Patient demographics, diagnoses, and care needs in a Norwegian Community Virtual Ward versus Skilled Nursing Facility: a longitudinal comparative cohort study

Since the early 2000s, Virtual Wards have referred to models where patients receive care at home rather than in traditional healthcare facilities. In 2021, the municipality of Bodø, Norway established a Community Virtual Ward (CVW) model, offering enhanced medical follow-up for older home residents. Unlike previous models, this CVW is fully municipality operated, features broad inclusion criteria, and includes a dedicated physician. The initiative responds to challenges related to longevity, frailty and task-shifting from hospitals to primary care. This study aimed to compare patient demographics and care needs between a CVW and a traditional Skilled Nursing Facility (SNF), and to access whether the CVW model can serve as a viable alternative to institutional care. A longitudinal comparative cohort study was conducted with 55 participants transitioning from hospital to either a CVW or a SNF. Data on demographics, frailty, functional independence, and service utilization were collected at admission, discharge, and three months post-discharge. Descriptive and regression analyses were used to identify predictors of recovery and service needs. CVW patients were younger, had fewer chronic conditions, lower frailty levels, and shorter admission periods compared to SNF patients. Across both groups, baseline frailty and functional independence at discharge were key determinants of recovery and service utilization 90 days post-discharge. Differences between groups were statistically significant for frailty, functional scores, and length of stay. Comorbidities were associated with smaller improvements during the inpatient stay but did not predict longer-term recovery. The findings suggest that the CVW model is a viable alternative to short-term institutional care for mildly frail patients who benefit from rehabilitation-focused, home-based services. SNFs remain essential for frailer individuals requiring intensive support. The results highlight the need for systematic frailty assessment in primary care to optimize care pathways for aging populations.