Reducing inequality in avoidable emergency admissions: Case studies of local health care systems in England

Reducing inequality in avoidable emergency admissions: Case studies of local health care systems in England using a realist approach.
J Health Serv Res Policy. 2021 Jul 21:13558196211021618. doi: 10.1177/13558196211021618.

• People in disadvantaged areas are more likely to have an avoidable emergency hospital admissions. This study used case studies of five CCGs with varying levels of socio-economic inequality to identify potential determinants of avoidable emergency admissions.

Abstract

Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions

Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions.
BMC Health Serv Res. 2021 Jul 12;21(1):687. doi: 10.1186/s12913-021-06692-x.

• An evaluation of the impact on emergency hospital admissions of two large nationally-initiated service integration programmes in England: the Pioneer (November 2013 to March 2018) and Vanguard (January 2015 to March 2018) programmes found that health and social care integration programmes can mitigate but not prevent rises in emergency admissions over the longer-term.

Abstract

Reducing preventable admissions to hospital and long-term care – A High Impact Change Model LGA

Reducing preventable admissions to hospital and long-term care – A High Impact Change Model
LGA

• This High Impact Change Model aims to support local care, health, and wellbeing partners to work together to prevent, delay or divert the need for acute hospital or long-term bed-based care.
• The model focuses on two goals and five high impact changes that help realise one or both goals. 
• The two goals are:
• Goal 1: Prevent crisis: Actions to prevent crises developing or advancing into preventable admissions
• Goal 2: Stop crisis becoming an admission: Actions to divert or prevent an attendance at A&E becoming an admittance to hospital or long-term bed-based care
• The five high impact changes and the goal or goals they relate to:
• Change 1: Population health management approach to identifying those most at risk (Goal 1)
• Change 2: Target and tailor interventions and support for those most at risk (Goal 1)
• Change 3: Practise effective multi-disciplinary working (Goals 1 and 2)
• Change 4: Educate and empower individuals to manage their health and wellbeing (Goals 1 and 2)
• Change 5: Provide a coordinated and rapid response to crises in the community (Goal 2)
•  Case studies and supporting materials are included as appropriate.

Hospital admissions after vertical integration of general practices with an acute hospital

Hospital admissions after vertical integration of general practices with an acute hospital: a retrospective synthetic matched controlled database study
British Journal of General Practice 2020; 70 (699): e705-e713. DOI: https://doi.org/10.3399/bjgp20X712613

• A retrospective database study using synthetic controls of an NHS hospital in Wolverhampton integrated with 10 general practices, providing primary medical services for 67 402 registered patients. 
•  Across the 10 practices, pooled rates of ED attendances did not change significantly after vertical integration. However, there were statistically significant reductions in the rates of unplanned hospital admissions and unplanned hospital readmissions per 100 patients per month. These effect sizes represent 888 avoided unplanned hospital admissions and 168 readmissions for a population of 67 402 patients per annum. Utilising NHS reference costs, the estimated savings from the reductions in unplanned care are ∼£1.7 million.

Evaluation of the impact of the Vanguard programme on hospital admissions

New integrated care models in England associated with small reduction in hospital admissions in longer-term: A difference-in-differences analysis
Health Policy August 2020 124(8) p826-833 https://doi.org/10.1016/j.healthpol.2020.06.004

• An evaluation of the New Care Models programme (2015-18) found that Vanguard sites had higher hospital utilisation than non-participants in the pre-intervention period. In the post-intervention period, there is clear evidence of a substantial increase in emergency admissions among non-Vanguard sites. The Vanguard integrated care programme slowed the rise in emergency admissions, especially in care home sites and in the third and final year. There was no significant reduction in bed-days. The researchers conclude that integrated care policies should not be relied upon to make large reductions in hospital activity in the short-run, especially for population-based models.
• NIHR Evidence - The Vanguard programme to integrate health and social care achieved some of its aims but took time to show an effect - Informative and accessible health and care research

Hospital discharge and preventing unnecessary hospital admissions (COVID-19)

Hospital discharge and preventing unnecessary hospital admissions (COVID-19)
SCIE August 2020

• This guide discusses the lessons learned from hospital discharge and avoidance during the COVID-19 pandemic. It highlights challenges faced and good practice to prevent unnecessary admissions going forward.

Determining when a hospital admission of an older person can be avoided in a subacute setting: a systematic review and concept analysis

Determining when a hospital admission of an older person can be avoided in a subacute setting: a systematic review and concept analysis
Journal of Health Services Research & Policy, 1355819619886885 5 Dec 2019 https://doi.org/10.1177/1355819619886885 [not available through NHS OpenAthens]

• A systematic review of the evidence for when a hospital admission for an older person can be avoided in subacute settings. identified 17 studies. Analysis identified a set of criteria for ambulatory care sensitive conditions and common medical scenarios for the older person that can be treated in the subacute setting with appropriate tools and resources.

Abstract

Evaluating integrated care: why are evaluations not producing the results we expect?

Evaluating integrated care: why are evaluations not producing the results we expect?
Nuffield Trust 18 November 2019

• With a number of different integrated care models not reducing hospital admissions as expected, this briefing outlines the reasons why this might be happening highlighting model design, design, implementation failure, unrealistic expectations, and underuse of process evaluation. 
• It includes advice for model design and implementation, for commissioners of evaluation, and for evaluators on how to address these issues.

Outcomes of hospital admissions among frail older people: a 2-year cohort study

Outcomes of hospital admissions among frail older people: a 2-year cohort study
British Journal of General Practice 2019; 69 (685): e555-e560. DOI:https://doi.org/10.3399/bjgp19X704621

• This study compared 2 year mortality for cohorts of patients from two populations aged ≥70 years discharged from hospital units: those following short ‘ambulatory’ admissions (<72 admissions.="" after="" ambulatory="" and="" are="" discharged="" even="" experience="" following="" found="" frailty="" from="" hospital="" hours="" increased="" individuals="" inpatient="" it="" li="" longer="" mortality="" resource="" short="" stays.="" that="" those="" use="" was="" who="" with="">

Abstract

Personalised Integrated Care Programme: Evaluation of impact on hospital activity

Personalised Integrated Care Programme: Evaluation of impact on hospital activity
Nuffield Trust 31 January 2019

• Age UK’s Personalised Integrated Care Programme (PICP) aims to improve the lives of older people through practical support, underpinned by a change in the way that the health and care system works together for these people locally. The scheme is targeted at older people who are deemed to be at risk of a future emergency admission.
• Detailed analysis (n=1996) concludes that it has almost certainly not been able to reduce costs or emergency admissions. While in some areas there was no apparent impact on hospital activity, overall there was a higher than expected use of emergency and outpatient services, and a corresponding increase in costs. 
• The results suggest that the scheme may be identifying unmet need in the population, which manifests in greater use of hospital care. 

Reducing emergency hospital admissions: a population health complex intervention of an enhanced model of primary care and compassionate communities

Reducing emergency hospital admissions: a population health complex intervention of an enhanced model of primary care and compassionate communities
Br J Gen Pract 8 October 2018; bjgp18X699425

• This retrospective study measured the impact of a complex intervention from a General Practice in Frome, Somerset over a 44-month period on unplanned admissions to hospital. The intervention, based on patient-centred goal setting and care planning combined with a compassionate community social approach, demonstrated a progressive reduction in unplanned admissions.

Understanding new models of integrated care: a systematic review

Understanding new models of integrated care in developed countries: a systematic review
Health Services and Delivery Research v6(29) August 2018

• A systematic review of the research literature on new models of care identified three outcomes in which the research was more in agreement: (1) that new models may increase patient satisfaction, (2) that staff believe that the quality of care is improved and (3) that new models may increase patient access to services. 
• There was some suggestion that patient waiting time and the number of outpatient appointments may be reduced. The research studies did not agree regarding outcomes such as length of stay in hospital, numbers of admissions and appointments and whether new models might increase or reduce the cost of health-care provision.

See NIHR signal Ways of integrating care that better coordinate services may benefit patients

Plain English Summary

Medicine safety: indicators for safer prescribing

Medicine safety: indicators for safer prescribing
DHSC 10 May 2018

• The Medicines Safety Programme is developing a series of prescribing indicators which link prescribing data with hospital admission. The purpose is to identify prescribing that could potentially increase the risk of harm and that may be associated with hospital admission. 
• The indicators will be available on an open access Medicines Safety Dashboard.

Variations in mortality across the week following emergency admission to hospital

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14
Health Services and Delivery Research November 2017, 5(30)

• Retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. 
• Nationally excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes after severity of patient illness was accounted for. Mortality rates are also elevated for patients admitted during night-time periods. 
• The estimated cost of implementing 7-day services exceeds the maximum amount that the NICE would recommend the NHS should spend on eradicating excess mortality at weekends.

Flow of patients between the NHS and social care - local performance metrics

Local area performance metrics
Department of Health, 29 November 2017

• A new dashboard which allows local areas of assess the flow of patients across the boundary between the NHS and social care. 
• It provides a set of six measures indicating how health and social care partners in every Local Authority area in England are performing at the interface between health and social care. Included in the dashboard is a breakdown of delayed days attributable to social care per 100,000 of the population and the equivalent for NHS-attributable delays. 
• The metrics are:
• Emergency Admissions (65+) per 100,000 65+ population 
• 90th percentile of length of stay for emergency admissions (65+) 
• TOTAL Delayed Days per day per 100,000 18+ population 
• Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/ rehabilitation services 
• Proportion of older people (65 and over) who are discharged from hospital who receive reablement/ rehabilitation services 
• Proportion of discharges (following emergency admissions) which occur at the weekend 

Mortality risks and A&E admissions at weekends

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records
Lancet 9 May 2017 DOI: http://dx.doi.org/10.1016/S0140-6736(17)30782-1

• This analysis of mortality rate (within 30 days) of emergency admission to four NHS hospitals used a range of common haematology and biochemistry test results or other proxies for workload did not find an association between hospital workload and mortality. It is suggested that the weekend effect arises from patient-level differences at admission rather than reduced hospital staffing or services.

Abstract:

Health and housing: building the evidence base

Health and housing: building the evidence base
Housing LIN, 3 April 2017

• This evidence review suggests that closer working between the NHS and the housing sector can help reduce hospital admissions and emergency department visits, speed up the discharge of older patients and maintain the independence of older people.

Shifting the balance of care: Great expectations

Shifting the balance of care: Great expectations
Nuffield Trust 1 March 2017

• Drawing on a review of the STPs and an in-depth literature review of 27 initiatives to move care out of hospital, the report looks their impact, particularly on cost, and what has contributed to their success or otherwise. ( A number of brief case studies are included)
•  It explores five key areas: elective care, urgent and emergency care, admission avoidance and easier discharge, at risk populations, and self-care.
• The analysis suggests that some STPs are targeting up to 30% reductions in some areas of hospital activity, including outpatient care, A&E attendances and emergency inpatient care over the next four years but at the same time suggests that the falls in hospital activity projected in many STPs will be extremely difficult to realise as the economic benefits are frequently overstated.
• Where schemes have been most successful, they have: targeted particular patient populations; improved access to specialist expertise in the community; provided active support to patients including continuity of care; appropriately supported and trained staff; and addressed a gap in services rather than duplicating existing work.
• The report concludes that, while out-of-hospital care may be better for patients, it is not likely to be cheaper for the NHS in the short to medium term – and certainly not within the tight timescales under which the STPs are expected to deliver change. The wider problem remains: more patient-centred, efficient and appropriate models of care require more investment than is likely to be possible given the current funding envelope. 

Geographic variation in unplanned admissions

Using geographic variation in unplanned ambulatory care sensitive condition admission rates to identify commissioning priorities: an analysis of routine data from England
Journal of Health Services Research & Policy, 30 November 2016

Abstract
Objectives: To use geographic variation in unplanned ambulatory care sensitive condition admission rates to identify the clinical areas and patient subgroups where there is greatest potential to prevent admissions and improve the quality and efficiency of care.

Methods: We used English Hospital Episode Statistics data from 2011/2012 to describe the characteristics of patients admitted for ambulatory care sensitive condition care and estimated geographic variation in unplanned admission rates. We contrasted geographic variation across admissions with different lengths of stay which we used as a proxy for clinical severity. We estimated the number of bed days that could be saved under several scenarios.

Results: There were 1.8 million ambulatory care sensitive condition admissions during 2011/2012. Substantial geographic variation in ambulatory care sensitive condition admission rates was commonplace but mental health care and short-stay (less than 2 days) admissions were particularly variable. Reducing rates in the highest use areas could lead to savings of between 0.4 and 2.8 million bed days annually.

Conclusions: Widespread geographic variations in admission rates for conditions where admission is potentially avoidable should concern commissioners and could be symptomatic of inefficient care. Further work to explore the causes of these differences is required and should focus on mental health and short-stay admissions.

Investigations into unsafe discharge from hospital

A report of investigations into unsafe discharge from hospital
Parliamentary and Health Service Ombudsman 11 May 2016

• This report focuses on nine experiences drawn from recent complaints which illustrate the problems with regards to unsafe discharge from hospital. The most serious issues identified are:
• Issue one: Patients being discharged before they are clinically ready to leave hospital
• Issue two: Patients not being assessed or consulted properly before their discharge
• Issue three: Relatives and carers not being told that their loved one has been discharged
• Issue four: Patients being discharged with no home-care plan in place or being kept in hospital due to poor co-ordination across services
• The report highlights three key areas that warrant particular attention:
• Failures to check people's mental capacity and offer legal protections for those who lack capacity
• Carers and relatives not being treated as partners in discharge planning
• Poor co-ordination within and between services