What do we know about designing and delivering care closer to home?

Monitor has recently issued a series of guides on care closer to home, to support transformation programmes. The pack of guides shares the experience of a number of trusts who have implemented new services alongside analysis of the literature base and financial modelling. Whilst the guides are presented from a provider perspective, there are some useful insights for local health and social care economies.

Methods

The guides are based on:

a literature review of around 50 papers;
simulation modelling to understand financial impacts;
and conversations with over 30 trusts implementing transformation programmes to reduce admissions, reduce length of stay, enable early discharge, and improve pathways, to extract learning and develop case studies.

Findings

The literature review suggests there is evidence to support care closer to home for patients with less severe needs, with comparable health outcomes and improved patient satisfaction. The evidence base seems less clear for patients with more severe needs, where the risk is greater. Some clinical utilisation reviews have suggested up to 50% of patients may be treated at more appropriate levels of care; however, the evidence base on utilisation review is underdeveloped and assessments may not take into account the availability of alternative services.

There is a risk of iatrogenic harm for patients who do not need to be in hospital, particularly for frail elderly patients. Some studies have shown improved outcomes (readmissions, mortality, rates of illness) for community-based care, such as home visiting and reablement. There is, however, a risk of poorer outcomes should patients’ conditions deteriorate rapidly. Much of the evidence is underdeveloped, with many small scale and short-term follow-up studies; this highlights the need for local evaluation.

Whilst health outcomes are generally comparable to inpatient care, there are risks for patients whose needs escalate quickly

The analysis of financial impacts is based on modelling on cost expenditure of four different models (telehealth; enhanced step-up services; rapid response and early supported discharge; and reablement services). The findings of the analysis suggest that these models are more likely to reduce the rate of expenditure growth rather than deliver savings.

The report also highlights that some interventions may offer greater flexibility due to lower fixed costs. To deliver savings, acute capacity will need to be reduced, which is politically challenging, and relies on substantial and consistent bed day reductions; it is noted that savings are unlikely to be possible within the short term so a long term vision is required. This vision will need to incorporate a range of system-level approaches to manage capacity and patient flow, including, for example, diagnostics and patient transport. The guide also includes information to support business case development.

Modelling suggests interventions are more likely to reduce expenditure growth than deliver savings

Some implementation challenges are common across different contexts: targeting the right patients; meeting the needs of higher severity patients; recruitment and retention of staff; building credibility and scale; and collecting data to enable robust evaluation. The lessons learned suggest the need for a clear focus – for example, is admission avoidance intended to support patients in crisis or preventing crises from occurring? Monitor is developing tools to support risk sharing agreements and capitation based payments; there is also work underway to support new payment approaches for the New Care Models Vanguards which will be shared.

It’s critical to target the right patients

The 15 case studies offer some insight into the design and implementation of a range of interventions, although there is limited and variable information on outcomes:

Admissions avoidance: the use of telehealth to offer remote advice/support and coordinate referrals for patients at risk of exacerbation; a rapid response service to offer short-term intensive support to patients in crisis; emergency ambulatory care; step up/down services; single point of access in mental health; acute-level care for end of life patients.
Admissions avoidance and length of stay reduction: short term assessment, rehabilitation and reablement; step-down services aim to support self management and independent living.
Improving acute pathways: comprehensive geriatric assessment; psychiatric liaison services; ambulatory care and supported discharge.
Early discharge: early supported discharge with multidisciplinary teams; discharge to assess services.

Commentary

Whilst the guides offer some interesting insights, I felt they were provider-focused missing the opportunity for a system-level perspective. The case studies were mixed in terms of the amount of context provided; the assumptions and expectations; and the detail of the outcomes measured.

I also thought that there could have been more detail on workforce planning, given that recruitment and retention was one of the key implementation challenges identified. I felt that the implementation challenges, whilst interesting, could have drawn more on established literature on theory-based evaluation.

However, given the evidence base is variable, the insights shared may help local health and social care economies to think through some of the challenges in designing, delivering and evaluating care closer to home.

Commissioners will need to develop focused aims and consider what outcomes should be measured

Specifically, commissioners may wish to reflect on:

the aims of specific interventions and what outcomes will be measured;
how outcomes will be decided and measured and what data is needed;
how specific interventions fit into a system-wide approach and with other interventions;
how the financial impacts will be modelled and evaluated;
how to incorporate the learning from other programmes.