The Health Services and Delivery Research programme has published a new study focused on unplanned admissions in people aged over 85. The study offers some interesting insights and will be of interest to commissioners, given the challenges which local health and social care economies face in managing pressures in the system.

Unplanned admissions in this age group (aged 85 and over) are of particular concern as patients are at higher risk of iatrogenic harm and often experience difficulties transitioning back to normal life.

Methods

The study aimed to:

• identify the features of health and social care economies associated with higher and lower increases in unplanned admission rates in those aged 85 years and over;
• develop recommendations to inform strategy and service design;
• explore the implications of implementing the recommendations.

The study adopted a mixed methods approach, using routine data, interviews and focus groups at 6 case study sites – 3 of which showed a rapid increase in unplanned admissions (“deteriorating”) and 3 which showed a decline (“improving”). Each of the sites included acute and community providers, commissioners and social care. Interviews were held with senior staff and patient representatives.

The authors acknowledge their approach has some limitations including: the use of historical data, disruption due to the large-scale reforms during the study, and the limitations of the model used (to develop recommendations) in recognising the influence of external context.

Findings

The quantitative analysis of routine data (2007/8 to 2009/10; the sources are listed on page 13) showed an annual increase of 5.5% in average admission rates for people aged 85 years and over in “deteriorating” sites.  For “improving” sites, the analysis showed an annual drop of 1%.  The research team suggest that the key differences between deteriorating and improving sites were:  the volume of zero-day admissions, readmissions and rates of admission for acute ambulatory care sensitive conditions. There is a suggestion that access to GP services could also be a factor.

The qualitative analysis suggests a number of critical success factors associated with effective management of unplanned admissions:

• a system-wide strategy, characterised by a shared vision/values across all services with specific policies for this age group and a range of specific community-based interventions across agencies (e.g. rapid access teams; intermediate care; voluntary services; out of hours services);
• strong leadership based on collaboration, commitment to quality and continuity;
• a focus on prevention (e.g. in deteriorating sites, there seems to be a focus on managing delayed discharges rather than preventing admissions);
• a long-term view supported by shared responsibility for resourcing improvement projects (e.g. matched funding) and time to embed changes;
• investment in primary care;
• an integrated approach to planning and delivery, through joined up governance and ways of working;
• a patient-centred approach addressing the whole pathway of care, rather than a focus on particular aspects such as discharge;
• capacity of community-based teams;
• close alignment between services, specifically with out of hours services (e.g. information sharing);
• collaboration with the voluntary sector;
• integration of community care through a single provider enabled greater integration with other agencies and implementation of innovation and improvement.

The authors note that the “deteriorating” sites exhibited many positive features (e.g. increased reablement funding, central role of community matrons and gerontologists), however suggesting that the negative features seemed to tip the balance towards lower system performance, suggesting that the critical success factors may act as strong enablers of integrated, system-wide transformation.  On the flip side, “improving” sites also faced challenges (e.g. staff retention, contractual changes to services) suggesting a sustained and continuous effort is needed to balance out barriers to positive change.

The research team also intended to explore implementation of recommendations at two sites; however, due to unforeseen circumstances, the study focused on one site only.  Due to the time needed to embed change, the learning is ongoing – the report highlights the need for change champions who know the system well, including a good understanding of work already underway; and clarity on decision making.

Recommendations

The research team propose 20 recommendations (page 91), prioritised from a list of 47, following feedback from participants from the 6 sites and the project’s Steering Group.  The original list of 47 is worth a look (page 74) as there a few commissioner-specific recommendations (e.g. use of flexible funding, outcomes-based contracts) which don’t make the final list. The recommendations for local health and social care economies are based on the McKinsey 7S model (Structure; Strategy; Systems; Shared values; Style; Staff; Skills). Here are a few highlights (in the authors’ own words):

• Avoid transient pilots with no follow-through and multiple initiatives which are inadequately promoted/marketed;
• Consider how palliative care teams are integrated as part of the overall system of care;
• Integrate social work and nursing teams that cross the boundary between community and hospital;
• Understand and address the impact that early-discharge policies can have on admissions unless additional and compensatory changes are made to the system to accommodate these patients;
• Provide a specialist community-based 24/7 response service for people with urgent mental health needs;
• Enable professionals across the system to better understand each other’s roles, priorities and ways of working […]; consider rotating staff through services to enhance this knowledge transfer.

Commentary

One of the key messages from the study is the implicit acknowledgement that there are no quick wins or silver bullets to addressing unplanned admissions. A system-wide response takes time and is based on strong relationships and long-term planning. Therein lies the challenge for commissioners, having to operate in a constantly shifting environment and to balance national priorities with local needs.  The key seems to be in nurturing a collaborative and coordinated approach to address the inherent fragmentation and unintended biases within the system and increasing diversification of providers.

The recommendations suggest an initial focus on strategy, to develop the foundation for system-level integration; for example, commissioners may wish to start by considering:

• is there a shared vision across the local health and social care economy for managing unplanned admissions in this age group?
• how are you ensuring a system-wide vision which includes all services and agencies involved in delivering care?
• how do health and social care commissioners currently work together and where can improvements be made?
• how sustainable and realistic is the current portfolio of improvement projects and pilots?

Link

Wilson, A et al. (2015) Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]: a mixed-methods case study approach, Health Services and Delivery Research, 3 (37).