Goodwin et al, 2012, · Web viewScheme ref no. SN2 Scheme name: Supporting independence wellbeing...

ANNEX 1 – Detailed Scheme Description: Evidence Base

Scheme ref no. NN1

Scheme name: Predictive Modelling & Complex Need Risk Stratification,including End of Life Support

The evidence basePlease reference the evidence base which you have drawn on

- to support the selection and design of this scheme- to drive assumptions about impact and outcomes

Predictive Modelling & Complex Need Risk Stratification

Statistical models can be used to identify or predict individuals who are at high risk of future hospital admissions in order to target care to prevent emergency admissions. The evaluation of predictive modelling options1 suggests including GP data in predictive modelling is particularly important, and including all patients in an area rather than just those with prior hospital use was found to improve case-finding. It also suggests2 using an ‘impactability model’ to identify high risk patients who are most likely to benefit from preventive care.

End of Life Support

There is evidence that Marie Curie nursing services delivering nursing support at the end of life is effective at reducing emergency admissions compared with similarly matched controls. In addition, patients cared for by Marie Curie nurses were significantly more likely to die at home and had lower average costs of all hospital services. 3 4

The King’s Fund report ‘Transforming Our HealthCare System – ten priorities for commissioners’ recommends for end of life care, commissioners should contract for a pathway or package of care in order to encourage providers to work together to deliver a more streamlined service. However, packages should be structured so that they can cater for a range of individual needs and preferences5.

1 Lewis G, Georghiou T, Steventon A, Vaithianathan R, Chitnis X, Billings J, Blunt I, Wright L, Roberts A, Bardsley M (2013). Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. London: NIHR Service Delivery and Organisation programme. www.nets.nihr.ac.uk/__data/assets/pdf_file/0011/87923/FR-09-1816-1021.pdf2 Bennett L & Humphries R, 2014. ‘Making best use of the Better Care Fund: Spending to save?’ The King’s Fund3 Chitnis X,et al (2012) The Impact of the Marie Curie Nursing Service on Place of Death and Hospital Use at theEnd of Life. Nuffield Trust.4 Chitnis X, et al (2013) ‘Effect of a home-based end-of-life nursing service on hospital use at the end of life and place of death: a study using administrative data and matched controls’, BMJ Supportive & Palliative Care 1–9.5 Naylor et al – revised 2013 - ‘Transforming Our HealthCare System – ten priorities for commissioners’ - The king’s Fund http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/10PrioritiesFinal2.pdf

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Scheme ref no. NN2

Scheme name: Integrated Community Care Teams,including reablement and rehabilitation



Integrated Community Care Teams

Evaluating integrated and community-based care – the Nuffield Trust review of national integrated care pilots and virtual wards6 showed reductions in planned admissions and in outpatient attendances for some interventions that involved case management using multidisciplinary teams and those using virtual wards, but no evidence of a general reduction in emergency admissions.

King’s Fund analysis of the evidence7 suggests that joint commissioning between health and social care that results in a multi-component approach is likely to achieve better results than those that rely on a single or limited set of strategies.

The Torbay integrated care model has reduced the use of hospital beds by a third from 750 in 1998/1999 to 502 in 2009/2010. Emergency bed day use for people aged 75 and over fell by 24% between 2003 and 2008 and by 32% for people aged 85 and over8 9.

The Institute of Public Care at Oxford Brookes University reports that joint health and social care investment in dental care, podiatry services, incontinence, dehydration monitoring (liquid intake), falls prevention and stroke recovery services has a positive impact on admissions to residential care10.

Structured Discharge Planning by multi-disciplinary teams

A Cochrane database systematic review of hospital discharge planning provides robust evidence that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to

6 Evaluating integrated and community-based care – a review of national integrated care pilots and virtual wards http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/evaluation_summary_final.pdf

7 Goodwin et al, 2012, Integrated care for patients and populations: Improving outcomes by working together – The

King’s Fund: http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together8 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/south-devon-and-torbay-coordinated-care-case-study-kingsfund13.pdf9 Thistlethwaite, P. (2011) "Integrating health and social care in Torbay: improving care for Mr Smith" The King's Fund, London: http://www.kingsfund.org.uk/sites/files/kf/field/field_document/PARR-combined-predictive-model-final-report-dec06.pdf10 CARE SERVICES IMPROVEMENT PARTNERSHIP. Care Services Efficiency Delivery Programme; Configuring joint preventive services: a structured approach to service transformation and delivering better outcomes for older people

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http://www.scie-socialcareonline.org.uk/searchp.asp?query=author=%22CARE%20SERVICES%20IMPROVEMENT%20PARTNERSHIP.%20Care%20Services%20Efficiency%20Delivery%20Programme%22

http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/south-devon-and-torbay-coordinated-care-case-study-kingsfund13.pdf


hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain. The review assessed randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients11.

A Cochrane systematic review of randomised controlled trials recruiting stroke patients in hospital assessed the difference between those receiving conventional care with those with early discharge with rehabilitation at home (early supported discharge) 12. Results showed that early supportive discharge significantly reduced the length of hospital stay equivalent to approximately seven days. Early Supported Discharge can reduce long-term mortality and institutionalisation rates for up to 50% of patients, as well as lower overall costs.

Specialist team for Continence Care

Urinary incontinence significantly increases the risk of hospitalisation and admission to nursing homes13. An intervention involving behavioural and lifestyle counselling provided by specialised nurses led to reduced incontinent events and incontinence pad use14. This may mean that the costs of professional time are offset by reductions in pad costs15

Reablement and Rehabilitation

Reablement Services

The evidence base for reablement services is limited by a lack of robust studies. However, there is evidence that reablement can reduce on-going homecare costs to social care16. The results showed a reduced use of home care services over time associated with median cost savings per person of approximately AU $12,500 over nearly 5 years when compared with individuals who had received a conventional home care service.

Glendinning et al (2010) showed that there is a 60% reduction in social care costs for those receiving reablement17.

11 Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2013, Issue 1.

12 Fearon P, Langhorne P Services for reducing duration of hospital care for acute stroke patients. Cochrane Database Syst Rev. 2012 Sep 12;9:CD000443.

13 Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age and Ageing 26(5):367-374.14 Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. CMAJ. 14;166(10):1267–127315 Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A guide for commissioners written by continence care professionals http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf

16 Lewin GF et al 2013 - Evidence for the long term cost effectiveness of home care reablement programs. Clin Interv Aging.

2013;8:1273-81.17 Glendinning et al (2010) Home Care Re-ablement Services: Investigating the longer-term impacts (prospective longitudinal study) SPRU/PSSRU report http://socialwelfare.bl.uk/subject-areas/services-activity/social-work-care-services/spru/135160Reablement10.pdf

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Physical Rehabilitation

A Cochrane review of 67 trials, involving 6300 participants showed that physical rehabilitation for long-term care residents may be effective, reducing disability with few adverse events, but effects appear quite small and may not be applicable to all residents. There is insufficient evidence to reach conclusions about improvement sustainability, cost-effectiveness, or which interventions are most appropriate18.

Scheme ref no. NN3

Scheme name: Independence, Self-Care & Self-Management Programme



Independence, Self-Care & Self-Management Programme

Patient self-management seems to be beneficial for patients with COPD and asthma.19 20 21 The Cochrane reviews concluded that education with self-management reduced unplanned hospital admissions in adults with asthma, and in chronic obstructive pulmonary disease COPD patients but not in children with asthma. There is evidence for the role of education in reducing unplanned hospital admissions in heart failure patients22.

There is some evidence that demonstrates that investment in learning for older people can reduce the costs of medical and social care and improve the quality of life for older people, their families and communities, NIACE, 201023.

18 Crocker T Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013 Feb

28;2:CD004294.19 Purdy; Avoiding Hospital Admissions – What does the research evidence say? Kings Fund Dec 2010 http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf

20 Effing T, Self-management education for patients with chronic obstructive pulmonary disease. Cochrane Database

Syst Rev. 2007 Oct 17;(4):CD002990.21 Tapp S, Lasserson T, Rowe B (2007). ‘Education interventions for adults who attend the emergency room for acute asthma (Cochrane Review)’. Cochrane Database of Systematic Reviews, issue 3, article CD003000. DOI: 10.1002/14651858.CD003000.pub2.22 Kirsty J. Boyd; Living with advanced heart failure: a prospective, community based study of patients and their carers The European Journal of Heart Failure 6 (2004) 585– 591

23 NIACE: Lifelong Learning: Contributing to wellbeing and prosperity http://www.niace.org.uk/sites/default/files/2010-Spending-Review.pdf

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http://www.niace.org.uk/sites/default/files/2010-Spending-Review.pdf


Scheme ref no. NN4

Scheme name: Integrated Falls Management Programme



Integrated Falls Management Programme

There have been a series of Cochrane reviews relating to falls prevention24 25. The most recent - a Cochrane review of 159 randomised controlled trials of falls prevention interventions revealed that group and home-based exercise programmes and home safety interventions significantly reduce rate of falls and risk of falling, multifactorial assessment and intervention programmes significantly reduce the rate of falls but not the risk of falling, and Tai Chi significantly reduces the risk of falling but not the rate of falls.

The Cochrane reviews provide additional evidence on the following interventions:

a) Exercise for preventing falls Group and home-based exercise programmes, and home safety interventions

reduce rate of falls and risk of falling. Tai Chi reduces risk of falling.

b) Exercise for improving balance and physical functioning in older people Progressive Resistance Strength Training is an effective intervention for improving

physical functioning in older people, including improving strength and the performance of some simple and complex activities. However, some caution is needed with transferring these exercises for use with clinical populations because adverse events are not adequately reported26.

There is some evidence that some types of exercise (gait, balance, co-ordination and functional tasks; strengthening exercise; 3D exercise and multiple exercise types) are moderately effective, immediately post intervention, in improving clinical balance outcomes in older people.

c) Medications and medical devices Gradual withdrawal of psychotropic medication reduced the rate of, but not risk of

falling. A prescribing modification programme for primary care physicians

24 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for

preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art.

No.: CD007146. DOI: 10.1002/14651858.CD007146.pub325 Interventions for preventing falls in older people in nursing care facilities and hospitals (Review) 2010 The Cochrane Collaboration.26 The Cochrane Library. Falls Prevention and Balance in Older People. Available at: 2011.http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html.

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http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html


significantly reduced risk of falling27. The effectiveness of the provision of hip protectors in reducing the incidence of hip

fracture in older people is still not clearly established. Poor acceptance and adherence by older people offered hip protectors have been key factors contributing to the continuing uncertainty28.

A Department of Health economic evaluation of fracture prevention services has modelled that each hip fracture avoided will save on average over £12,000 for the NHS and £3,879 for social care over two years, and an avoided fracture of the humerus, spine or forearm will avoid over £5,000 for the NHS and over £200 for social care. Over a five year period, the NHS and local authority social care save over £290,000, against an additional £234,181 revenue costs, which nationally equates to a saving of £8.5 million over five years. The model anticipates 797 fractures of the hip, humerus, spine or forearm from a population of 320,000.29

Interventions for preventing falls in older people living in the community found potential cost-savings when delivering falls prevention interventions to subgroups of people at high risk of falling. The Otago Exercise Programme, involving people aged over 80, resulted in fewer hospital admissions and therefore cost-savings30. Salkeld et al found cost-savings when delivering a home safety programme to participants with a previous fall31 and Rizzo et al found cost-savings when delivering a multifactorial intervention of people with four or more of eight risk factors32.

Scheme ref no. NN5

Scheme name: Living Well with Dementia Programme



Living Well with Dementia Programme27Hill KD , Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem Drugs Aging. 2012 Jan 1;29(1):15-30.

28 Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews 2010, Issue 10.29 Department of Health (2009) Fracture Prevention Services: an economic evaluation. http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fractures.pdf30 Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697-70131 Salkeld G, et al, 2000:The cost effectiveness of a home hazard reduction program to reduce falls among older

persons. Aust N Z J Public Health. 2000 Jun;24(3):265-71.32 Rizzo JA et al 1996: The cost-effectiveness of a multifactorial targeted prevention program for falls among

community elderly persons. Med Care. 1996 Sep;34(9):954-69.

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http://www.ncbi.nlm.nih.gov/pubmed/8792783

http://www.ncbi.nlm.nih.gov/pubmed?term=Rizzo%20JA%5BAuthor%5D&cauthor=true&cauthor_uid=8792783


http://www.ncbi.nlm.nih.gov/pubmed?term=Salkeld%20G%5BAuthor%5D&cauthor=true&cauthor_uid=10937402

http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fractures.pdf


In a systematic review of RCTs, four out of six good quality studies found that case management of dementia patients was associated with delayed or reduced institutionalisation, although in one study this was only significant in one of three countries studied. However, none of the good quality studies found evidence for savings in healthcare expenditure or reduced hospitalisation rate/emergency visits. NHS investment in early assessment services for people with dementia can produce significant savings for social care, particularly in relation to residential care (National Dementia Strategy – Impact Assessment – economic case for early assessment and memory services)33.

Scheme ref no. NN6

Scheme name: Urgent Care Programme



Urgent Care Programme

The Keogh report on the Urgent and Emergency Care Review sets out proposals for the future of urgent and emergency care services in England.34 35 There are five key elements, all of which must be taken forward to ensure success. The report suggests that we must – Provide better support for people to self- care. Help people with urgent care needs to get the right advice in the right place, first

time. Provide highly responsive urgent care services outside of hospital so people no

longer choose to queue in A&E. Ensure that those people with more serious or life threatening emergency care needs

receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery.

Connect all urgent and emergency care services together so the overall system becomes more than just the sum of its parts.

The evidence base for change identified a number of areas for improvement within the current system of urgent and emergency care in England.36 37 In summary:33 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf34 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review, End of Phase 1 Report (2013).http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf35 NHS England (2013). Transforming urgent and emergency care services in England - Update on the Urgent and Emergency Care Review (2014).http://www.nhs.uk/NHSEngland/keogh-review/Documents/uecreviewupdate.FV.pdf36 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review, End of Phase 1 Report, Appendix I – Revised Evidence Base from the Urgent and Emergency Care Review.http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%201.EvBase.FV.pdf

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More people are using the urgent and emergency care system to access healthcare, leading to mounting costs and increased pressure on resources.

Overall fragmentation of the system means that many patients may not be able to access the most appropriate urgent or emergency care service to suit their needs, leading to unnecessary attendances and resource use.

Poor access to social care being responsible for both emergency admissions and poorly managed discharge resulting in re-admission or delayed transfers of care.

Accident and Emergency departments have seen a significant number of patients that could be managed in other settings, adding to those with life-threatening conditions.38 One interpretation of this is that the new services are meeting a previously unmet need. Alternatively, it could be that the increased provision has led to supply induced demand and therefore increased uptake, or demand caused by a failure to intervene earlier in the urgent and emergency care pathway or system.

Rising costs across urgent and emergency care services can be associated with fragmentation of the current system of urgent and emergency care. This fragmentation leads to confusion among patients about how and where to access the care they need,39 and many people are unable to navigate to the level of care appropriate to their condition, leading to multiple calls or attendances and unnecessary use of A&E or ambulance services.40 It is estimated that around three-quarters of A&E attendances relate to serious or life-threatening conditions and about one quarter could have been treated elsewhere.41

42 43 However there is variation between different A&E departments, with deprived urban areas having the highest proportion of patients who did not require hospital treatment.

Evidence suggests that patients’ experience of GP services, particularly when related to ease of access, affects uptake and interaction with primary care. This affects the way in which patients choose to access health care because patients that are not satisfied with their GP practice are more likely either to resort to using urgent and emergency care services for primary care needs; or only seek help when they become acutely ill, increasing the risk of emergency admission.44

Urgent care services are highly fragmented and difficult to navigate causing many patients to experience difficulty choosing the service most appropriate to their needs.45 46 Variations in opening hours, clinical expertise, access to diagnostics and nomenclature can lead to confusion and referrals to a number of urgent care services within the same 37 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review End of Phase 1 Report, Appendix 3 – Summary of Engagement Responses.http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%203.Engage.Results.FV.pdf38 Coleman, P et al (2011) Why do patients with minor or moderate conditions that could be managed in other settings attend the emergency department?; Emergency Medicine Journal; 29: 487-49139 NHS Alliance (2012) A practical way forward for clinical commissioners; NHS Alliance on behalf of NHS Clinical Commissioners and sponsored by NHSCB (Now NHS England)40 Bickerton, J. et al (2012) Streaming primary urgent care: a prospective approach; Primary Health Care Research & Development; 13(2): 142-152.41 Cooperative Pharmacy (2011) Reducing needless A&E visits could save NHS millions42 NHS Networks (2011) New Choose Well Campaign43 Self Care Forum (2012) Over 2 million unnecessary A&E visits “wasted”; found at: http://www.selfcareforum.org/2012/10/30/over-2-million-unnecessary-ae-visits-wasted/44 The King’s Fund (2012) Data briefing: improving GP services in England: exploring the association between quality of care and experience of patients45 The King’s Fund (2011) Managing urgent activity – urgent care46 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process; Emergency Medicine Journal

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episode of care. This increases cost, delay and clinical risk and leads to poor patient experience.47

The evidence base for improving urgent and emergency care in England indicates that there is variation in access to primary care services across England leading to many patients accessing urgent and emergency care services for conditions that could be treated in primary care.48

There is a clear need to adopt a whole-system approach to commissioning more accessible, integrated and consistent urgent and emergency care services to meet patients unscheduled care needs.49

Scheme ref no. NN7

Scheme name: Improving Mental Health outcomes



Improving Mental Health outcomes

Intensive Case Management for Mental Health patients

A Kings Fund Paper in 201050 on the research evidence around avoiding hospital admissions recommended that commissioners and providers should consider implementing intensive and/or assertive case management for people with mental health illnesses. This is most effective when focused on patients with frequent hospital use and assertive case management by multidisciplinary teams may reduce mental health admissions.

A Cochrane review of ‘Intensive case management for severe mental illness’ (2011)51 found that ICM is of value at least to people with severe mental illnesses who are in the sub-group of those with high level hospitalisation (about 4 days a month in past 2 years) and the intervention should be performed close to the original model.

Integrating Mental Health into Chronic Disease Management

There is a growing evidence base that suggests that more integrated ways of working with collaboration between mental health and other professionals offers the best chance of improving outcomes for both mental health and physical conditions. There is also 47 Primary Care Foundation (2011) Breaking the mould without breaking the system. Primary Care Foundation48 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process; Emergency Medicine Journal49 NHS England (2013). Transforming urgent and emergency care services in England. http://www.nhs.uk/NHSEngland/keogh-review/Pages/urgent-and-emergency-care-review.aspx50 Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010.51 Intensive case management for severe mental illness (Review). Dieterich M, Irving CB, Park B, Marshall M. Wiley 2010.

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evidence that the costs of including psychological or mental health initiatives within disease management or rehabilitation programmes can be more than outweighed by the savings arising from improved physical health and decreased service use52.

Integrated Care Pathways for Mental Health

An Evidence briefing (2011)53 produced by the Centre for Reviews and Disseminations found that there is some evidence suggesting that ICPs can reduce mental health hospital costs, most studies were not conducted in the UK NHS.

Mental health promotion through early intervention in psychosis is thought to be cost-saving for the NHS54. This involves a multidisciplinary team with emphasis on an assertive approach to maintaining contact with the patient and encouraging a return to normal vocational pursuits. UK evidence shows it can reduce relapse and readmission to hospital and improve quality of life.

Early intervention in psychosis (modelled on a target group of people aged 15-35 years) is thought to save the NHS over £5 for every £1 spent within one year.

Crisis Resolution and Home Treatment for Mental Health patients (CRHT)

Crisis Resolution and Home Treatment (CRHT) services for mental health patients have been shown to decrease unplanned hospital admissions and length of stay55,56.

The National Audit Office suggests that the NHS could save £12-50 million annually by increasing the number of patients taking part in CRHT programmes57 Integration of CRHT or other community teams with inpatient staff can lead to reductions in bed use, and this approach in Norfolk has led to annual savings of approximately £1 million58.

52 The Kings Fund and Centre for Mental Health : Long-term conditions and mental health, Naylor et al 201253 Evidence briefing on integrated care pathways in mental health settings. National Institute for health research. Sept 2011.54 Knapp M, McDaid D, Parsonage M (eds) (2011). Mental Health Promotion and Mental Illness Prevention: The economic case. London: Department of Health.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdf

55 National Audit Offi ce (2007a). Helping People Through Mental Health Crisis: The role of Crisis Resolution and Home Treatment services. London: The Stationery Office. Available at: www.nao.org.uk/publications/0708/helping_people_through_mental.aspx56 Chiles JA, Lambert MJ, Hatch AL (1999). ‘The impact of psychological interventions on medical cost offset: A meta-analytic review’. Clinical Psychology: Science and Practice, vol 6, no 2, pp 204–2057 Howard C, Dupont S, Haselden B, Lynch J, Wills P (2010). ‘The effectiveness of a group cognitive-behavioural breathlessness intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease’. Psychology, Health and Medicine, vol 15, no 4, pp 371–85.58 Department of Health (2009) partnerships for Older people projects final report. London. Department of Health

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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdf

Scheme ref no. SN1

Scheme name: Integrated primary care teams, including risk profiling



Integrated primary care teams






A Cochrane database systematic review of hospital discharge planning provides robust evidence that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health




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outcomes and cost remains uncertain. The review assessed randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients64.



Urinary incontinence significantly increases the risk of hospitalisation and admission to nursing homes66. An intervention involving behavioural and lifestyle counselling provided by specialised nurses led to reduced incontinent events and incontinence pad use67. This may mean that the costs of professional time are offset by reductions in pad costs68.

Risk profiling

Risk stratification or predictive modelling




66 Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age and Ageing 26(5):367-374.67 Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. CMAJ. 14;166(10):1267–127368 Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A guide for commissioners written by continence care professionals. http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf69 Lewis G, Georghiou T, Steventon A, Vaithianathan R, Chitnis X, Billings J, Blunt I, Wright L, Roberts A, Bardsley M (2013). Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. London: NIHR Service Delivery and Organisation programme. www.nets.nihr.ac.uk/__data/assets/pdf_file/0011/87923/FR-09-1816-1021.pdf70 Bennett L & Humphries R, 2014. ‘Making best use of the Better Care Fund: Spending to save?’ The King’s Fund

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Scheme ref no. SN2

Scheme name: Supporting independence wellbeing and self-care;Including: Local integrated housing, health and wellbeing solutions; and tele care



Supporting independence wellbeing and self-care

Education and Self-Management



Local integrated housing, health and wellbeing solutions

Supported and Sheltered Housing

There is some evidence from a variety of case studies that local authorities are able to reduce their spend on residential care and increase the level of support for people to live in their own homes by facilitating supported housing69, 76, 77; for people with learning

71 Purdy; Avoiding Hospital Admissions – What does the research evidence say? Kings Fund Dec 2010 http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf


Syst Rev. 2007 Oct 17;(4):CD002990.73 Tapp S, Lasserson T, Rowe B (2007). ‘Education interventions for adults who attend the emergency room for acute asthma (Cochrane Review)’. Cochrane Database of SystematicReviews, issue 3, article CD003000. DOI: 10.1002/14651858.CD003000.pub2.74 Kirsty J. Boyd; Living with advanced heart failure: a prospective, community based study of patients and their carers The European Journal of Heart Failure 6 (2004) 585– 591

75 NIACE: Lifelong Learning: Contributing to wellbeing and prosperity http://www.niace.org.uk/sites/default/files/2010-Spending-Review.pdf76

77 The Business Case for Extra Care Housing in Adult Social Care: An Evaluation of Extra Care Housing schemes in

East Sussexhttp://www.housinglin.org.uk/Topics/type/resource/?cid=8988&msg=0

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http://www.housinglin.org.uk/Topics/type/resource/?cid=8988&msg=0



disabilities; and for older people (sometimes referred to as extra-care housing, very-sheltered housing or assisted living). The results from the case studies provide growing evidence that even people with medium–high care needs can be supported in their own homes with the right staffing, technology, aids and adaptations. This is recognised in the Government’s national housing strategy for an ageing society, Lifetime Homes, Lifetime Neighbourhoods, and in More Choice, Greater Voice78.

Research into the financial benefits of the Supporting People programme found that for most groups, packages of housing-related support services avoid costs elsewhere and as well as promoting independence produce a net financial benefit. The cost to savings ratio for older people’s housing support was particularly favourable: £327.9m to £1,398.3m79.

Home Improvement Interventions

There is a range of evidence demonstrating the resultant cost benefits of home repairs, adaptations and hospital discharge housing related help in the Fit for Living Network. This showed that for every £1 spent on handyperson services (which provide fast, low cost help with adaptations and repairs), £1.70 was saved, the majority to social services, health and the police; hospital discharge schemes offering housing help to speed up patient release save local government social care budgets at least £120 a day.

An analysis by Care and Repair Cymru of the outcomes of their Rapid Response Adaptations programmes identified that every £1 spent generated £7.50 cost savings to the NHS. These savings were associated with speeded up hospital discharge, prevention of people going into hospital and prevention of accidents and falls in the home providing an adaptation in a timely fashion can reduce social care costs by up to £4,000 a year.

The cost effectiveness of Home adaptations – a report by The University of Bristol based on a review of case studies revealed: 80

Adaptations to the home can reduce the need for Homecare daily visits. In the cases reviewed – between £1,200 and £29,000 saved per year

Savings in home care costs by home adaptations mainly found in younger disabled people. In older people adaptations are found through prevention of accidents or deferring admission to residential care and improved quality of life

Home adaptations can reduce the need for residential care in disabled people Findings on the impact of adaptations include 70% increased feelings of safety and an

increase of 6.2 points on the SF 36 scores for mental health Home adaptations that improve the environment for visually impaired people leads to

savings through prevention of falls. The provision of adaptations and equipment can save money by speeding hospital

discharge and preventing hospital admission Audit commission stresses effectiveness and value of investment in equipment and

adaptation to prevent unnecessary and wasteful health costs

78 Lifetime Homes, Lifetime Neighbourhoods, and in More Choice, Greater Voice – A publication by communities and local government - 2008: http://www.cpa.org.uk/cpa/lifetimehomes.pdf79 Communities and Local Government (July 2009) ‘Research into the financial benefits of the supporting people programme’ http://tiny.cc/k5czx

80 The cost effectiveness of Home adaptations: Report - Better Outcomes, lower costs – University of Bristol Office for Disability Issues (Heywood and Turner, 2007) http://odi.dwp.gov.uk/docs/res/il/better-outcomes-report.pdf

14

http://odi.dwp.gov.uk/docs/res/il/better-outcomes-report.pdf

http://tiny.cc/k5czx

http://www.cpa.org.uk/cpa/lifetimehomes.pdf

Adaptations give support to carers and avoid health care costs for strain and injury

Tele Health

Tele health is effective in reducing hospital admissions in people with chronic heart failure (meta-analysis of 11 randomised controlled trials showed a significant 21% reduction in hospital admissions in this group of patients81.

In addition, the results of a meta-analysis study support the use of telephone-delivered CBT as a tool for improving health in people with chronic illness82.

Tele Care

Tele care and Falls prevention: There is some evidence from a longitudinal prospective cohort study that a light path plus tele-assistance reduced falls and significantly reduced post-fall hospitalisation83.

Tele care and Dementia Care: The British psychological Society (2007) recommends that dementia care plans should include environmental modifications to aid independent functioning84.

Two case studies are highlighted below that show the effectiveness of tele care. This is low quality evidence and must be interpreted with caution. Evidence from evaluation of tele care provision in Essex and impact for social care found that for every £1 spent on tele care, £3.82 was saved in traditional care85. Tele care in North Yorkshire project evaluation estimates one year savings in care packages of £1 million86.

Scheme ref no. SN3

Scheme name: Integrated care for people with dementia


81 Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF (2010). 'Structured telephone support or telemonitoring programmes for patients with chronic heart failure (Cochrane Review)'. Cochrane Database of Systematic Reviews, issue 8, article CD007228.

82 Muller I, Telephone-delivered cognitive behavioural therapy: a systematic review and meta-analysis. J Telemed

Telecare . 2011;17(4):177-84.83 E.A. Tchalla, et al The effect of fall prevention and management technologies Gerontechnology 2012; 11(2):347

84The British Psychological Society (2007) Dementia – available at: http://www.nice.org.uk/nicemedia/pdf/CG42Dementiafinal.pdf85 Evaluating telecare and telehealth interventionsWSDAN briefing paper: http://www.kingsfund.org.uk/sites/files/kf/Evaluating-telecare-telehealth-interventions-Feb2011.pdf86 Department of Health (2009) ‘Use of resources in adult social care A guide for local authorities’ http://www.thinklocalactpersonal.org.uk/_library/Resources/Personalisation/Personalisation_advice/298683_Uses_of_Resources.pdf

15

http://www.kingsfund.org.uk/sites/files/kf/Evaluating-telecare-telehealth-interventions-Feb2011.pdf




Integrated care for people with dementia


Scheme ref no. SN4

Scheme name: Integrated falls prevention



Integrated falls prevention



a) Exercise for preventing falls Group and home-based exercise programmes, and home safety interventions


b) Exercise for improving balance and physical functioning in older people

87 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf88 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for


No.: CD007146. DOI: 10.1002/14651858.CD007146.pub389 Interventions for preventing falls in older people in nursing care facilities and hospitals (Review) 2010 The Cochrane Collaboration.

16

Progressive Resistance Strength Training is an effective intervention for improving physical functioning in older people, including improving strength and the performance of some simple and complex activities. However, some caution is needed with transferring these exercises for use with clinical populations because adverse events are not adequately reported90.


c) Medications and medical devices Gradual withdrawal of psychotropic medication reduced the rate of, but not risk of

falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling91.

The effectiveness of the provision of hip protectors in reducing the incidence of hip fracture in older people is still not clearly established. Poor acceptance and adherence by older people offered hip protectors have been key factors contributing to the continuing uncertainty92.



90 The Cochrane Library. Falls Prevention and Balance in Older People. Available at: 2011.http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html.91Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem Drugs Aging. 2012 Jan 1;29(1):15-30.

92 Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews 2010, Issue 10.93 Department of Health (2009) Fracture Prevention Services: an economic evaluation. http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fractures.pdf94 Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697-70195 Salkeld G, et al, 2000:The cost effectiveness of a home hazard reduction program to reduce falls among older

persons. Aust N Z J Public Health. 2000 Jun;24(3):265-71.96 Rizzo JA et al 1996: The cost-effectiveness of a multifactorial targeted prevention program for falls among

17








Scheme ref no. SN5

Scheme name: Urgent Care Programme



Urgent Care Programme

The Keogh report on the Urgent and Emergency Care Review sets out proposals for the future of urgent and emergency care services in England.97 98 There are five key elements, all of which must be taken forward to ensure success. The report suggests that we must – Provide better support for people to self- care. Help people with urgent care needs to get the right advice in the right place, first




Connect all urgent and emergency care services together so the overall system becomes more than just the sum of its parts.

The evidence base for change identified a number of areas for improvement within the current system of urgent and emergency care in England.99 100 In summary: More people are using the urgent and emergency care system to access healthcare,

leading to mounting costs and increased pressure on resources. Overall fragmentation of the system means that many patients may not be able to

access the most appropriate urgent or emergency care service to suit their needs, leading to unnecessary attendances and resource use.


Accident and Emergency departments have seen a significant number of patients that

community elderly persons. Med Care. 1996 Sep;34(9):954-69.

97 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review, End of Phase 1 Report (2013).http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf98 NHS England (2013). Transforming urgent and emergency care services in England - Update on the Urgent and Emergency Care Review (2014).http://www.nhs.uk/NHSEngland/keogh-review/Documents/uecreviewupdate.FV.pdf99 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review, End of Phase 1 Report, Appendix I – Revised Evidence Base from the Urgent and Emergency Care Review.http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%201.EvBase.FV.pdf100 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review End of Phase 1 Report, Appendix 3 – Summary of Engagement Responses.http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%203.Engage.Results.FV.pdf

18


could be managed in other settings, adding to those with life-threatening conditions.101 One interpretation of this is that the new services are meeting a previously unmet need. Alternatively, it could be that the increased provision has led to supply induced demand and therefore increased uptake, or demand caused by a failure to intervene earlier in the urgent and emergency care pathway or system.

Rising costs across urgent and emergency care services can be associated with fragmentation of the current system of urgent and emergency care. This fragmentation leads to confusion among patients about how and where to access the care they need,102

and many people are unable to navigate to the level of care appropriate to their condition, leading to multiple calls or attendances and unnecessary use of A&E or ambulance services.103 It is estimated that around three-quarters of A&E attendances relate to serious or life-threatening conditions and about one quarter could have been treated elsewhere.104 105 106 However there is variation between different A&E departments, with deprived urban areas having the highest proportion of patients who did not require hospital treatment.


Urgent care services are highly fragmented and difficult to navigate causing many patients to experience difficulty choosing the service most appropriate to their needs.108

109 Variations in opening hours, clinical expertise, access to diagnostics and nomenclature can lead to confusion and referrals to a number of urgent care services within the same episode of care. This increases cost, delay and clinical risk and leads to poor patient experience.110


There is a clear need to adopt a whole-system approach to commissioning more 101 Coleman, P et al (2011) Why do patients with minor or moderate conditions that could be managed in other settings attend the emergency department?; Emergency Medicine Journal; 29: 487-491102 NHS Alliance (2012) A practical way forward for clinical commissioners; NHS Alliance on behalf of NHS Clinical Commissioners and sponsored by NHSCB (Now NHS England)103 Bickerton, J. et al (2012) Streaming primary urgent care: a prospective approach; Primary Health Care Research & Development; 13(2): 142-152.104 Cooperative Pharmacy (2011) Reducing needless A&E visits could save NHS millions105 NHS Networks (2011) New Choose Well Campaign106 Self Care Forum (2012) Over 2 million unnecessary A&E visits “wasted”; found at: http://www.selfcareforum.org/2012/10/30/over-2-million-unnecessary-ae-visits-wasted/107 The King’s Fund (2012) Data briefing: improving GP services in England: exploring the association between quality of care and experience of patients108 The King’s Fund (2011) Managing urgent activity – urgent care109 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process; Emergency Medicine Journal110 Primary Care Foundation (2011) Breaking the mould without breaking the system. Primary Care Foundation111 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process; Emergency Medicine Journal

19

accessible, integrated and consistent urgent and emergency care services to meet patients unscheduled care needs.112

Scheme ref no. SN6

Scheme name: Supporting good mental health



Supporting good mental health





There is a growing evidence base that suggests that more integrated ways of working with collaboration between mental health and other professionals offers the best chance of improving outcomes for both mental health and physical conditions. There is also evidence that the costs of including psychological or mental health initiatives within disease management or rehabilitation programmes can be more than outweighed by the savings arising from improved physical health and decreased service use115.


112 NHS England (2013). Transforming urgent and emergency care services in England. http://www.nhs.uk/NHSEngland/keogh-review/Pages/urgent-and-emergency-care-review.aspx113 Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010.114 Intensive case management for severe mental illness (Review). Dieterich M, Irving CB, Park B, Marshall M. Wiley 2010.115 The Kings Fund and Centre for Mental Health : Long-term conditions and mental health, Naylor et al 2012

20






The National Audit Office suggests that the NHS could save £12-50 million annually by increasing the number of patients taking part in CRHT programmes120. Integration of CRHT or other community teams with inpatient staff can lead to reductions in bed use, and this approach in Norfolk has led to annual savings of approximately £1 million121.

Scheme ref no. SN7

Scheme name: Good end of life care



Good end of life care

There is evidence that Marie Curie nursing services delivering nursing support at the end 116 Evidence briefing on integrated care pathways in mental health settings. National Institute for health research. Sept 2011.117 Knapp M, McDaid D, Parsonage M (eds) (2011). Mental Health Promotion and Mental Illness Prevention: The economic case. London: Department of Health.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdf


21


of life is effective at reducing emergency admissions compared with similarly matched controls. In addition, patients cared for by Marie Curie nurses were significantly more likely to die at home and had lower average costs of all hospital services. 122 123


Scheme ref no. NCH1

Scheme name: Primary Care, includingDevelopment of primary care localitiesRisk stratification system, including primary care data



Development of primary care localities

The development of seamless working across the interface between primary, community and acute care to improve access to assessment, diagnostics and treatment and the development of a "skills mix" of specialists and generalists for nurses, AHPs, GP's and other clinicians working in primary and community care.125 126 The strategy recommended that:

Primary care teams should be grouped in natural localities with a population of 30,000 or more.

Budgets should be devolved to management teams in natural communities or localities.

Practitioners should have appropriate access to each other’s information systems.

Meeting the needs of people, particularly older people, at risk or in need in the community or requiring timely discharge from hospital into care homes or complex and resource intensive packages of community care, requires flexibility of resource deployment across a significant client base if delays because of lack of availability of resource are not to occur. A single primary care team based budget could not meet fluctuations in demand.

122 Chitnis X,et al (2012) The Impact of the Marie Curie Nursing Service on Place of Death and Hospital Use at theEnd of Life. Nuffield Trust.123 Chitnis X, et al (2013) ‘Effect of a home-based end-of-life nursing service on hospital use at the end of life and place of death: a study using administrative data and matched controls’, BMJ Supportive & Palliative Care 1–9.124 Naylor et al – revised 2013 - ‘Transforming Our HealthCare System – ten priorities for commissioners’ - The king’s Fund http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/10PrioritiesFinal2.pdf125 Department of Health, Social Services and Public Safety. Primary Care Strategic Framework – Integrated Working. http://www.dhsspsni.gov.uk/integrated_working.pdf126 Department of Health, Social Services and Public Safety. Primary Care Strategic Framework – Caring for People Beyond Tomorrow (2005). http://www.dhsspsni.gov.uk/index/hss/primary_care-strategy.htm

22

http://www.dhsspsni.gov.uk/integrated_working.pdf

This is best achieved through grouping primary care teams. This should be organised on the basis of federations of primary care teams in natural communities or localities. A population base of 30,000 or more should provide sufficient scale.

This grouping of primary care teams on a natural community/locality basis will assist primary and community care to work with other agencies and to engage communities and community leadership. It can also ensure that primary and community care addresses the needs of the small number of people who are not registered on a practice list. It can encourage approaches such as community development and health promotion, which go beyond individual treatment and which foster partnerships in meeting need and promoting health and wellbeing.127

Risk stratification system, including primary care data


Scheme ref no. NCH2

Scheme name: Community Health & Care Services, includingIntegration of community health & care teams in Norwich localitiesCare co-ordination teamsIntegrated support for people with long-term conditions7 day case management for patients with complex health and care needsFalls PreventionSeven day social care assessment and care management (community)Integrated end of life careIntegrated dementia careIntegrated community mental health services



127 Department of Health, Social Services and Public Safety. Reform Programme for Primary and Community Care Services 2005-2008. http://www.dhsspsni.gov.uk/index/hss/primary_care-strategy.htm128 Lewis G, Georghiou T, Steventon A, Vaithianathan R, Chitnis X, Billings J, Blunt I, Wright L, Roberts A, Bardsley M (2013). Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. London: NIHR Service Delivery and Organisation programme. www.nets.nihr.ac.uk/__data/assets/pdf_file/0011/87923/FR-09-1816-1021.pdf129 Bennett L & Humphries R, 2014. ‘Making best use of the Better Care Fund: Spending to save?’ The King’s Fund

23

Integration of community health & care teams in Norwich localities; Care co-ordination teams and Integrated support for people with long-term conditions

Integrated Teams


King’s Fund analysis of the evidence131 suggests that joint commissioning between health



King’s Fund: http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together

24

and social care that results in a multi-component approach is likely to achieve better results than those that rely on a single or limited set of strategies.




A Cochrane database systematic review of hospital discharge planning provides robust evidence that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain. The review assessed randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients135.



Urinary incontinence significantly increases the risk of hospitalisation and admission to nursing homes137. An intervention involving behavioural and lifestyle counselling provided by specialised nurses led to reduced incontinent events and incontinence pad use138. 132 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/south-devon-and-torbay-coordinated-care-case-study-kingsfund13.pdf133 Thistlethwaite, P. (2011) "Integrating health and social care in Torbay: improving care for Mr Smith" The King's Fund, London: http://www.kingsfund.org.uk/sites/files/kf/field/field_document/PARR-combined-predictive-model-final-report-dec06.pdf134 CARE SERVICES IMPROVEMENT PARTNERSHIP. Care Services Efficiency Delivery Programme; Configuring joint preventive services: a structured approach to service transformation and delivering better outcomes for older people



137 Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age and Ageing 26(5):367-374.138 Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence: a

25




This may mean that the costs of professional time are offset by reductions in pad costs139.

Falls Prevention



d) Exercise for preventing falls Group and home-based exercise programmes, and home safety interventions


e) Exercise for improving balance and physical functioning in older people Progressive Resistance Strength Training is an effective intervention for improving

physical functioning in older people, including improving strength and the performance of some simple and complex activities. However, some caution is needed with transferring these exercises for use with clinical populations because adverse events are not adequately reported142.


f) Medications and medical devices Gradual withdrawal of psychotropic medication reduced the rate of, but not risk of


The effectiveness of the provision of hip protectors in reducing the incidence of hip fracture in older people is still not clearly established. Poor acceptance and adherence by older people offered hip protectors have been key factors

randomized controlled trial. CMAJ. 14;166(10):1267–1273139 Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A guide for commissioners written by continence care professionals. http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf140 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in

older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI:

10.1002/14651858.CD007146.pub3

141 Interventions for preventing falls in older people in nursing care facilities and hospitals (Review) 2010 The Cochrane Collaboration.142 The Cochrane Library. Falls Prevention and Balance in Older People. Available at: 2011.http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html.143Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem Drugs Aging. 2012 Jan 1;29(1):15-30.

26


contributing to the continuing uncertainty144.



7 day case management for patients with complex health and care needs and 7 day social care assessment and care management (community)

Where hospitals, primary and community care providers and social services have reduced services at weekends it becomes more difficult to transfer or discharge patients at a rate that is consistent with weekdays. A recent report from the National Audit Office found that 0.83 million acute bed days were lost due to delayed discharges in 2012/13. A lack of availability of specialist community and primary care services, resulting in more patients on an end of life care pathway dying in hospital.149

Optimal lengths of stay can only be achieved if all health and social care services are provided seven days a week. More than one trust referred to patient audits which found that a third or more of patients in hospital at weekends could actually be cared for outside hospital; but this is hard to achieve when there is only a limited service from primary and social care at weekends.150

144 Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews 2010, Issue 10.145 Department of Health (2009) Fracture Prevention Services: an economic evaluation. http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fractures.pdf146 Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697-701147 Salkeld G, et al, 2000:The cost effectiveness of a home hazard reduction program to reduce falls among older persons. Aust N

Z J Public Health. 2000 Jun;24(3):265-71.148 Rizzo JA et al 1996: The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly

persons. Med Care. 1996 Sep;34(9):954-69.

149 National Audit Office (2013) Emergency admissions to hospital: managing the demand.150 Healthcare Financial Management Association (2013). Costing seven day services. The financial implications of seven day services for acute emergency and urgent services and supporting diagnostics. NHS Services, Seven Days a Week Forum. http://www.england.nhs.uk/wp-content/uploads/2013/12/costing-7-day.pdf

27








There is a growing body of evidence that case mix-adjusted mortality rates are higher for patients admitted electively or as emergencies to hospital ‘out-of-hours’, with most research focussing on weekends. The size of the weekend effect lies between 0.2% and 1% absolute increase in crude mortality over all admissions. Factors contributing to increased mortality may include inadequate numbers of skilled staff, healthcare error and adverse events, lack of organisation and structure for care delivery, and reduced access to specific interventions. [Freemantle 2012, Mohammed 2012, Cram 2004, Cavallazzi 2010, Aylin 2010, Kruse 2011, Buckley 2012, MaGaughey 2007, James 2010, Worni 2012, De Cordova 2012, Deshmukh 2012, Kane 2007, Cho 2008, Needleman 2002, Pronovost 2002, Wallace 2012, Kim 2010, Aiken 2002, Penoyer 2010].151 152

In a major study, retrospective statistical analysis of routinely collected acute hospital admissions in England, involving all patient discharges from all acute hospitals in

151 Academy of Medical Royal Colleges (2012). Seven day consultant present care. Academy of Medical Royal Colleges. http://www.aomrc.org.uk/doc_view/9532-seven-day-consultant-present-care152 NHS Improvement. (2012) Equality for all: Delivering safe care – seven days a week.http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx

28

http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx

England over a year (April 2008-March 2009), showed that weekend admission appears to be an independent risk factor for dying in hospital and this risk is more pronounced in the elective setting.153

Further evidence of this “weekend effect” was reported in an analysis of NHS inpatient data from 2009/10 by Freemantle et al. The analysis concluded that being admitted at the weekend is associated with an increased risk of mortality within 30 days of admission compared to weekdays. This ranged from an 11% increase on Saturday to a 16% increase on Sunday when compared to patients admitted on a Wednesday.154

Studies have shown an association between seven day physiotherapy services and a reduction in overall length of stay for patients.155 156

The report by the Centre for Mental Health cites a wide body of evidence suggesting a reduction in length of stay of 2-5 days per patient is achievable. An evaluation of the RAID (Rapid Assessment, Interface and Discharge) service in Birmingham identified reduction of 14,500 hospital bed-days (equivalent to £3.55m) in the first full year of implementation.157

Suissa et al showed that patients hospitalised for COPD or pneumonia are at increased

153 Mohammed et al (2012). Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency setting: a retrospective database study of national health service hospitals in England. BMC Health Services Research 2012, 12:87. http://www.biomedcentral.com/1472-6963/12/87154 Freemantle, N. Et al (2012) Weekend hospitalization and additional risk of death: An analysis of inpatient data. J R Soc Med 105(2):74-84, http://jrs.sagepub.com/content/105/2/74.full155 Cardiff and Vale University Health Board (2009). Extended day and seven-day physiotherapy service in acute medicine.156 Rapoport J and Judd-Van Eerd M (1989) Impact of Physical Therapy Weekend Coverage on Length of Stay in an Acute Care Community Hospital. Journal of the American Physical Therapy Association. 69: 32-37.157 NHS Services, Seven Days a Week Forum (2013). Evidence base and clinical standards for the care and onward transfer of acute inpatients. http://www.england.nhs.uk/wp-content/uploads/2013/12/evidence-base.pdf

29

risk of death when staying over on a Friday or a weekend. The additional 40-56 deaths per 100,000 patients staying in hospital on those days are most likely due to reduced access to healthcare at that time.158

Study from Scotland showed that patients admitted as emergencies to medicine on public holidays had significantly higher mortality at 7 and 30 days compared with patients admitted on other days of the week.159

Another Scottish study also showed that despite a general reduction in mortality over the last 11 years, there is still a significant excess mortality associated with weekend emergency admissions.160

Integrated end of life care

There is evidence that Marie Curie nursing services delivering nursing support at the end of life is effective at reducing emergency admissions compared with similarly matched controls. In addition, patients cared for by Marie Curie nurses were significantly more likely to die at home and had lower average costs of all hospital services. 161 162


Integrated dementia care


Integrated community mental health services

158 Suissa S, Dell'Aniello S, Suissa D, Ernst P (2014). Friday and weekend hospital stays: effects on mortality. Eur Respir J. pii: erj00077-2014.159 Smith S, Allan A, Greenlaw N, Finlay S, Isles C (2014). Emergency medical admissions, deaths at weekends and the public holiday effect. Emerg Med J.;31(1):30-4. doi: 10.1136/emermed-2012-201881.160 Handel AE, Patel SV, Skingsley A, Bramley K, Sobieski R, Ramagopalan SV (2012). Weekend admissions as an independent predictor of mortality: an analysis of Scottish hospital admissions. BMJ Open. 6;2(6). pii: e001789. doi: 10.1136/bmjopen-2012-001789.161 Chitnis X,et al (2012) The Impact of the Marie Curie Nursing Service on Place of Death and Hospital Use at theEnd of Life. Nuffield Trust.162 Chitnis X, et al (2013) ‘Effect of a home-based end-of-life nursing service on hospital use at the end of life and place of death: a study using administrative data and matched controls’, BMJ Supportive & Palliative Care 1–9.163 Naylor et al – revised 2013 - ‘Transforming Our HealthCare System – ten priorities for commissioners’ - The king’s Fund http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/10PrioritiesFinal2.pdf164 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf

30





There is a growing evidence base that suggests that more integrated ways of working with collaboration between mental health and other professionals offers the best chance of improving outcomes for both mental health and physical conditions. There is also evidence that the costs of including psychological or mental health initiatives within disease management or rehabilitation programmes can be more than outweighed by the savings arising from improved physical health and decreased service use167.




Early intervention in psychosis (modelled on a target group of people aged 15-35 years)

165 Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010.166 Intensive case management for severe mental illness (Review). Dieterich M, Irving CB, Park B, Marshall M. Wiley 2010.167 The Kings Fund and Centre for Mental Health : Long-term conditions and mental health, Naylor et al 2012168 Evidence briefing on integrated care pathways in mental health settings. National Institute for health research. Sept 2011.169 Knapp M, McDaid D, Parsonage M (eds) (2011). Mental Health Promotion and Mental Illness Prevention: The economic case. London: Department of Health.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdf

31


is thought to save the NHS over £5 for every £1 spent within one year.




Scheme ref no. NCH3

Scheme name: Intermediate Care: Seven day supported discharge and intermediate care management



Seven day supported discharge and intermediate care management

Where hospitals, primary and community care providers and social services have reduced services at weekends it becomes more difficult to transfer or discharge patients at a rate that is consistent with weekdays. A recent report from the National Audit Office found that 0.83 million acute bed days were lost due to delayed discharges in 2012/13. A lack of availability of specialist community and primary care services, resulting in more patients on an end of life care pathway dying in hospital.174

Optimal lengths of stay can only be achieved if all health and social care services are provided seven days a week. More than one trust referred to patient audits which found that a third or more of patients in hospital at weekends could actually be cared for outside hospital; but this is hard to achieve when there is only a limited service from primary and social care at weekends.175

170 National Audit Offi ce (2007a). Helping People Through Mental Health Crisis: The role of Crisis Resolution and Home Treatment services. London: The Stationery Office. Available at: www.nao.org.uk/publications/0708/helping_people_through_mental.aspx171 Chiles JA, Lambert MJ, Hatch AL (1999). ‘The impact of psychological interventions on medical cost offset: A meta-analytic review’. Clinical Psychology: Science and Practice, vol 6, no 2, pp 204–20172 Howard C, Dupont S, Haselden B, Lynch J, Wills P (2010). ‘The effectiveness of a group cognitive-behavioural breathlessness intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease’. Psychology, Health and Medicine, vol 15, no 4, pp 371–85.173 Department of Health (2009) partnerships for Older people projects final report. London. Department of Health174 National Audit Office (2013) Emergency admissions to hospital: managing the demand.175 Healthcare Financial Management Association (2013). Costing seven day services. The financial implications of seven day services for acute emergency and urgent services and supporting diagnostics. NHS Services, Seven Days a Week Forum. http://www.england.nhs.uk/wp-content/uploads/2013/12/costing-7-day.pdf

32

There is a growing body of evidence that case mix-adjusted mortality rates are higher for patients admitted electively or as emergencies to hospital ‘out-of-hours’, with most research focussing on weekends. The size of the weekend effect lies between 0.2% and 1% absolute increase in crude mortality over all admissions. Factors contributing to increased mortality may include inadequate numbers of skilled staff, healthcare error and adverse events, lack of organisation and structure for care delivery, and reduced access to specific interventions. [Freemantle 2012, Mohammed 2012, Cram 2004, Cavallazzi 2010, Aylin 2010, Kruse 2011, Buckley 2012, MaGaughey 2007, James 2010, Worni 2012, De Cordova 2012, Deshmukh 2012, Kane 2007, Cho 2008, Needleman 2002, Pronovost 2002, Wallace 2012, Kim 2010, Aiken 2002, Penoyer 2010].176 177

In a major study, retrospective statistical analysis of routinely collected acute hospital admissions in England, involving all patient discharges from all acute hospitals in England over a year (April 2008-March 2009), showed that weekend admission appears to be an independent risk factor for dying in hospital and this risk is more pronounced in the elective setting.178

Further evidence of this “weekend effect” was reported in an analysis of NHS inpatient data from 2009/10 by Freemantle et al. The analysis concluded that being admitted at the weekend is associated with an increased risk of mortality within 30 days of admission compared to weekdays. This ranged from an 11% increase on Saturday to a 16% increase on Sunday when compared to patients admitted on a Wednesday.179

Studies have shown an association between seven day physiotherapy services and a reduction in overall length of stay for patients.180 181

The report by the Centre for Mental Health cites a wide body of evidence suggesting a reduction in length of stay of 2-5 days per patient is achievable. An evaluation of the RAID (Rapid Assessment, Interface and Discharge) service in Birmingham identified reduction of 14,500 hospital bed-days (equivalent to £3.55m) in the first full year of implementation.182

Suissa et al showed that patients hospitalised for COPD or pneumonia are at increased risk of death when staying over on a Friday or a weekend. The additional 40-56 deaths per 100,000 patients staying in hospital on those days are most likely due to reduced access to healthcare at that time.183

176 Academy of Medical Royal Colleges (2012). Seven day consultant present care. Academy of Medical Royal Colleges. http://www.aomrc.org.uk/doc_view/9532-seven-day-consultant-present-care177 NHS Improvement. (2012) Equality for all: Delivering safe care – seven days a week.http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx178 Mohammed et al (2012). Weekend admission to hospital has a higher risk of death in the elective setting than in the emergency setting: a retrospective database study of national health service hospitals in England. BMC Health Services Research 2012, 12:87. http://www.biomedcentral.com/1472-6963/12/87179 Freemantle, N. Et al (2012) Weekend hospitalization and additional risk of death: An analysis of inpatient data. J R Soc Med 105(2):74-84, http://jrs.sagepub.com/content/105/2/74.full180 Cardiff and Vale University Health Board (2009). Extended day and seven-day physiotherapy service in acute medicine.181 Rapoport J and Judd-Van Eerd M (1989) Impact of Physical Therapy Weekend Coverage on Length of Stay in an Acute Care Community Hospital. Journal of the American Physical Therapy Association. 69: 32-37.182 NHS Services, Seven Days a Week Forum (2013). Evidence base and clinical standards for the care and onward transfer of acute inpatients. http://www.england.nhs.uk/wp-content/uploads/2013/12/evidence-base.pdf183 Suissa S, Dell'Aniello S, Suissa D, Ernst P (2014). Friday and weekend hospital stays: effects on mortality. Eur Respir J. pii: erj00077-2014.

33

http://www.nhsiq.nhs.uk/improvement-programmes/acute-care/seven-day-services.aspx

Study from Scotland showed that patients admitted as emergencies to medicine on public holidays had significantly higher mortality at 7 and 30 days compared with patients admitted on other days of the week.184

Another Scottish study also showed that despite a general reduction in mortality over the last 11 years, there is still a significant excess mortality associated with weekend emergency admissions.185

Scheme ref no. NCH4

Scheme name: Community Assets, includingSupporting self-care (education, tools and resources)Development of voluntary and community 'pre-primary' intervention fund to maintain health, wellbeing, and independenceCarersHousing support, including supported housing, disability adaptationsCommunity equipment services, assistive technology



Supporting self-care (education, tools and resources); and Development of voluntary and community 'pre-primary' intervention fund to maintain health, wellbeing, and independence


184 Smith S, Allan A, Greenlaw N, Finlay S, Isles C (2014). Emergency medical admissions, deaths at weekends and the public holiday effect. Emerg Med J.;31(1):30-4. doi: 10.1136/emermed-2012-201881.185 Handel AE, Patel SV, Skingsley A, Bramley K, Sobieski R, Ramagopalan SV (2012). Weekend admissions as an independent predictor of mortality: an analysis of Scottish hospital admissions. BMJ Open. 6;2(6). pii: e001789. doi: 10.1136/bmjopen-2012-001789.186 Purdy; Avoiding Hospital Admissions – What does the research evidence say? Kings Fund Dec 2010 http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf



34


Carers

Carer Support Services

A systematic review and meta-analysis of cognitive re-framing for carers of people with dementia showed beneficial effects over usual care for carer mental health191.

A report assessing the effectiveness and cost-effectiveness of support and services to informal carers of older people by the audit commission in 2004192 showed that Day care, Home/help care and Institutional respite care (but not in all cases) may lead to delayed admissions to institutional care (and may be cost-effective).

Respite Care

A report for the Princess Royal Trust for Carers and Crossroads Care (2011)193 states that investing in respite care results in savings resulting from reduced costs to health and social care: spending more on breaks, training, information, advice and emotional support for carers reduces overall spending on care by more than £1bn per annum, as a result of reductions in unwanted (re)admissions, delayed discharges and residential care stays.

A focused review of the UK literature by the Audit commission looked at the effectiveness and cost effectiveness of respite care of older adults (60+ or 65+) and included cost effectiveness studies from the US literature194. Day care, home help/care, institutional respite care and social work/counselling were found to be effective and/or cost-effective for carers in terms of one or more of the outcomes in improving carer welfare and delaying admission to institutional care.

Housing support, including supported housing, disability adaptations


There is some evidence from a variety of case studies that local authorities are able to reduce their spend on residential care and increase the level of support for people to live in their own homes by facilitating supported housing69, 195, 196; for people with learning

190 NIACE: Lifelong Learning: Contributing to wellbeing and prosperity http://www.niace.org.uk/sites/default/files/2010-Spending-Review.pdf191 Vernooij-Dansen, M., Draskovic, I., McCleery, J., & Downs, M. (2011). Cognitive reframing for carers of people with dementia. The Cochrane Collaboration(11).192 The effectiveness and cost-effectiveness of support and services to informal carers of older people http://archive.auditcommission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalStudies/LitReview02final.pdf193 The Princess Royal Trust for Carersand Crossroads Care. (2011). Supporting Carers: The case for change194 Pickard, L. (2004). The effectiveness and cost-effectiveness of support and services to informal carers of older people. A review of the literature prepared for the audit commission. Audit Commission.195

196 The Business Case for Extra Care Housing in Adult Social Care: An Evaluation of Extra Care Housing schemes in

East Sussexhttp://www.housinglin.org.uk/Topics/type/resource/?cid=8988&msg=0

35


http://archive.auditcommission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalStudies/LitReview02final.pdf




disabilities; and for older people (sometimes referred to as extra-care housing, very-sheltered housing or assisted living). The results from the case studies provide growing evidence that even people with medium–high care needs can be supported in their own homes with the right staffing, technology, aids and adaptations. This is recognised in the Government’s national housing strategy for an ageing society, Lifetime Homes, Lifetime Neighbourhoods, and in More Choice, Greater Voice197.







Savings in home care costs by home adaptations mainly found in younger disabled people. In older people adaptations are found through prevention of accidents or deferring admission to residential care and improved quality of life

Home adaptations can reduce the need for residential care in disabled people Findings on the impact of adaptations include 70% increased feelings of safety and

an increase of 6.2 points on the SF 36 scores for mental health Home adaptations that improve the environment for visually impaired people leads to



adaptation to prevent unnecessary and wasteful health costs

197 Lifetime Homes, Lifetime Neighbourhoods, and in More Choice, Greater Voice – A publication by communities and local government - 2008: http://www.cpa.org.uk/cpa/lifetimehomes.pdf198 Communities and Local Government (July 2009) ‘Research into the financial benefits of the supporting people programme’ http://tiny.cc/k5czx


36




Adaptations give support to carers and avoid health care costs for strain and injury

Community equipment services, assistive technology

Tele Health



Tele Care




Scheme ref no. WN1

Scheme name: Integrated Care Organisation – further development of the model200 Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF (2010). 'Structured telephone support or telemonitoring programmes for patients with chronic heart failure (Cochrane Review)'. Cochrane Database of Systematic Reviews, issue 8, article CD007228.




37






{Includes a Multi-disciplinary Team structure based around primary care and involving community health and social care; and a process for identifying high-risk patients.

The main evidence base drawn upon was the evaluation of the ICO pilots, both nationally and locally. Although at a national level, the pilots did not deliver outcomes that were as strong as anticipated, locally it was considered successful in demonstrating a more integrated way of working that had the potential to provide a more coordinated approach, benefitting both patient and professionals.Since that evaluation, the local scheme has continued to provide a platform for building an integrated response to high-risk patients with reported evidence of successful admission avoidance.}

Multi-disciplinary Team structure based around primary care and involving community health and social care







King’s Fund: http://www.kingsfund.org.uk/publications/integrated-care-patients-and-populations-improving-outcomes-working-together208 http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/south-devon-and-torbay-coordinated-care-case-study-kingsfund13.pdf209 Thistlethwaite, P. (2011) "Integrating health and social care in Torbay: improving care for Mr Smith" The King's Fund, London: http://www.kingsfund.org.uk/sites/files/kf/field/field_document/PARR-combined-predictive-model-final-report-dec06.pdf210 CARE SERVICES IMPROVEMENT PARTNERSHIP. Care Services Efficiency Delivery Programme; Configuring joint preventive services: a structured approach to service transformation and delivering better outcomes for older

38









A process for identifying high-risk patients

Risk stratification or predictive modelling

Statistical models can be used to identify or predict individuals who are at high risk of future hospital admissions in order to target care to prevent emergency admissions. The evaluation of predictive modelling options216 suggests including GP data in predictive

people



213 Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age and Ageing 26(5):367-374.214 Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. CMAJ. 14;166(10):1267–1273215 Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A guide for commissioners written by continence care professionals. http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf216 Lewis G, Georghiou T, Steventon A, Vaithianathan R, Chitnis X, Billings J, Blunt I, Wright L, Roberts A, Bardsley M (2013). Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. London: NIHR Service Delivery and Organisation programme. www.nets.nihr.ac.uk/__data/assets/pdf_file/0011/87923/FR-09-1816-1021.pdf

39

modelling is particularly important, and including all patients in an area rather than just those with prior hospital use was found to improve case-finding. It also suggests217 using an ‘impactability model’ to identify high risk patients who are most likely to benefit from preventive care.

Scheme ref no. WN2

217 Bennett L & Humphries R, 2014. ‘Making best use of the Better Care Fund: Spending to save?’ The King’s Fund40

Scheme name: Integrated Reablement Service



{There is evidence that each element of the proposed new service separately contributes towards reducing avoidable admissions to both hospital and care homes.}

Integrated Reablement Service




218 Lewin GF et al 2013 - Evidence for the long term cost effectiveness of home care reablement programs. Clin Interv

Aging. 2013;8:1273-81.219 Glendinning et al (2010) Home Care Re-ablement Services: Investigating the longer-term impacts (prospective longitudinal study) SPRU/PSSRU report http://socialwelfare.bl.uk/subject-areas/services-activity/social-work-care-services/spru/135160Reablement10.pdf

220 Crocker T Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013 Feb

28;2:CD004294.41

Scheme ref no. WN3

Scheme name: Integrating services to reduce hospital admissions and enable timely discharges.



{There is a well-established evidence base on the positive impact of the current range of local services and on the added value where they are integrated across health and social care.There is also a small amount of evidence on the impact of seven day working in this field based local experience over the winter period.}

Integrating services to reduce hospital admissions and enable timely discharges.

Evaluating integrated and community-based care – the Nuffield Trust review of national integrated care pilots and virtual wards221 showed reductions in planned admissions and


42

in outpatient attendances for some interventions that involved case management using multidisciplinary teams and those using virtual wards, but no evidence of a general reduction in emergency admissions.






A Cochrane systematic review of randomised controlled trials recruiting stroke patients in hospital assessed the difference between those receiving conventional care with those with early discharge with rehabilitation at home (early supported discharge) 227. Results showed that early supportive discharge significantly reduced the length of hospital stay equivalent to approximately seven days. Early Supported Discharge can reduce long-




227 Fearon P, Langhorne P Services for reducing duration of hospital care for acute stroke patients. Cochrane

Database Syst Rev. 2012 Sep 12;9:CD000443.

43




term mortality and institutionalisation rates for up to 50% of patients, as well as lower overall costs.



Scheme ref no. WN4

Scheme name: Supporting independence and well-being



{Includes provision of excellent quality information on the availability of community-based low-level support services.

There is evidence at a national level that the availability of basic support services at an early stage in a person’s frailty can improve well-being, reduce the incidence of falls and delay the need to access statutory health and social care services.}

Supporting independence and well-being

Education and Self-Management

Patient self-management seems to be beneficial for patients with COPD and asthma.231 232 233 The Cochrane reviews concluded that education with self-management reduced unplanned hospital admissions in adults with asthma, and in chronic obstructive pulmonary disease COPD patients but not in children with asthma. There is evidence for the role of education in reducing unplanned hospital admissions in heart failure

228 Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age and Ageing 26(5):367-374.229 Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. CMAJ. 14;166(10):1267–1273230 Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A guide for commissioners written by continence care professionals. http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf231 Purdy; Avoiding Hospital Admissions – What does the research evidence say? Kings Fund Dec 2010 http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf


Syst Rev. 2007 Oct 17;(4):CD002990.233 Tapp S, Lasserson T, Rowe B (2007). ‘Education interventions for adults who attend the emergency room for acute asthma (Cochrane Review)’. Cochrane Database of SystematicReviews, issue 3, article CD003000. DOI: 10.1002/14651858.CD003000.pub2.

44

patients234.


Scheme ref no. WN5

Scheme name: Dementia diagnosis and support model around primary care



Dementia diagnosis and support model around primary care


Scheme ref no. GYW1

Scheme name: Community based support interventions, Self-care & self-management, includingIntegrated reablement / rehab recoveryRisk StratificationCarer Support including Carer BreaksGreater use of assistive technologyHousing and Health Programme

234 Kirsty J. Boyd; Living with advanced heart failure: a prospective, community based study of patients and their carers The European Journal of Heart Failure 6 (2004) 585– 591

235 NIACE: Lifelong Learning: Contributing to wellbeing and prosperity http://www.niace.org.uk/sites/default/files/2010-Spending-Review.pdf236 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf

45





Community based support interventions, Self-care & self-management



Integrated reablement / rehab recovery

Reablement Services



237 Purdy; Avoiding Hospital Admissions – What does the research evidence say? Kings Fund Dec 2010 http://www.kingsfund.org.uk/sites/files/kf/Avoiding-Hospital-Admissions-Sarah-Purdy-December2010.pdf



241 NIACE: Lifelong Learning: Contributing to wellbeing and prosperity http://www.niace.org.uk/sites/default/files/2010-Spending-Review.pdf

242 Lewin GF et al 2013 - Evidence for the long term cost effectiveness of home care reablement programs. Clin Interv

Aging. 2013;8:1273-81.243 Glendinning et al (2010) Home Care Re-ablement Services: Investigating the longer-term impacts (prospective longitudinal study) SPRU/PSSRU report http://socialwelfare.bl.uk/subject-areas/services-activity/social-work-care-services/spru/135160Reablement10.pdf

46



Physical Rehabilitation


Risk Stratification


Carer Support including Carer Breaks

Carer Support Services

A systematic review and meta-analysis of cognitive re-framing for carers of people with dementia showed beneficial effects over usual care for carer mental health247.

A report assessing the effectiveness and cost-effectiveness of support and services to informal carers of older people by the audit commission in 2004248 showed that Day care, Home/help care and Institutional respite care (but not in all cases) may lead to delayed admissions to institutional care (and may be cost-effective).

Respite Care

A report for the Princess Royal Trust for Carers and Crossroads Care (2011)249 states that investing in respite care results in savings resulting from reduced costs to health and social care: spending more on breaks, training, information, advice and emotional support for carers reduces overall spending on care by more than £1bn per annum, as a result of reductions in unwanted (re)admissions, delayed discharges and residential care

244 Crocker T Physical rehabilitation for older people in long-term care. Cochrane Database Syst Rev. 2013 Feb 28;2:CD004294.

245 Lewis G, Georghiou T, Steventon A, Vaithianathan R, Chitnis X, Billings J, Blunt I, Wright L, Roberts A, Bardsley M (2013). Impact of ‘virtual wards’ on hospital use: a research study using propensity matched controls and a cost analysis. London: NIHR Service Delivery and Organisation programme. www.nets.nihr.ac.uk/__data/assets/pdf_file/0011/87923/FR-09-1816-1021.pdf246 Bennett L & Humphries R, 2014. ‘Making best use of the Better Care Fund: Spending to save?’ The King’s Fund247 Vernooij-Dansen, M., Draskovic, I., McCleery, J., & Downs, M. (2011). Cognitive reframing for carers of people with dementia. The Cochrane Collaboration(11).248 The effectiveness and cost-effectiveness of support and services to informal carers of older people http://archive.auditcommission.gov.uk/auditcommission/sitecollectiondocuments/AuditCommissionReports/NationalStudies/LitReview02final.pdf249 The Princess Royal Trust for Carersand Crossroads Care. (2011). Supporting Carers: The case for change

47



stays.

A focused review of the UK literature by the Audit commission looked at the effectiveness and cost effectiveness of respite care of older adults (60+ or 65+) and included cost effectiveness studies from the US literature250. Day care, home help/care, institutional respite care and social work/counselling were found to be effective and/or cost-effective for carers in terms of one or more of the outcomes in improving carer welfare and delaying admission to institutional care.

Greater use of assistive technology

Tele Health



Tele Care




250 Pickard, L. (2004). The effectiveness and cost-effectiveness of support and services to informal carers of older people. A review of the literature prepared for the audit commission. Audit Commission.

251 Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF (2010). 'Structured telephone support or telemonitoring programmes for patients with chronic heart failure (Cochrane Review)'. Cochrane Database of Systematic Reviews, issue 8, article CD007228.




48




Housing and Health Programme


There is some evidence from a variety of case studies that local authorities are able to reduce their spend on residential care and increase the level of support for people to live in their own homes by facilitating supported housing69, 257, 258; for people with learning disabilities; and for older people (sometimes referred to as extra-care housing, very-sheltered housing or assisted living). The results from the case studies provide growing evidence that even people with medium–high care needs can be supported in their own homes with the right staffing, technology, aids and adaptations. This is recognised in the Government’s national housing strategy for an ageing society, Lifetime Homes, Lifetime Neighbourhoods, and in More Choice, Greater Voice259.







Savings in home care costs by home adaptations mainly found in younger disabled

257

258 The Business Case for Extra Care Housing in Adult Social Care: An Evaluation of Extra Care Housing schemes in East Sussexhttp://www.housinglin.org.uk/Topics/type/resource/?cid=8988&msg=0259 Lifetime Homes, Lifetime Neighbourhoods, and in More Choice, Greater Voice – A publication by communities and local government - 2008: http://www.cpa.org.uk/cpa/lifetimehomes.pdf260 Communities and Local Government (July 2009) ‘Research into the financial benefits of the supporting people programme’ http://tiny.cc/k5czx


49





people. In older people adaptations are found through prevention of accidents or deferring admission to residential care and improved quality of life

Home adaptations can reduce the need for residential care in disabled people Findings on the impact of adaptations include 70% increased feelings of safety and

an increase of 6.2 points on the SF 36 scores for mental health Home adaptations that improve the environment for visually impaired people leads to



adaptation to prevent unnecessary and wasteful health costs Adaptations give support to carers and avoid health care costs for strain and injury

50

Scheme ref no. GYW2

Scheme name: Integrated community health and social care teams



Integrated community health and social care teams






A Cochrane database systematic review of hospital discharge planning provides robust evidence that a discharge plan tailored to the individual patient probably brings about reductions in hospital length of stay and readmission rates for older people admitted to 262 Evaluating integrated and community-based care – a review of national integrated care pilots and virtual wards http://www.nuffieldtrust.org.uk/sites/files/nuffield/publication/evaluation_summary_final.pdf



51




hospital with a medical condition. The impact of discharge planning on mortality, health outcomes and cost remains uncertain. The review assessed randomised controlled trials (RCTs) that compared an individualised discharge plan with routine discharge care that was not tailored to the individual patient. Participants were hospital inpatients267.




Scheme ref no. GYW3

Scheme name: Urgent Care programme, including Rapid response vehicle, including Integrated falls service.



Urgent Care programme, including Rapid response vehicle

The Keogh report on the Urgent and Emergency Care Review sets out proposals for the future of urgent and emergency care services in England.272 273 There are five key 267 Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. Cochrane Database of Systematic Reviews 2013, Issue 1.


269 Thom DH, et al (1997) Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality. Age and Ageing 26(5):367-374.270 Borrie MJ et al (2002) Interventions led by nurse continence advisers in the management of urinary incontinence: a randomized controlled trial. CMAJ. 14;166(10):1267–1273271 Cost-effective commissioning for Continence Care, All Party Parliamentary Group For Continence Care Report -A guide for commissioners written by continence care professionals. http://www.appgcontinence.org.uk/pdfs/CommissioningGuideWEB.pdf272 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review, End of Phase 1 Report (2013).

52

elements, all of which must be taken forward to ensure success. The report suggests that we must – Provide better support for people to self- care. Help people with urgent care needs to get the right advice in the right place, first




Connect all urgent and emergency care services together so the overall system

http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.FV.pdf273 NHS England (2013). Transforming urgent and emergency care services in England - Update on the Urgent and Emergency Care Review (2014).http://www.nhs.uk/NHSEngland/keogh-review/Documents/uecreviewupdate.FV.pdf

53

becomes more than just the sum of its parts.

The evidence base for change identified a number of areas for improvement within the current system of urgent and emergency care in England.274 275 In summary: More people are using the urgent and emergency care system to access healthcare,

leading to mounting costs and increased pressure on resources. Overall fragmentation of the system means that many patients may not be able to

access the most appropriate urgent or emergency care service to suit their needs, leading to unnecessary attendances and resource use.


Accident and Emergency departments have seen a significant number of patients that could be managed in other settings, adding to those with life-threatening conditions.276

274 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review, End of Phase 1 Report, Appendix I – Revised Evidence Base from the Urgent and Emergency Care Review.http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%201.EvBase.FV.pdf275 NHS England (2013). High quality care for all, now and for future generations: Transforming urgent and emergency care services in England - Urgent and Emergency Care Review End of Phase 1 Report, Appendix 3 – Summary of Engagement Responses.http://www.nhs.uk/NHSEngland/keogh-review/Documents/UECR.Ph1Report.Appendix%203.Engage.Results.FV.pdf276 Coleman, P et al (2011) Why do patients with minor or moderate conditions that could be managed in other settings attend the emergency department?; Emergency Medicine Journal; 29: 487-491

54

One interpretation of this is that the new services are meeting a previously unmet need. Alternatively, it could be that the increased provision has led to supply induced demand and therefore increased uptake, or demand caused by a failure to intervene earlier in the urgent and emergency care pathway or system.

Rising costs across urgent and emergency care services can be associated with fragmentation of the current system of urgent and emergency care. This fragmentation leads to confusion among patients about how and where to access the care they need,277

and many people are unable to navigate to the level of care appropriate to their condition, leading to multiple calls or attendances and unnecessary use of A&E or ambulance services.278 It is estimated that around three-quarters of A&E attendances relate to serious or life-threatening conditions and about one quarter could have been treated elsewhere.279 280 281 However there is variation between different A&E departments, with

277 NHS Alliance (2012) A practical way forward for clinical commissioners; NHS Alliance on behalf of NHS Clinical Commissioners and sponsored by NHSCB (Now NHS England)278 Bickerton, J. et al (2012) Streaming primary urgent care: a prospective approach; Primary Health Care Research & Development; 13(2): 142-152.279 Cooperative Pharmacy (2011) Reducing needless A&E visits could save NHS millions280 NHS Networks (2011) New Choose Well Campaign281 Self Care Forum (2012) Over 2 million unnecessary A&E visits “wasted”; found at: http://www.selfcareforum.org/2012/10/30/over-2-million-unnecessary-ae-visits-wasted/

55

deprived urban areas having the highest proportion of patients who did not require hospital treatment.


Urgent care services are highly fragmented and difficult to navigate causing many patients to experience difficulty choosing the service most appropriate to their needs.283

284 Variations in opening hours, clinical expertise, access to diagnostics and nomenclature can lead to confusion and referrals to a number of urgent care services within the same episode of care. This increases cost, delay and clinical risk and leads to poor patient experience.285


There is a clear need to adopt a whole-system approach to commissioning more accessible, integrated and consistent urgent and emergency care services to meet patients unscheduled care needs.287

Integrated Crisis and Rapid Response Service

There is a lack of robust evidence to evaluate the effectiveness of crisis response services. However some case studies provide positive results.288 There are recommendations from The ‘Silver Book’289 – a guidance document for care for frail older people during the first 24 hours of an urgent care episode.

The national evaluation of the Department of Health Partnerships for Older People Projects pilots (POPPs) found economic benefits from targeted intensive interventions to prevent crisis (e.g. falls services) or at a time of crisis (e.g. rapid response hospital admissions avoidance services) or post-crisis re-ablement services. For every £1 spent on such services to support older people, hospitals were found to save £1.20 in spending on emergency beds.290

282 The King’s Fund (2012) Data briefing: improving GP services in England: exploring the association between quality of care and experience of patients283 The King’s Fund (2011) Managing urgent activity – urgent care284 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process; Emergency Medicine Journal285 Primary Care Foundation (2011) Breaking the mould without breaking the system. Primary Care Foundation286 Booker et al (2013) Patients who call emergency ambulances for primary care problems: a qualitative study of the decision-making process; Emergency Medicine Journal287 NHS England (2013). Transforming urgent and emergency care services in England. http://www.nhs.uk/NHSEngland/keogh-review/Pages/urgent-and-emergency-care-review.aspx288 Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010.289 Quality care for older people with urgent and emergency care needs http://www.bgs.org.uk/campaigns/silverb/silver_book_complete.pdf

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http://www.bgs.org.uk/campaigns/silverb/silver_book_complete.pdf

Information from ‘A vision for social care’ 291 the Care Services Efficiency Delivery Programme suggests that an integrated crisis or rapid response service, that responds to people who have a crisis within a four hour period could save an average of £2 million per PCT and £0.5 million per local authority by reducing ambulance call-outs, unnecessary admissions to hospital and unplanned entry to long term nursing or residential care.292

Integrated falls service



g) Exercise for preventing falls Group and home-based exercise programmes, and home safety interventions


h) Exercise for improving balance and physical functioning in older people Progressive Resistance Strength Training is an effective intervention for improving

physical functioning in older people, including improving strength and the

290 Karen Windle et al, 2009: National Evaluation of Partnerships for Older People Projects: Final Report Dept of Health291 A Vision for Adult Social Care – 2010. Dept of Health: http://www.cpa.org.uk/cpa_documents/vision_for_social_care2010.pdf292 Humphries, 2011 Social care funding and the NHS An impending crisis? The King’s Fund: http://www.kingsfund.org.uk/sites/files/kf/Social-care-funding-and-the-NHS-crisis-Kings-Fund-March-2011.pdf293 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for


No.: CD007146. DOI: 10.1002/14651858.CD007146.pub3294 Interventions for preventing falls in older people in nursing care facilities and hospitals (Review) 2010 The Cochrane Collaboration.

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http://www.kingsfund.org.uk/sites/files/kf/Social-care-funding-and-the-NHS-crisis-Kings-Fund-March-2011.pdf

http://www.cpa.org.uk/cpa_documents/vision_for_social_care2010.pdf

http://www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Olderpeople/PartnershipsforOlderPeopleProjects/index.htm

performance of some simple and complex activities. However, some caution is needed with transferring these exercises for use with clinical populations because adverse events are not adequately reported295.


i) Medications and medical devices Gradual withdrawal of psychotropic medication reduced the rate of, but not risk of


The effectiveness of the provision of hip protectors in reducing the incidence of hip fracture in older people is still not clearly established. Poor acceptance and adherence by older people offered hip protectors have been key factors contributing to the continuing uncertainty297.



295 The Cochrane Library. Falls Prevention and Balance in Older People. Available at: 2011.http://www.thecochranelibrary.com/details/browseReviews/579145/Falls-prevention--balance-in-older-people.html.296Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem Drugs Aging. 2012 Jan 1;29(1):15-30.

297 Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database of Systematic Reviews 2010, Issue 10.298 Department of Health (2009) Fracture Prevention Services: an economic evaluation. http://www.cawt.com/Site/11/Documents/Publications/Population%20Health/Economics%20of%20Health%20Improvement/fractures.pdf299 Robertson MC, Devlin N, Gardner MM, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial. British Medical Journal. 2001 Mar 24;322(7288):697-701300 Salkeld G, et al, 2000:The cost effectiveness of a home hazard reduction program to reduce falls among older persons. Aust N Z J Public Health. 2000 Jun;24(3):265-71.301 Rizzo JA et al 1996: The cost-effectiveness of a multifactorial targeted prevention program for falls among community elderly persons. Med Care. 1996 Sep;34(9):954-69.

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Scheme ref no. GYW4

Scheme name: Support for people with dementia and older people with functional mental health problems living in the community



Support for people with dementia and older people with functional mental health problems living in the community

Dementia Care






There is a growing evidence base that suggests that more integrated ways of working with collaboration between mental health and other professionals offers the best chance of improving outcomes for both mental health and physical conditions. There is also evidence that the costs of including psychological or mental health initiatives within

302 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf303 Avoiding hospital Admissions: What does the research evidence say? The Kings Fund. Sarah Purdy. December 2010.304 Intensive case management for severe mental illness (Review). Dieterich M, Irving CB, Park B, Marshall M. Wiley 2010.

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disease management or rehabilitation programmes can be more than outweighed by the savings arising from improved physical health and decreased service use305.








305 The Kings Fund and Centre for Mental Health : Long-term conditions and mental health, Naylor et al 2012306 Evidence briefing on integrated care pathways in mental health settings. National Institute for health research. Sept 2011.307 Knapp M, McDaid D, Parsonage M (eds) (2011). Mental Health Promotion and Mental Illness Prevention: The economic case. London: Department of Health.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215626/dh_126386.pdf


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