Avoidable admissions: time to ask the patients?

Tasked with reducing unscheduled demand on hospital services, commissioners and providers are interested in identifying and reducing “avoidable” admissions, particularly for elderly patients as hospital care can reduce independence and even cause harm.

This study takes an interesting approach, asking patients and practitioners for their views. As the authors argue, the NHS is moving towards a co-production culture but surprisingly, this study claims to be the first to ask older people what they think. This seems like a huge missed opportunity to engage with elderly patients.

Methods

The research, funded by the NIHR Research for Patient Benefit programme, comprised:

A literature review exploring the prevalence of avoidable admissions and proposed solutions;
Interviews with clinicians and managers across 3 case study sites;
Interviews with older people and/or their carers, who had been admitted during a specified period to one of the 3 case study sites;
Feedback from GPs and/or social workers on the admission for each of the older people interviewed;
A multidisciplinary focus group to explore a range of perspectives on vignettes developed from the patient interviews.

Findings

This is a detailed report and I can only give a flavour of the findings here:

Interestingly, the study found most admissions in the cohort studied to be “appropriate”. Only 9 of 104 older people suggested that an alternative to hospital may have been more appropriate; importantly, however, the medical staff involved in reviewing the cases felt the admissions were appropriate.
The researchers point to unhelpful language (“appropriate” vs “inappropriate”) highlighting that reviews of admissions are retrospective and can underplay the frontline pressures of making a quick decision. There is also little consensus about what constitutes an “inappropriate” admission. Some participants distinguished between “medical” and “social” admissions whereas others felt this was too simplistic.
The range of initiatives (e.g. discharge to assess, rapid response teams) can add rather than address complexity; this can be worsened by poor communication and coordination between services.

The role of care navigator is suggested as a way of improving coordination across multiple services

The impact of funding cuts in social care is evident, with social care professionals under-resourced to get involved in preventative measures.
Some patients have delayed seeking help during a crisis; it’s suggested that negative media coverage of how people use the NHS may discourage people with a genuine need for care.
Certain roles may have a key role to play in preventing admissions. Consultant geriatricians have a critical role in assessment of patients, providing specialist expertise but also in building knowledge of older peoples needs. GPs and paramedics could also play a role in the community to provide care and support to older people at significant risk of admission.
The experience of patients with dementia and their family or carers suggests that there’s an urgent need to improve skills and knowledge of people working with older patients.
Improving understanding is key; not only of the medical, social and mental problems of older people but also knowledge of local services and resources and awareness of other teams.

This study suggests that older people may delay seeking help when they need it.

Commentary

Interestingly, the findings seem to challenge some assumptions about the appropriateness of admissions, though the authors readily admit the case study sites may not be generalisable. Very few patients in the study presented directly to Emergency Departments and many sought alternatives before dialling 999. A number of the patients in the study had had contact with health services in the weeks leading up to their admission, suggesting there may be opportunities to prevent the admission through earlier intervention.

There is a risk that introducing new services adds even more complexity for patients.

The suggestion that older people may delay seeking help also suggests an urgent need to communicate with and engage older people to encourage them to seek help earlier. Engagement is a strong theme throughout the report and commissioners may wish to review their approach to involving older people and carers in designing better systems of care.

The study offers important insights not only from older people who have been admitted but the professionals involved in their care. It’s clear that systems of care are complex and in trying to improve care for older people, there’s a risk of adding to this complexity rather than improving the patient’s journey through the system.