CARE Virtual Ward Donegal
The CARE (Community Acute Respiratory Excellence) Virtual Ward (CVW) in Donegal is a pioneering initiative funded by the Sláintecare integration innovation Fund (SIIF), offering a 20-bedded virtual ward that brings healthcare closer to patients in their own homes.
Delivered through a funded managed service model, the programme ensures seamless integration of technology into patient care. Partnering with PMD, patients are onboarded and upskilled to use the technology effectively, ensuring they feel confident and supported throughout their care journey.
At the heart of the virtual ward is the Respiratory Integrated Care team, which oversees clinical assessment, care planning, and implementation. This multidisciplinary team ensures each patient receives tailored, high-quality care.
The virtual platform leverages cutting-edge technology, including RespiraSense for continuous respiratory monitoring. This novel solution detects signs of respiratory compromise or deterioration , empowering healthcare professionals with critical data to make informed clinical decisions and deliver timely interventions.
The Need for Community-Based Care
The CARE VW addresses a growing need for innovative, patient-centred care that reduces reliance on hospital stays. For patients with chronic illnesses or complex care needs, traditional hospital settings can be disruptive, costly, and often unnecessary.
By enabling care to take place within the community, the virtual ward not only enhances the patient experience but also alleviates pressure on acute hospital services. Patients benefit from receiving personalised care in a familiar environment, promoting better recovery and overall well-being.
This approach reflects the principles of Sláintecare by prioritizing integrated care, improving access to services, and delivering care closer to home. The CARE VW empowers patients to actively engage with their treatment while ensuring they remain connected to a dedicated team of healthcare professionals.
How the Virtual Ward Works
The CARE VW in Donegal combines advanced technology with personalised care pathways to provide seamless and effective healthcare.
At its core is a comprehensive digital platform that integrates Bluetooth-enabled technology, a bespoke app, and a staff-facing dashboard. Patients wear the RespiraSense device overnight to monitor their respiratory rate, which is a critical indicator of their condition. Each morning, patients upload their data via the app, which is transmitted to the clinical dashboard. The system generates a Green, Orange, or Red (GOR) status based on the patient’s care pathway, signalling when clinical intervention is required.
To support proactive care, the Respiratory Advanced Nurse Practitioner (ANP) prescribes COPD Rescue Packs to suitable patients, ensuring early and effective management of exacerbations. Additionally, the bespoke app delivers personalised educational multimedia content to enhance patient understanding of their condition, helping them recognise and respond to early warning signs. Patients also complete a daily questionnaire that provides valuable insights into their health and informs the clinical team’s decision-making.
The virtual ward targets specific patient cohorts:
- Supports early discharge for patients identified in acute settings, with referrals from COPD Outreach Team, Respiratory Clinical Nurse Specialists (CNS) at LUH, Respiratory Physiotherapists and Respiratory ANPs.
Daily engagement between patients and the clinical team is central to the programme, fostering collaboration and ensuring timely interventions. Through this innovative approach, the virtual ward not only supports better patient outcomes but also strengthens the connection between patients and their healthcare providers.
Success Stories and Impact
The CARE VW in Donegal has transformed the management of COPD, empowering patients and expanding access to care across the county. One of the standout successes of the programme is the Academy Cohort, which focuses on onboarding patients while they are well. This approach allows patients to become familiar with the virtual ward platform, gain vital education on early identification of exacerbations, and partner with the Respiratory Integrated Care (RIC) team in proactively managing their condition. By empowering patients to take an active role in their care, the programme fosters confidence and self-management, reducing dependency on hospital services.
- Academy Cohort: Patients currently well but with two or more hospital admissions for COPD in the past year, those known to respiratory consultants at LUH, or with spirometry-diagnosed COPD.
- GP Academy Cohort: Patients currently well but with three or more exacerbations in the past year. These patients are referred via Healthlink to the Respiratory Integrated Care (RIC) team at the Errigal CDM Hub for onboarding.
This innovation has expanded the COPD Outreach Service in Donegal, breaking its previous geographical limitation of a 33KM radius from the hospital. Now, patients across the entire county, regardless of location, can benefit from equitable care.
For actively exacerbating patients, the CARE VW provides a critical alternative to hospital admission. Patients who have participated in the Academy Programme can be referred during an active exacerbation for immediate support. GP referrals for new exacerbations are also accepted, offering the virtual ward as a practical alternative to inpatient care. Referrals are seamlessly integrated from various sources, including RIC teams, LUH Respiratory Physicians, ANPs in the Emergency Department, and GPs.
Daily huddles ensure that every patient receives tailored clinical oversight. During these meetings, the multidisciplinary team discusses each patient, and the most appropriate course of action is determined—whether that’s a clinic visit, a home visit, or a review at the Errigal CDM Hub. With resources like chest X-rays and arterial blood gases (ABG) available to the RIC team, decisions are informed and patient-centered. The process is overseen by ANPs, ensuring clinical excellence and continuity of care.
Operational Monday to Friday from 08:00 to 16:00, the CARE VW is not designed for 24/7 monitoring but instead emphasizes empowering patients. The platform uses digital tools to detect early signs of exacerbation, connects patients with the RIC team, and ensures timely interventions. By equipping patients with the knowledge and tools to self-manage their condition, the programme prevents deterioration, reduces hospital admissions, and improves overall outcomes.
This innovative model of care not only enhances the quality of life for COPD patients but also demonstrates how technology and collaboration can overcome geographical and systemic barriers to deliver equitable and efficient healthcare.
Role of Collaboration and Innovation
The success of the CARE Virtual Ward is rooted in its collaborative approach and innovative use of technology, breaking down traditional barriers in healthcare delivery.
One of the programme’s most impactful partnerships is with the National Ambulance Service (NAS). Outside the ward’s operational hours (Monday to Friday, 08:00–16:00), patients are advised to follow standard procedures if their condition deteriorates, such as contacting their GP or emergency services. To enhance care continuity, the RIC team develops a watch-list of high-risk patients, complete with individualised care plans and Eircodes. This list is shared with the NAS to ensure informed and efficient responses outside working hours. Calls to the NAS are triaged to community paramedics, where appropriate, enabling timely reviews and avoiding unnecessary hospital admissions while maintaining a link back to the RIC team.
The CARE Virtual Ward stands out for several unique features:
Direct GP Referrals: GPs have direct access to refer patients to the CARE programme.
Pathways with Community Healthcare Providers: Collaboration extends to multiple stakeholders, ensuring integrated care.
Empowered Decision-Making: The Respiratory ANP has autonomy over admissions and discharges, with governance from an Acute Respiratory Consultant. Weekly multidisciplinary team (MDT) discussions further reinforce decision-making with input from the full respiratory team.
Patient Education and Self Management: Patient awareness is a cornerstone of the programme. Bespoke multimedia content created by the RIC team, such as videos on airway clearance techniques and inhaler use, is accessible through the app and prescribed to patients as needed.
The platform’s adaptability also opens the door for expansion beyond COPD management. Its structure can be easily transferred to other chronic conditions, positioning the CARE model as a scalable solution within the Chronic Disease Management (CDM) service.
Cardiology Pathways in Donegal
The CARE VW success sets the stage for broader digital integration within Donegal’s CDM services. Current cardiology pathways, though not yet digitally enabled, demonstrate the potential for future innovation:
Heart Failure Pathway: Patients are referred to the CDM hub by their GP, where referrals are triaged, diagnostics are performed, and care plans are developed collaboratively between Advanced Nurse Practitioners (ANPs), Clinical Nurse Specialists (CNS), and cardiologists.
Atrial Fibrillation Pathway: From triage to elective cardioversion, patients are managed comprehensively, with follow-up by CNS and cardiologists to ensure optimal care.
Palpitation Pathway: Patients are monitored using devices like Kardia AliveCor and enrolled in nurse-led services, which include virtual clinics and rhythm monitoring, ensuring timely intervention.
Heart Virtual Clinic: This pathway fosters collaboration between GPs and cardiologists via virtual consultations, enabling precise diagnostics and effective treatment planning.
The CARE Virtual Ward’s collaborative model and innovative technology can serve as a blueprint for digitally transforming these pathways, bringing the benefits of remote monitoring, patient education, and community-focused care to a wider population.
Outcomes to Date and Looking Ahead
The CARE VW has delivered impressive outcomes, showcasing its effectiveness in improving patient care and reducing pressure on acute healthcare services.
Outcomes to Date – CARE VW
- 192 patients admitted to the virtual pathway, with 48 readmissions managed as an alternative to acute hospital admission.
- 156 rescue scripts issued, supporting early intervention and preventing complications.
- 842 potential acute bed days released and 156 A&E attendances avoided, easing the strain on acute hospital resources.
- A significant reduction in readmission rates at Letterkenny University Hospital (LUH) from 27.8% to 13.08%, exceeding the Sláintecare target of 22%.
- A 22% reduction in overall COPD admissions to LUH, surpassing the Sláintecare target of 15%.
These outcomes highlight the tangible benefits of combining innovative technology with collaborative care pathways, ultimately ensuring better access to care and improved patient outcomes.
Outcomes to Date – Cardiology Pathways in Donegal
Although not yet digitally enabled, the cardiology pathways in Donegal have also demonstrated significant success:
- 23-25% reduction in overall admissions to LUH for heart failure (HF), based on HIPE data from 2021 to 2023.
- 50% decrease in HF readmissions, showcasing the impact of structured care plans.
- 9% reduction in atrial fibrillation (AF) admissions and a 37% drop in AF readmissions between January–June 2023 and the same period in 2024.
These achievements underscore the potential for even greater improvements with the integration of digital solutions similar to those used in the CARE CVW.
Looking Ahead
Building on its success, the CARE VW team is exploring opportunities to expand its innovative model to other pathways:
IV Diuretic Administration in the Community Setting
Discussions are underway with the Pathfinder team in Donegal to enable community-based IV diuretic administration for heart failure patients who do not respond to oral therapies. We are hoping to develop a pathway with OPAT to facilitate IV antibiotics in the community especially to increase the number of supported discharges
This pathway would involve support from the Pathfinder team for administration and monitoring through point-of-care testing, with governance provided by the IC Cardiologist and care planning managed by the IC CNS/ANP service.
The scalability of the CARE VW model offers a pathway to transform chronic disease management across multiple disciplines. By leveraging technology, fostering collaboration, and empowering patients, the HSE can continue to deliver equitable, high-quality care while reducing the burden on acute services.
Conclusion
The planned expansion of the CARE VW to include cardiology pathways in Donegal represents a pivotal step forward in chronic disease management. By supporting patients on heart failure and atrial fibrillation (A-fib) pathways, CARE VW will enable clinicians to detect early signs of clinical deterioration and intervene promptly. This timely intervention will enhance patient outcomes, reduce hospital admissions, and strengthen care delivery at the right time, in the right place, by the right person.
The potential integration of an IV diuretic service into the CARE model further underscores its transformative capacity. Close monitoring and intervention for heart failure patients within the community setting are expected to significantly lower primary admissions and readmissions, reinforcing Donegal’s commitment to equitable, high-quality care.
Beyond cardiology, many patients attending respiratory and cardiology services are also engaged with diabetes management. Integration across all three chronic disease management (CDM) services is essential for delivering holistic, individualized care. The extension of CARE VW across these pathways will optimize management for patients with multiple comorbidities, strengthen integrated care pathways, and enhance the patient experience.
The demand for CDM services in Donegal continues to grow, with over 21,000 patient contacts recorded in the 12-month period from November 2023 to October 2024, and more than 2,000 patient contacts in just the last two months. Expanding virtual care pathways will not only address this increasing demand but also create a more cohesive integration between acute and community teams under the new Regional Executive Office (REO) structure.
Ultimately, the mainstreaming of CARE VW will strengthen clinical pathways, offer GPs alternative referral options beyond traditional acute-centric models, and empower patients to actively manage their chronic conditions. By enabling patients to stay well at home, this innovative model is a cornerstone in transforming healthcare delivery in Donegal and setting a benchmark for other regions across Ireland.
Health Service Excellence Award Winners 2024 - 'Improving Patient Experience'
For more information on this programme please email: CareVirtualWardDGL@hse.ie
View the HSE CDM Hub Patient Testimony below.