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Against a background of an ageing population, rising emergency admissions and a policy direction moving towards providing care in the least intensive setting, this paper presents the dramatic results achieved in a 22‐week pilot of undivided health and social care replicating the Castlefields study and using Unique Care principles. In the context of practice‐based commissioning, where GP practices develop and commission services that represent the best model of care and use of resources for their patients, the potential for creating savings from this approach are discussed.

The purpose of this paper is to observe and analyse the effects of the use of telemedicine in care homes on the use of acute hospital resources.

The study was an uncontrolled retrospective observational review of data on emergency hospital admissions and Emergency Department (ED) visits for care home residents in Airedale, Wharfedale and Craven. Acute hospital activity for residents was observed before and after the installation of telemedicine in 27 care homes. Data from a further 21 care homes that did not use telemedicine were used as a control group, using the median date of telemedicine installation for the “before and after” period. Patient outcomes were not considered.

Care homes with telemedicine showed a 39 per cent reduction in the costs of emergency admissions and a 45 per cent reduction in ED attendances after telemedicine installation. In the control group reductions were 31 and 31 per cent, respectively. The incremental difference in costs between the two groups of care homes was almost £1.2 million. The cost of telemedicine to care commissioners was £177,000, giving a return on investment over a 20-month period of £6.74 per £1 spent.

The results should be interpreted carefully. There is inherent bias as telemedicine was deployed in care homes with the highest use of acute hospital resources and there were some methodological limitations due to poor data. Nevertheless, controlling the data as much as possible and adopting a cautious approach to interpretation, it can be concluded that the use of telemedicine in these care homes was cost-effective.

There are very few telemedicine studies focused on care homes.

The purpose of this paper is to identify and analyse the readmission risk prediction tools reported in the literature and their benefits when it comes to healthcare organisations and management.

Readmission risk prediction is a growing topic of interest with the aim of identifying patients in particular those suffering from chronic diseases such as congestive heart failure, chronic obstructive pulmonary disease and diabetes, who are at risk of readmission. Several models have been developed with different levels of predictive ability. A structured and extensive literature search of several databases was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis strategy, and this yielded a total of 48,984 records.

Forty-three articles were selected for full-text and extensive review after following the screening process and according to the eligibility criteria. About 34 unique readmission risk prediction models were identified, in which their predictive ability ranged from poor to good (c statistic 0.5–0.86). Readmission rates ranged between 3.1 and 74.1% depending on the risk category. This review shows that readmission risk prediction is a complex process and is still relatively new as a concept and poorly understood. It confirms that readmission prediction models hold significant accuracy at identifying patients at higher risk for such an event within specific context.

Since most prediction models were developed for specific populations, conditions or hospital settings, the generalisability and transferability of the predictions across wider or other contexts may be difficult to achieve. Therefore, the value of prediction models remains limited to hospital management. Future research is indicated in this regard.

This review is the first to cover readmission risk prediction tools that have been published in the literature since 2011, thereby providing an assessment of the relevance of this crucial KPI to health organisations and managers.

Following the development of a service that consisted of a “single point of contact” to coordinate end-of-life care (EoLC), including EoLC facilitators and an urgent response team, we aimed to explore whether the provision of coordinated EoLC would support patients being cared or dying in their preferred place and avoid unwanted hospital admissions.

Using a realist evaluation approach, the authors examined “what worked for whom, how, in what circumstances and why”. Multiple data were collected, including activity/performance indicators, observations of management meetings, documents, satisfaction survey and 30 interviews with service providers and users.

Advance care planning (ACP) increased through the first three years of the service (from 45% to 83%) and on average 74% of patients achieved preferred place of death. More than 70% of patients avoided an emergency or unplanned hospital admission in their last month of life. The mechanisms and context identified as driving forces of the service included: 7/7 single point of contact; coordinating services across providers; recruiting and developing the workforce; understanding and clarifying new roles; and managing expectations.

This was a service evaluation and the outcomes are related to the specific context and mechanisms. However, findings can be transferable to similar settings.

“Single point of contact” services that offer coordinated EoLC can contribute in supporting people to be cared and die in their preferred place.

This paper provides an evaluation of a novel approach to EoLC and creates a set of hypotheses that could be further tested in similar services in the future.

Homelessness is a colossal issue, precipitated by a wide array of social determinants, and mirrored in substantial health disparities and a revolving hospital door. Connecting people to safe and secure housing needs to be part of the health system response. The paper aims to discuss these issues.

This mixed-methods paper presents emerging findings from the collaboration between an inner city hospital, a specialist homeless medicine GP service and Western Australia’s inaugural Housing First collective impact project (50 Lives 50 Homes) in Perth. This paper draws on data from hospitals, homelessness community services and general practice.

This collaboration has facilitated hospital identification and referral of vulnerable rough sleepers to the Housing First project, and connected those housed to a GP and after hours nursing support. For a cohort (n=44) housed now for at least 12 months, significant reductions in hospital use and associated costs were observed.

While the observed reductions in hospital use in the year following housing are based on a small cohort, this data and the case studies presented demonstrate the power of care coordinated across hospital and community in this complex cohort.

This model of collaboration between a hospital and a Housing First project can not only improve discharge outcomes and re-admission in the shorter term, but can also contribute to ending homelessness which is itself, a social determinant of poor health.

Coordinated care between hospitals and programmes to house people who are homeless can significantly reduce hospital use and healthcare costs, and provides hospitals with the opportunity to contribute to more systemic solutions to ending homelessness.

This article demonstrates how the role of the community matron has developed in Cornwall over the past three years, and how this role can be understood as the lynchpin of an integrated approach to the care and management of patients with complex needs and multiple long‐term conditions. In recent years there has been growing recognition that current models of care delivery would be likely to struggle to meet the future demands of an ageing population. Cornwall's approach is to build on the introduction of the community matron service, and to support a new model of care delivery which will encompass use of assistive technology as an additional tool to support those with long‐term conditions. The article will demonstrate the current effectiveness of the service in terms of savings for the health and social care community, and presents a case study to show how integrated working can be used to facilitate improved outcomes for patients.

This paper aims to demonstrate the approach taken in Norfolk, UK, to engage patients and staff to develop and improve services by stimulating improvements in integrated working. The two year programme focused on making specific improvements that patients said they wanted to see by working with staff who volunteered to take part in the programme.

The “Integrating Care in Norfolk” pilot (ICN) was one of 16 national pilots. GPs from 32 practices worked with local community staff to redesign services to meet “patient pledges”. The impact of changes on patients, staff and services were evaluated locally using questionnaires and by analysing data combined in a performance dashboard. The ICN was subject to both national and local evaluations, which provided a basis for comparison.

The local evaluation showed that progress had been made towards meeting objectives, including patients and staff satisfaction and reducing unplanned admissions. GPs recorded improvements to joint working, and all staff concerned chose to continue the project beyond the pilot period.

The findings of the local evaluation contrasted with those of the national evaluation. The Norfolk study demonstrated the positive impact of integrating care on patients, staff and services. The national study concluded that there were minimal or negative impacts of integrating care, although the study amalgamated all 16 pilots, with very different clients, services and objectives.

The ICN was novel in the way that patients and staff were engaged. Patients were invited to set an agenda for change, and provided a mandate to staff from each organisation to redesign their services. This approach may provide a solution to sustainable integrated working. The ICN was evaluated locally as well as nationally as part of the DH ICP programme, enabling respective findings to be compared and validated.

In a novel approach, two part-time “Link Nurses” within an NE Hampshire practice of 16,500 patients were funded by a local charity, to assess and manage unmet needs of isolated frail elderly patients at home. The paper aims to discuss these issues.

Patients in this vulnerable group with no recorded healthcare contact for a prolonged period were identified from practice computer records. One group was to be assessed at home, and appropriate interventions effected. Follow-up visits or telephone contacts also offered support to carers as well as isolated individuals. A matching quasi control group was identified but not visited, to assess the overall impact on the patients, GP and other healthcare contacts. Difficulties with the control group were encountered and addressed.

Important unmet healthcare needs were found amongst the visited patients, which the nurses were able to address themselves, or refer to the GPs or appropriate agencies. The control group demonstrated greater demand for out-of-hours, GP and district nurse contacts, and more unplanned hospital admissions.

Besides dealing with unmet needs at home, ongoing support by local GP nurses may reduce bed-blocking by moving away from “crisis management” of patients in this vulnerable group.

Few other trials have employed practice nurses to see and manage frail elderly patients in their homes.

Polypharmacy, the concurrent use of multiple medicines by one individual, is a common and growing challenge driven by an ageing population and the growing number of people living longer with chronic conditions. Up to 11% of unplanned hospital admissions in the UK are attributable to, mostly avoidable, harm from medicines. However, this topic is not yet central to integrated practice. This paper reviews the challenge that polypharmacy presents to the health and care system and offers lessons for integrated policy and practice.

Two commonly encountered scenarios illustrate the relevance of addressing inappropriate polypharmacy to integrated practice. An overview of the literature on polypharmacy and frailty, including two recent large studies of policy and practice in Europe, identifies lessons for practitioners, managers, policy makers and commissioners.

Comprehensive change strategies should extend beyond pharmacist led deprescribing initiatives. An inter-professional and systems thinking approach is required, so all members of the integrated team can play their part in realising the value of holistic prescribing, appropriate polypharmacy and shared decision making.

Awareness and education about polypharmacy should be embedded in inter-professional training for all practitioners who care for people with multimorbidity or frailty.

This paper will help policy makers, commissioners, managers and practitioners understand the value of addressing polypharmacy within their integrated services. Best practice national guidance developed in Scotland illustrates how to target resources so those at greatest risk of harm from polypharmacy can benefit from effective pharmaceutical care as part of holistic integrated care.

The purpose of this paper is to show how the new arrangements for commissioning services in the English NHS can facilitate innovations in service delivery leading to improvements in outcomes and cost effectiveness.

The study uses cost modelling based upon the Hospital Episodes Statistics compiled by the NHS Information Centre to calculate recent expenditure upon treatment of routine childhood illnesses managed as short stay hospital admissions, and then uses a case study of a children's walk‐in centre to show how an alternative service can be provided, and a new service embedded in general practice to show a further alternative type of provision.

The study finds that large sums are currently being spent on inappropriate treatment of routine childhood conditions, especially in large urban conurbations. It demonstrates that in the case studies, the alternative provision can provide a viable and effective alternative.

The research is based upon historical data by necessity. The new commissioning groups are not co‐located with the historical PCTs on which this study is based. The data are collected by providers and co‐ordinated by the NHS Information Centre. Therefore the investigators do not have control over the data quality. The second case study is a new service and therefore is used as an illustration of other service types.

This study suggests that paediatric ambulatory services can be provided at lower cost with better outcomes.

This study provides the basis for a pilot study in Salford, where additional social benefits are targeted including better school attendance and increased self‐awareness over child health amongst local families.

The study provides quantitative evidence for commissioning alternative paediatric ambulatory services.