There’s no place like home Helping patients receive care closer to home A rapid literature review

1. There’s no place like homeHelping patients receive care closer to home A rapid literature review Geri Arthur Specialty Registrar

2. Introduction • Describe why this work was needed • The methodology • The results

3. Why was the work needed • Request to NPHS from multi-agency steering group • Evidence to inform the reconfiguration of some primary care services across North Wales • Work comprised a population profile; a service review with needs assessment; a literature review and policy review document to feed into first 30 day cycle of the “90 day methodology” used

4. Policy context A raft of policy documents have made the case for care being provided closer to the patient Acknowledgement that the way services are currently provided is not sustainable Changing population demographic putting pressure on systems

5. Inclusion criteria • Types of studies: All • Participants: >65yrs, people with chronic conditions • Interventions: risk stratification tools, case management, disease management

6. Search strategy • Electronic databases: OVID collection (EMBASE, Medline, PsychINFO, HMIC, Ovid Journals Database) • Cochrane Library , DARE • Internet: WAG, DH, Google, Kings Fund, NICE, Birmingham University HSMC, Improvement Foundation • English language • 2006 – 2009 (previous review by Webb in 2006, updated*) * Welsh Assembly Government. International overview of the evidence on effective service models in chronic disease management. WAG; 2006

7. Supporting self-management

8. Expert Patient Programme Effects • Improved self efficacy • Mixed effects seen on psychological health and quality of life • No change in use of healthcare • Modest improvements in some clinical outcomes Some misconceptions about the original Stanford model

9. Lack of evidence • Written information for patients – may work as part of a comprehensive programme • Patient-held records – as above • Written care plans - as above • Self monitoring – may improve some outcomes e.g. BP, blood glucose but don’t help to move care outside of hospital

10. Risk stratification

11. What is risk stratification? • Simplest versions are GP disease registers • Risk stratification tools may be a list of trigger questions (EARLI), a software based algorithm using in-patient data (PARR) or combining secondary & primary care data (Combine Predictive Model) in order to target care at those who will benefit most.

12. Risk stratification • PARR • EARLI • SPARRA • PRISM • Combined Predictive Model

13. Risk stratification of populations • Some evidence that disease registers improve outcomes but don’t shift care to primary care settings • 1 meta-analyses indicates positive effect on clinical outcomes if high risk populations are targeted • Some evidence that targeting high risk individuals may be cost effective

14. Risk stratification of populations (contd) • PARR – risk score of 50, 54.3% of admitted patients were correctly identified, 34.7% incorrectly identified (high scores have greater specificity and lower sensitivity) • Criticism is that previous admission rates are part of the algorithm – are reductions due to intervention? Misses patients where admission could be prevented if they have not had an admissions previously.

15. Community based care

16. What is case management? When an individual has numerous long term conditions and complex needs, their care becomes more difficult for them to manage. Case management is where a named coordinator, e.g. a Community Matron, actively manages and joins up care by offering, amongst others, continuity of care, coordination and a personalised care plan for vulnerable people most at risk. Glossary of terms – http://www.cpa.org.uk/sap/glossary/glossary.html

17. Case management • Significant investment • Methodology from USA • No new money, self financing • Target for number of matrons & emergency bed day reduction

18. Case Management Examples are Pfizer, Evercare, Kaiser Permanente & Unique Care • The evidence effect is inconsistent in terms of: • Quality of care • Clinical outcomes • Resource use

19. Case Management (contd) • Pfizer – no high level evidence • Kaiser study flawed – different populations targeted by Kaiser & NHS , wrong NHS costs were used and non standardised data for NHS bed days • Before and after study of Evercare showed a tendency to higher admissions rates • Unique Care – lots of small scales studies

20. Case Management (contd) • There is some evidence to support the use of risk stratification tools to target care • The evidence for case management is inconclusive • There is a need for high quality studies evaluating case management style interventions

21. Specialist nurses • No difference in care given between hospital and by specialist nurses • For some disciplines may be equivalent at reduced cost e.g. COPD, asthma, arthritis, heart failure, diabetes, anti-coagulant therapy

22. Home visiting Most evidence relates to the elderly Some evidence of: • Reduced mortality • Reduction in residential home admissions • Increased patient satisfaction • No evidence of reduced hospital admissions

23. Rapid response for admission avoidance Services that are used to treat sub-acute illness and avoid hospital admission • Subjective evaluation of ‘avoided’ admission • Services in Emergency Departments tend to save money for patients and carers not the NHS

24. Intervention involving secondary care providers

25. Integrated / shared care Involves integrated working between primary and secondary care • Some evidence of beneficial effects on GP prescribing and communication • Cochrane review showed little reduction in referrals Joint management plans – Cochrane review • no improvements in physical health outcomes • No reduction in hospital admissions • No improved satisfaction

26. Discharge planning A comprehensive assessment of the patient to ensure their needs are met on discharge Good evidence: • Admission reduction • Reduce length of stay • Beneficial in transfer of patients from hospital

27. Location of services

28. Hospital at home This intervention describes services that require health professionals to deliver them and can be provided at home but have traditionally been provided in hospital Some evidence of: • Reduced length of stay • Increased patient satisfaction • Reduction in incidence of complications e.g. confusion No differences in outcomes but there is a reduction in cost

29. Intermediate Care This is care provided on the primary / secondary care interface and can include aggressive follow-up and admission prevention • Little evidence that it reduces hospital usage However where evidence of benefit existed the key features for success were: • Effective partnership working between health and social care Main barriers were poor joint working and short term funding

30. Rehabilitation Hospital and community services are comparable Cochrane review showed that supported discharge with rehab at home resulted in: • Reduction in long term dependency • Reduction in length of hospital stay • Reduction in admission to institutional care Another Cochrane review – difficult to differentiate according to venue of rehab. Some evidence for condition specific e.g. MS, pulmonary rehab

31. Key messages • Healthcare systems need to change in response to demographic shifts and changes in disease patterns • Good evidence for disease specific self-management programmes, mixed evidence for generic programmes • Mixed evidence for risk stratification tools, and specificity suffers with increased sensitivity so if you seek to capture more at-risk cases you will add increasing numbers of not-at-risk cases too • Good evidence for enhanced discharge planning, evidence that outreach services or consultant liaison models do not improve outcomes other than prescribing • Limited evidence that broad chronic care programmes have positive effects, although patient satisfaction tends to be high. • Good evidence that hospital at home services and specialist nurse led services can provide equivalent care to in-patient services • There is evidence that rehabilitation in community settings is equivalent to hospital care • There is no high level evidence in relation to function of community hospitals • Lack of research evidence of benefit is not the same as evidence of no benefit

32. Acknowledgements • Isabel Puscas • Nigel Monaghan • Mary Webb • Dr John Arthur

33. Questions?