Hospital at home and virtual wards provide safe alternatives to hospital care in the community. There is considerable variation in how they are operationalised at a local level. In general, their common feature is to provide healthcare in people’s homes through a multidisciplinary clinical team. Care is delivered both remotely and face to face. They aim to help avoid admission as well as facilitate rapid discharge.
The models vary in terms of who leads the service; the hours of operation; the staffing model; the conditions they support; the length of support; how technology is used; and how patients and professionals access the service.
In March 2025, NIHR Evidence held a webinar showcasing research on 2 home-based alternatives to hospital care from 3 evidence reviews: admission avoidance hospital at home and virtual wards for people with frailty. Definitions for these models can vary, but for the purposes of this webinar, we have used the following definitions.
- Admission avoidance hospital at home - active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period.
- Virtual wards for people with frailty - care is provided to the patient in their own home; a multidisciplinary team makes decisions and plans care remotely from the patient and provides oversight of care.
The webinar addressed:
- the key elements of hospital at home and virtual wards
- their impact on outcomes
- their impact on service costs
- factors that contribute to their success.
Background
An ageing population, with increasing numbers of people living with frailty, are placing growing demands on hospital services. A 2022 Health Foundation projection suggested that based on current trends England could need between 23,000 - 39,000 additional hospital beds by 2030/31.
On current estimates 1 in 5 emergency hospital admissions are avoidable. The number of people who faced discharge delays increased by 43% between 2021 and 2024, reaching a peak of 14,096 people per day in January 2024. Aside from the inappropriate use of hospital resources, there are compelling reasons to reduce the reliance on hospitals from a patient’s perspective. A long hospital stay can reduce someone’s independence and trigger a move from home to long-term supported care with associated emotional and financial cost. This is particularly true for vulnerable people, such as the growing number of people with dementia.
Shifting care from hospital to the community is core to the government’s ambition to build a health and social care system fit for the future. The success of home based alternatives to hospital care will be key to the achievement of this ambition.
Hospital at home: outcomes, costs and factors for success
The first presentation was delivered by Sasha Shepperd, Professor of Health Services Research, University of Oxford and Graham Ellis, Professor at Glasgow Caledonian Universities, geriatrician, and Deputy Chief Medical Officer for Scotland. Their talk focused on hospital at home, including effectiveness, costs and factors for success. It drew upon findings from a randomised trial of hospital at home versus hospital admission and 2 Cochrane evidence reviews authored by Sasha Shepperd: Admission avoidance hospital at home and Factors influencing the implementation of hospital at home.
The findings from the Cochrane reviews showed that there was no difference in the number of deaths after 6 months, or readmissions to hospital 3 to 12 months after being admitted to hospital at home or a hospital. Patient satisfaction was higher for hospital at home and treatment costs and the number of people in residential care after 6 months were lower compared to hospital care. Research indicated that maintaining routines at home facilitated faster recovery.
Key factors to support successful implementation included: having staff with acute care experience; effective teamwork and task sharing; and time-limited services.
Virtual wards for people with frailty
Around 10% of people aged over 65 live with frailty. This figure rises to between 25 to 50% for those aged over 85. People with frailty lose their in-built reserves and their health becomes increasingly vulnerable to events such as an infection or change in medication or environment. Discharging people with frailty from hospital and managing people with frailty at home who are acutely unwell can be a challenge.
Maggie Westby, Senior Research Associate, NIHR Applied Research Collaboration West, presented findings from a rapid realist review on virtual wards for people with frailty.
The review informed a policy brief for commissioners, which made recommendations for virtual wards for people with frailty. These included:
- virtual wards require 5 building blocks – common standards agreements, information sharing, appropriate multidisciplinary team composition, multidisciplinary meetings ('virtual ward rounds'), and a virtual ward coordinator
- virtual wards enabling the delivery of frailty management
- ensure patient and carer involvement and empowerment, such as communication via a known point of contact and shared decision making
- motivate professionals to work together – a ‘team-of-teams’ providing mutual support, trusting in shared goals, and reciprocal learning through team meetings
- work with primary care and integrated neighbourhood teams on a whole-system approach – provide reactive care to those experiencing a frailty crisis as well as proactive care to those at high risk of a crisis and ensure continuity of proactive care after discharge.
Conclusion
The webinar concluded with the researchers’ priorities for home-based alternatives to hospital care. These included:
- ensuring staff are properly trained and work effectively as a team
- supporting family members and carers to care for their loved one at home - these individuals are often not in full health themselves
- locating virtual wards within a whole system approach to frailty management, with proactive care to prevent frailty crises.
How to cite this Collection: NIHR Evidence; Hospital at home and virtual wards: What works?; March 2025; doi: 10.3310/nihrevidence_66104
Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
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