Re: Preventing admission of older people to hospital
Sir, we would like to put forward a number of caveats that will help generate a more balanced argument towards this discussion:
- The authors appear to heavily focus on community based case management models as the main intervention but have not acknowledged the national QIPP LTC model of care which recommends the 3 underpinning drivers for whole system change, of which case management forms only part of it and cannot be prescribed in silo. The ideal model of care has to be redesign of our existing services which should include a number of interventions starting with targeting strategies such as risk stratification, a single assessment framework followed by multi disciplinary meetings where anticipatory care planning is carried out, incorporating systematized self care self management using, among others, assistive technologies in partnership with the third sector and voluntary organisations. All of this need to be commissioned together at pace and scale.
- The authors have not acknowledged the importance of how and when patients should be identified / selected for case management and care coordination which will have an impact on admission avoidance. If frequent fliers are targeted when they are in ‘crisis’, chances are that any reduction of admissions would have occurred irrespective of any intervention due to regression to the mean. Integrated care approach should be implemented before the ‘crisis’ to avert the ‘crisis’ resulting in admission avoidance.
- Understanding urgent care activity is complex and not straightforward. There are a multitude of push and pull factors that contribute to it. A systematic review done by University of Bristol in 2012 looking quality of evidence in reducing unplanned admissions admitted that while most researched interventions, including case management, have demonstrated little benefit, they admit that few research studies include evaluation of system wide approaches, hence the impact of programmes of interventions are rarely reported in the research literature. This highlights the importance of robust evaluation of interventions as they are introduced into health and social care systems. In this regard we recommend that any future whole system phased transformational approach to managing urgent care should be underpinned by a robust rolling evaluation framework using complex adaptive systems theory to account for the dynamic nature and complex inter relationships between different patients, services and their interventions, and organisations rather than relying on specific ‘cause and effect’ associations.
- Finally in light of Roemer’s Law which implies that a hospital bed available is a hospital bed filled, stresses the importance of supply induced demand. Investment into any integrated model of care in the community ultimately needs to be aligned with a concomitant disinvestment in acute care capacity or reduction in hospital beds, to ensure desired outcomes and sustainability of the new model in question. In this regard, the main outcomes will not be unscheduled admissions because any reduction would have been planned at the outset, but rather outcomes on patient safety, impact on other urgent care services such as ambulance call outs, OOH/111 and unscheduled primary care activity.
Competing interests:
No competing interests
14 June 2013
Abraham P. George
Consultant in Public Health
Sharon Lee Kent Community Health Trust, Bruce Pollington Heart of Kent Hospice
Rapid Response:
Re: Preventing admission of older people to hospital
Sir, we would like to put forward a number of caveats that will help generate a more balanced argument towards this discussion:
- The authors appear to heavily focus on community based case management models as the main intervention but have not acknowledged the national QIPP LTC model of care which recommends the 3 underpinning drivers for whole system change, of which case management forms only part of it and cannot be prescribed in silo. The ideal model of care has to be redesign of our existing services which should include a number of interventions starting with targeting strategies such as risk stratification, a single assessment framework followed by multi disciplinary meetings where anticipatory care planning is carried out, incorporating systematized self care self management using, among others, assistive technologies in partnership with the third sector and voluntary organisations. All of this need to be commissioned together at pace and scale.
- The authors have not acknowledged the importance of how and when patients should be identified / selected for case management and care coordination which will have an impact on admission avoidance. If frequent fliers are targeted when they are in ‘crisis’, chances are that any reduction of admissions would have occurred irrespective of any intervention due to regression to the mean. Integrated care approach should be implemented before the ‘crisis’ to avert the ‘crisis’ resulting in admission avoidance.
- Understanding urgent care activity is complex and not straightforward. There are a multitude of push and pull factors that contribute to it. A systematic review done by University of Bristol in 2012 looking quality of evidence in reducing unplanned admissions admitted that while most researched interventions, including case management, have demonstrated little benefit, they admit that few research studies include evaluation of system wide approaches, hence the impact of programmes of interventions are rarely reported in the research literature. This highlights the importance of robust evaluation of interventions as they are introduced into health and social care systems. In this regard we recommend that any future whole system phased transformational approach to managing urgent care should be underpinned by a robust rolling evaluation framework using complex adaptive systems theory to account for the dynamic nature and complex inter relationships between different patients, services and their interventions, and organisations rather than relying on specific ‘cause and effect’ associations.
- Finally in light of Roemer’s Law which implies that a hospital bed available is a hospital bed filled, stresses the importance of supply induced demand. Investment into any integrated model of care in the community ultimately needs to be aligned with a concomitant disinvestment in acute care capacity or reduction in hospital beds, to ensure desired outcomes and sustainability of the new model in question. In this regard, the main outcomes will not be unscheduled admissions because any reduction would have been planned at the outset, but rather outcomes on patient safety, impact on other urgent care services such as ambulance call outs, OOH/111 and unscheduled primary care activity.
Competing interests: No competing interests