” says Deb. “If Mum gets an infection now, she can have her antibiotics at home. She doesn’t have to go through all that again.”
A team that sees the whole person
Jess, a member of the virtual frailty ward team, sees first-hand how much the service can mean — not just to patients, but to their families too.
“For people living with dementia, taking them out of their familiar environment and into hospital can be really distressing,” she explains. “This way, they stay where they’re most comfortable, and we bring the care to them.”
Jess and her colleagues provide a wide range of support — from medication reviews and IV treatment, to helping patients with everyday needs.
“Some people haven’t had a proper GP review in years. They can be on loads of meds that aren’t helping — or even causing problems,” she says. “We also support with meals, washing, dressing… even things like noticing they need a chair raiser to help them get up safely. You spot so much more when you see someone in their own home.”
“It makes me really proud. I feel so lucky to be part of it. When a patient is discharged, doing well, and happy — that’s job satisfaction.”
Looking ahead
The team hopes to expand the service further and continue building strong links in the community.
“We want to keep people safe, supported and at home for as long as possible,” says Jess. “We’re here for the patients — and for their families too. I’m really excited about where this is going.”
Helping Patients Stay Where They’re Happiest — At Home
I’m Deb Barnes, and I look after my mom, Thelma Barnes and in 2017, my mom got breast cancer, and her home is in in Eaglescliffe. So I work in Hartlepool. So we thought it would be best if she actually came to live with me rather than me live with her. She was in and out of hospital from about 2018 up to about about 2020/2021.
We got through COVID really well actually. And then after COVID, she started to develop these infections again and we’re at Havelock Grange in Hartlepool and there’s, a practice nurse there called Catherine who came out. She’s a lovely lady. And she was like, you know, your mum’s we’re gonna have to get something sorted again, and we think, she should go into hospital.
To which mum was really upset. And it was her that said, there’s actually a there’s a there’s a a service called the Frailty Virtual Ward. And that’s how we discovered the Frailty Virtual Ward. And really since then, you’re more at ease because you know that there’s someone gonna be there. If we need someone, we don’t have to do this journey to hospital because even the journey to hospital for someone old is really distressing.
You know, she can’t walk, so she’s got to be put either in a chair or on a stretcher. But for my mum and for me as her carer, looking after her, it’s just so much easier being on this virtual ward. So when these girls come in, it’s kind of you’re told exactly what’s wrong, what the treatment’s gonna be. Someone’s there at the end of the phone, and they do things like they suggest things so, for instance, her legs were dry and I was using one type of cream. And one of the girls came and said, listen, try this and it’ll be nice for her legs.
It’ll be easier for her. So they got me the cream. I put the cream on and her legs are fabulous. Now I wouldn’t have known about that. I wouldn’t have known them type of things, and you know that they’re there.
And for us, it’s not the upset of my mom going into hospital when she’s poorly. I know exactly what she’s gonna eat, what she’s gonna drink, it’s there. I help her feed her. She’s cared for well. And it’s just that reassurance because I’ve got the knowledge of what’s going on from the virtual ward that makes that happen.
The virtual ward got in touch with the district nurses to say right this is the medication that we’re doing and they always know what’s going on. But then also what the virtual ward do, they link with everybody. So about the second time we were on it, again mum had a water infection, it was something silly like my mum’s got a floating commode and it’s old, it was an old little wheelchair. And one of the girls, I was shown how I moved me mam, and one of the girls said to me that’s all rusty there and I said oh well you know it’s about four or five year old. She said I can deal with that too.
So the virtual lady got in touch with the people that supply all these things and within about twenty four hours the old one was took away and a new one was brought, which made our life so much easier. My mum, with her osteoarthritis, the girls from the virtual ward got in touch with like the physio people.
They came, they’re like part of our of what we do now. So they came in and looked and gave me suggestions and give us treatment and stuff like that. They also link with the, the district nurses.
So everyone kind of links together. I had a dietitian come, their link with the district nurses and the virtual ward. Physio people came last week and said that she needed to upgrade on a bed. They then talked to the district nurses and now she’s getting an upgrade on a bed. So everything’s linked in.
And in reality, the start of it was the virtual ward. It was the virtual ward that made me aware of everything that we could do. And said don’t worry we can sort this, we can get this, we can do this. Even for things like she needed some antibiotics. This is last year and her swallowing has gone a bit.
So we tried to get it I tried to get it in liquid form and couldn’t get it. So I rang up and said I’m having real difficulty. I was called back half an hour later and said Deb its at Billingham, we found it for you, just go and get it. So it’s the link up of everything that the virtual ward do that make me mum’s life so much easier but my life so much easier because I know I feel safe. It’s the safeness that I feel.
So for us, it’s absolutely brilliant and I’d recommend it to anybody, because not necessarily for the carer but for the patient. So to have my mum in her own environment, she’s clean, she’s tidy, she’s warm, she’s well fed. I know when she’s drinking a family can come and see her. You know the kids can come even, you don’t really want to take the kids in hospital, but the kids can come and see her. And all them little things make my mum feel better, which would make anybody who’s at home feel better.
So just little things. It’s not sometimes it’s not about medicine. It’s about the other things that make someone happy and make them feel loved and well cared for. And you can’t get that in a hospital, but you can get it on the virtual ward. So you also helped me with her medical emergency care plan.
So a doctor came out from her doctors when we when she very first moved here because she was in the doctors at Eaglescliffe. We came out. We discussed our medical needs and what our wishes were, which were not to go into hospital. And, all these things were discussed and no one ever looked at it again as a, as her health deteriorated. However, when the virtual ward came on board, they then looked at everything again and said, right, what do you want this?
My mum, we had a discussion about it. They updated this plan and she explained to my mum what one was and does she want one? And then we got one. Now I didn’t know about that. I didn’t know about I knew about the emergency plan but I didn’t know how to get it updated and the girls from the virtual ward got all that sorted for us.
So every time she now goes on to this virtual ward, they’re then updated. So she was on it two weeks ago. They said, Deb, have you got all the paperwork? I gave them all the paperwork. They’re re signed a do not resuscitate because it’s only, it’s only valid for a year or something like that.
And then they looked at a care plan again and said is this what you want? And I said yeah. And then it’s been amended to, to specifically say that she doesn’t want to go into hospital. She our first protocol is the virtual ward. Now I didn’t know any of them things.
It was from the virtual ward, but I then knew what they were. Hiya, I’m Jess. I’m one of the nurse practitioners. I work for the virtual frailty ward. So my part in virtual frailty ward is helping patients to stay at home and avoid hospital.
So it still blows my mind how we can deliver care, hospital based care to people in their own homes. It just helps people to stay comfortable and supported by their family. For those people who suffer from dementia, we’re not removing them from their home environment, and it’s really distressing for people if they need to go into hospital, be away from their family. So we have lots of support from different services whether it be pharmacists, so we look at people’s medication. Some people haven’t had a GP review for years, they can be on lots of medications which can be causing complications, we can look at that.
We can deliver intravenous medication at home, antibiotics to try and keep them out of hospital, which I think is fantastic. Patients get regular care, they get regular observations, they can get help and support with their meal preparation, whether it’s them washing and dressing, just need a little bit of help. So we can input lots of things even if it’s equipment that they need. We can go in and highlight that someone might need a little chair raiser to help them stand up from the chair. Little things.
Lots of things are missed when people are in hospital but us being able to go into somebody’s home and notice these things and we can help is just great. I just feel overwhelmed sometimes. I can be part of it and I am so thankful to be. I feel very, very proud to work for the trust, and it really gives me job satisfaction when we have tackled the problem and we discharge the patient and they’re happy and they’re well. And then they’ve always got us to call on again in the future if if they need to.
So we’re here for support for the families as well. You know, we’re we’re really good at listening. We want to keep the patients safe and in their own homes and just comfortable. You know, you can refer to us through your GP, through different services. The hospital can refer to us.
Once you are known to us, then that that’s easier as well. We’re hoping to expand and get better in the community, and I’m really excited for what it’s going to bring. And I’m I’m really proud of what I do, and, let’s see what the future brings.
How to refer
If you’re working in the Trust and think a patient might benefit from the virtual frailty ward, you can refer through your local GP, discharge team, or community services.