As the population ages, more people are living with complex health needs, including multiple conditions and frailty. These individuals often receive fragmented care, delivered by multiple health professionals across different organisations. This is often confusing and frustrating to the people involved, who may need to tell their story multiple times. It also brings risks to the quality and safety of the care delivered, for example, if treatment is duplicated or some necessary care is not delivered.
The NHS is responding to these problems by seeking to deliver care that is integrated around the needs of the patient, rather than organised according to the traditional divide between hospitals, primary care and community services.
The New Care Models vanguards, born out of the Five Year Forward View, lay the groundwork for this approach. The Five Year Forward View emphasised the need for evaluation to establish which models produce the best experience for patients and the best value for money.
Last week, the Improvement Analytics Unit published its fourth evaluation, looking at the impact on hospital use of integrated care teams for patients with complex needs in North East Hampshire and Farnham.
What changes were made in North East Hampshire and Farnham?
The Happy, Healthy, at Home vanguard, in North East Hampshire and Farnham, implemented several new models of care, including integrated care teams. These were multidisciplinary teams comprising community nurses, social workers, mental health practitioners, paramedics and pharmacists among others.
Teams met weekly to discuss the needs of some of their most complex patients, who were at risk of going into crisis. They coordinated care for their patients, and could draw on extra expertise as needed (such as from palliative care) and prompt visits from specialists to the person’s home (such as dementia assessments and podiatry appointments).
What did the report find?
Our evaluation examined data for patients who were referred to the integrated care teams in the first 23 months of its operation, from July 2015 to May 2017. We compared these patients with a similar group who were registered with a local GP but not referred into an integrated care team.
The chart below shows that the integrated care team patients had a similar profile of emergency admissions per person to the control group in the two years before they were referred into the integrated care team. However, after patients were referred to the integrated care team, they were admitted to hospital as an emergency more often than the control group, experiencing an additional 0.53 of these admissions per person per year on average.
There are several possible explanations for these findings, including the possibility that the two groups were not fully comparable. Once we had taken the entire body of evidence together, we concluded that the integrated care teams were very unlikely to have led to reductions in emergency admissions, at least in the first 23 months. We could not rule out the possibility that the team’s involvement might have led to increases in admissions.
Why are the findings important?
This study tells us that when establishing multidisciplinary, community-based teams to care for complex patients, it’s important to be realistic about what impact they are likely to have on emergency admissions.
The evidence we have on the impact of these teams is not perfect, but some studies are beginning to show that they do not lead to reductions in emergency admissions in the short term. An evaluation of the integrated care pilots (a previous national programme in England which ran from 2009-2011) examined the impact of similar multidisciplinary teams and found that they were associated with a 9% increase in emergency admissions after six months. Other evaluations have found no impacts on hospital use, including a randomised controlled trial from Toronto that targeted high-risk patients discharged from hospital.
Why integrated care teams are sometimes associated with higher levels of emergency admissions in the short term is still unknown. One theory is that the teams are identifying urgent needs for health care that might otherwise have remained unmet or unidentified. Another explanation is that the ICTs led to patients being more aware of their health needs, which led to them attending A&E and being admitted.
It's possible that these teams might begin to reduce emergency admissions over the longer term (as in one example from the United States) but being sure of this requires longer term evaluations than are typical in this country.
The implications for integrated care teams
This evaluation does not show that integrated care teams don’t work; it simply shows that, in this instance, they did not reduce emergency hospital admissions. We couldn’t examine whether they were successful at reducing fragmentation in care or improving patients’ experience of care or their quality of life.
Emergency admissions are likely to remain a focus for policy makers. Although they are sometimes necessary for delivering medical care, they can expose patients to stress, loss of independence and risk of infection, potentially reducing their health and wellbeing after leaving hospital. They are also expensive, and many patients would prefer to be treated elsewhere.
Other approaches are available that may reduce emergency admissions, as we highlighted in our recent briefing on the topic. Perhaps when it comes to integrated care teams, the benefit may lay elsewhere, in improvements in patients’ health, experience of care and quality of life.
Adam Steventon is Director of Data Analytics at the Health Foundation.
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