Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation

Roland, Martín; Lewis, Richard; Steventon, Adam; Abel, Gary; Adams, John; Bardsley, Martin; Brereton, Laura; Chitnis, Xavier; Conklin, Annalijn; Staetsky, Laura; Tunkel, Sarah; Ling, Tom

doi:10.5334/ijic.850

Cited by 62 publications

(101 citation statements)

References 29 publications

(31 reference statements)

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“…the Integrated Care Pilots (RAND Europe, 2012;Roland et al, 2012), the Partnership for Older People Pilots (Windle et al, 2009;Steventon et al, 2011), the Inner North West London Integrated Care Pilot (Nuffield Trust, 2013) -and there is little evidence that these have led to reductions in emergency hospital admissions or cost. (Nolte and McKee, 2008;Goodwin et al, 2013;Mason et al, 2015) Systematic reviews carried out by Cameron et al (2012) have identified factors that help or hinder joint working.…”

Section: "My Care Is Planned With People Who Work Together To Understmentioning

confidence: 99%

Early findings from the evaluation of the Integrated Care and Support Pioneers in England

Erens

Wistow

Mounier-Jack

et al. 2017

JICA

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PurposeIntegrating health and social care is a priority in England, although there is little evidence that previous initiatives have reduced hospital admissions or costs. Twenty-five Integrated Care Pioneers have been established to drive change 'at scale and pace'. The early phases of our evaluation (April 2014-June 2016) aimed to identify their objectives, plans and activities, and to assess the extent to which they have overcome barriers to integration. In the longer-term, we will assess whether integrated care leads to improved outcomes and quality of care and at what cost. Design/methodology/approachMixed methods involving documentary analysis, qualitative interviews and an online key informant survey. FindingsOver time, there was a narrowing of the integration agenda in most Pioneers. The predominant approach was to establish community-based multi-disciplinary teams focused on (older) people with multiple long-term conditions with extensive needs. Moving from design to delivery proved difficult, as many barriers are outside the control of local actors. There was limited evidence of service change. Research limitations/implicationsBecause the findings relate to the early stage of the 5+ years of the Pioneer programme (2014-19), it is not yet possible to detect changes in services or in user experiences and outcomes. Practical implicationsThe persistence of many barriers to integration highlights the need for greater national support to remove them. Originality/valueThe evaluation demonstrates that implementing integrated health and social care is not a short-term process and cannot be achieved without national support in tackling persistent barriers. AcknowledgementsThe authors would like to thank the members of staff in all the Pioneer sites who kindly agreed to be interviewed and to complete the online survey. We would also like to thank members of our PPI (patient and public involvement) Steering Group, who provided many helpful comments on documents and reports that formed part of our early evaluation. This work is an independent evaluation commissioned and funded by the Department of Health's Policy Research Programme. The views expressed are not necessarily those of the Department or its partners.

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Section: "My Care Is Planned With People Who Work Together To Understmentioning

confidence: 99%

Early findings from the evaluation of the Integrated Care and Support Pioneers in England

Erens

Wistow

Mounier-Jack

et al. 2017

JICA

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“…The Partnerships for Older People Projects (POPPs) 2006-09 had an effect on emergency bed days (Windle et al, 2009) and the Integrated Care Pioneers launched in 2013 claim some success in reducing the growth of emergency admissions (NHS England, 2017). However, evaluations of the Evercare pilots of case management for older people 2003-05 (Gravelle et al, 2007) and the Integrated Care Pilots 2009-11 (Roland et al, 2012) failed to show the desired impact on emergency admissions, although other benefits of the programmes were identified. A Nuffield Trust review of community-based interventions concluded that out of more than 30 evaluations, only one intervention had reduced emergency hospital admissions and therefore costs to the NHS (Bardsley et al, 2013).…”

Section: Integrated Care For Older Peoplementioning

confidence: 99%

New models of care: the policy discourse of integrated care

Hughes¹

2017

PPP

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New models of care are being pursued throughout England to balance increasing demand for improved health and social care services against reducing public expenditure. A dominant discourse has emerged about the value of community-based integrated care, despite failures of integrated care programmes to consistently demonstrate reductions in hospital admissions. Discourse analysis of integrated care policy establishes how issues of aging, hospital admissions and fragmentation are problematised, and how solutions of integrated care are made possible by the argumentative structures of the policy. These findings are discussed in relation to historical and political accounts of English health policy to identify the discursive conditions that contribute to making this discourse possible. It is argued that the policy of integrated care works as a discourse to manage tensions associated with health and social care funding, rather than as an intervention that can achieve a reduction in hospital admissions.Keywords: Interpretative policy analysis, discourse analysis, integrated health and social care, emergency hospital admissions, chronic health conditions, older people.Interpretative policy analysis, discourse analysis, integrated health and social care, emergency hospital admissions, chronic health conditions, older people Integrated care is a long-standing policy response by successive UK governments to concerns about the cost and complexity of the NHS and social services. The policy to integrate health and social care is intended to address inter-related financial, organisational and patient-centred concerns. Policies of integration and joining-up of services, budgets and government departments are neither limited to health policy, nor are new. A case study of the successful integration of health and social care for older people in Torbay (Thistlethwaite, 2011) refers to the Central Policy Review Staff's Joint Framework for Social Policies produced in 1975 to demonstrate the longevity of an approach that endorses inter-agency working. Similarly to efforts to integrate care, the Joint Framework seeks to constrain expenditure on social programmes and improve coordination between services, as well as conducting better analysis of complex problems (HMSO, 1975). Concerns relating to the high proportion of public sector resources people with complex needs consume as they receive a multiplicity of interventions from

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“…Of the 11 studies, eight were European, consisting of four studies (and five papers) from England, 48,49,52,54,55 two (related studies) in Germany, 27,46 one in Scotland 44 and one in Spain. 53 Three studies were undertaken in North America, one in Canada 45 and two in the USA (yielding three papers).…”

Section: Settingsmentioning

confidence: 99%

“…This included the use of community matrons 48,52,54,55 -senior nurses with a care co-ordination function, 54 who were introduced following Department of Health funding in support of the care of patients with long-term conditions. 60 The intended use of multidisciplinary teams (MDTs) was noted in five studies, 44,45,47,49,54 and virtual wards featured in three. 45,54,56 The virtual ward model is based on the use of predictive models to identify those at risk of emergency admission, and the provision of a period of intensive, multidisciplinary case management at home using the processes and staff associated with hospital wards.…”

Section: Interventionsmentioning

confidence: 99%

“…48,49,52,54,55 PARR uses data on prior hospitalisations to predict risk of rehospitalisation and, hence, calculates risk only for those patients with a previous admission. The combined predictive model was reported in three studies, 48,49,52 with single references to the Elder Risk Assessment (ERA), 50 Case Smart Suite Germany, 46 Length of stay, Acuity, Comorbidities, ED visits in previous 6 months (LACE), 45 Nairn Case Finder, 44 High Impact User Manager 52 and Adjusted Clinical Groups (ACGs). 53 An unnamed tool developed by the Senior Care Action Network Health Plan was used for the Levine et al study.…”

Section: Risk Tools Identifiedmentioning

confidence: 99%

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Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC)

Snooks

Bailey-Jones

Burge-Jones

et al. 2018

Health Serv Deliv Res

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Background With a higher proportion of older people in the UK population, new approaches are needed to reduce emergency hospital admissions, thereby shifting care delivery out of hospital when possible and safe. Study aim To evaluate the introduction of predictive risk stratification in primary care. Objectives To (1) measure the effects on service usage, particularly emergency admissions to hospital; (2) assess the effects of the Predictive RIsk Stratification Model (PRISM) on quality of life and satisfaction; (3) assess the technical performance of PRISM; (4) estimate the costs of PRISM implementation and its effects; and (5) describe the processes of change associated with PRISM. Design Randomised stepped-wedge trial with economic and qualitative components. Setting Abertawe Bro Morgannwg University Health Board, south Wales. Participants Patients registered with 32 participating general practices. Intervention PRISM software, which stratifies patients into four (emergency admission) risk groups; practice-based training; and clinical support. Main outcome measures Primary outcome – emergency hospital admissions. Secondary outcomes – emergency department (ED) and outpatient attendances, general practitioner (GP) activity, time in hospital, quality of life, satisfaction and costs. Data sources Routine anonymised linked health service use data, self-completed questionnaires and staff focus groups and interviews. Results Across 230,099 participants, PRISM implementation led to increased emergency admissions to hospital [ΔL = 0.011, 95% confidence interval (CI) 0.010 to 0.013], ED attendances (ΔL = 0.030, 95% CI 0.028 to 0.032), GP event-days (ΔL = 0.011, 95% CI 0.007 to 0.014), outpatient visits (ΔL = 0.055, 95% CI 0.051 to 0.058) and time spent in hospital (ΔL = 0.029, 95% CI 0.026 to 0.031). Quality-of-life scores related to mental health were similar between phases (Δ = –0.720, 95% CI –1.469 to 0.030); physical health scores improved in the intervention phase (Δ = 1.465, 95% CI 0.774 to 2.157); and satisfaction levels were lower (Δ = –0.074, 95% CI – 0.133 to –0.015). PRISM implementation cost £0.12 per patient per year and costs of health-care use per patient were higher in the intervention phase (Δ = £76, 95% CI £46 to £106). There was no evidence of any significant difference in deaths between phases (9.58 per 1000 patients per year in the control phase and 9.25 per 1000 patients per year in the intervention phase). PRISM showed good general technical performance, comparable with existing risk prediction tools (c-statistic of 0.749). Qualitative data showed low use by GPs and practice staff, although they all reported using PRISM to generate lists of patients to target for prioritised care to meet Quality and Outcomes Framework (QOF) targets. Limitations In Wales during the study period, QOF targets were introduced into general practice to encourage targeting care to those at highest risk of emergency admission to hospital. Within this dynamic context, we therefore evaluated the combined effects of PRISM and this contemporaneous policy initiative. Conclusions Introduction of PRISM increased emergency episodes, hospitalisation and costs across, and within, risk levels without clear evidence of benefits to patients. Future research (1) Evaluation of targeting of different services to different levels of risk; (2) investigation of effects on vulnerable populations and health inequalities; (3) secondary analysis of the Predictive Risk Stratification: A Trial in Chronic Conditions Management data set by health condition type; and (4) acceptability of predictive risk stratification to patients and practitioners. Trial and study registration Current Controlled Trials ISRCTN55538212 and PROSPERO CRD42015016874. Funding The National Institute for Health Research Health Services Delivery and Research programme.

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Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation

Cited by 62 publications

References 29 publications

Early findings from the evaluation of the Integrated Care and Support Pioneers in England

Early findings from the evaluation of the Integrated Care and Support Pioneers in England

New models of care: the policy discourse of integrated care

Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC)

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