Round up for May 2018
Lessons about the impact of new models of care
As the new models of care programme in England transitions to a new phase of place based systems of care, the Health Foundation highlights learning from this work about how systematic improvement should be designed and developed for impact.
The impact of redesigning urgent and emergency care in Northumberland report examines the impact of changes to A&E and urgent care services in Northumberland as result of collaborative work with the Northumbria Primary and Acute Care System (PACS) vanguard. The unexpected consequence that A&E attendance increased after redesign improved access highlights how outcomes in the short term may be something different to what is expected. This is echoed in the key messages from Nuffield Trust’s review of a wide range of initiatives implementing new models of care that were expected to impact on hospital use Shifting the balance of care: great expectations.
These findings highlight the risk of increasing demand for services when implementing new models and the crucial the role of effective targeting of the population group most ‘at risk’ for realising the intended benefits.
Developments in the implementation and evaluation of improvement at scale
The importance of taking time to adjust new models of care to the local context is also one of the key lessons highlighted in a report that draws on the experience across site leaders from the new care models programme. Some assembly required: implementing new models of care, explains 10 key lessons for those seeking to develop and implement systematic improvements. In addition to the time required for adaptation, which allows for experimentation and failure, the importance of building in capacity and capability for evaluation to facilitate this process is also highlighted.
The need for an adaptive and also co-productive approach to implementation and evaluation has also been highlighted in the experience of researchers evaluating integrated care which was discussed at Healthcare Improvement Scotland’s recent 6th Annual Research Symposium. The SUSTAIN project is an example of how an action-oriented approach is being used to evaluate improvement based on the Evidence Integration Triangle model, in which local stakeholders and research partners co-design and implement improvement at scale.
Developments in proactive and responsive care for older and frail people
Improving services for older people requires consideration of the quality and pro-activeness of care across multiple components and settings. A number of recent publications consider what is working to better support and manage the needs of older and frail people for continuing to live well.
- Earlier identification and response to older people's complex needs
A themed review from National Institute of Health Research (NIHR) considers the latest evidence from their studies on what is working to identify and manage the needs of frail older people to support them to live well and avoid known risks from hospital admission. Comprehensive Care looks at how needs are managed approaching hospital, including the role of earlier identification and assessment of needs. Findings from a qualitative study highlight the importance of drawing on the lived experience of emergency admissions for older people to better understand how deterioration that results in acute admission can be avoided.
The themed review also highlights the validation and testing of the electronic frailty index as a key development for improving the identification of individuals that would benefit from earlier support, and how this tool is being increasingly adopted in primary care across NHS England. In Scotland, work to develop and implement the tool in GP Clusters is being taken forward by the Living Well in Communities team in collaboration with a number of Health and Social Care Partnerships. Comprehensive geriatric assessment (CGA), once an individual has been identified for support in the community, is also demonstrating the impact possible through determining a frail older person’s capability and developing an integrated plan for care and long term follow up. While a previous Cochrane Review has demonstrated the impact of CGA once an older person is hospitalised, community-based CGA is also now being assessed in relation to the expected benefits of reducing the risk of function decline and optimising care.
Understanding how inter-professional collaboration works as an important area of practice improvement
Inter-professional collaboration is understood to be an important area of practice improvement. A recent systematic review by Cochrane has identified that, although research on inter-professional collaboration is continuing to develop, there is still uncertainty about the effectiveness of this as a practice based intervention for improving clinical and patient outcomes. Further studies are expected in future that will help to reduce this uncertainty.
The findings from a realist review are help to reduce some of the uncertainty about how inter-professional collaborations works in the context of integrated care programmes for older adults with complex needs. This review included evaluations of integrated care programmes for older adults with complex care needs. The quality of multidisciplinary team relationships are identified as being a key way of explaining how the mechanisms and context of integration of care may interact to determine success. Quality in relation to relationships can be understood from this review as requiring cross-sector team working, and close collaboration for knowledge sharing that allows care to be better coordinated.
- The challenges of improving the coordination and continuity of care
The coordination and continuity of care is understand to be an important component of models of care for older people but continues to be a challenging area to improve in practice.
In their recent briefing, the Health Foundation describe how patients experiencing higher continuity of care in NHS England general practice show a tendency to experience fewer hospital admissions for ambulatory care sensitive conditions. The challenges presented by a decline in continuity in primary care are discussed and a number of explanations offered for this including more GPs working part-time to take on other responsibilities. Controlling for patient characteristics, their analysis published in the BMJ found that there are fewer hospital admissions for those who experience higher continuity of care (i.e. those who see the same GP more often). However, solutions to the problem of continuity may need to be more multi-faceted than that expected as part of initiatives such as the named GP approach, which hasn’t produced the expected results.
- Further reading
This systematic review, including 43 papers, explains how three linked domains of barriers and facilitators should be considered when implementing patient focussed interventions in hospitals.
This rapid realist review provides an account of how multiple factors interact to enable successful pathways for frail older people that include organisational boundaries, role clarity for staff and outcomes being orientated towards to patients.
As part of an increasing focus on care homes and social care, the King’s Fund examines the experiences of staff across care homes, local authorities and clinical commissioning groups in relation to closer working.