Integrated care for older people by South Warwickshire NHS Foundation Trust and Partners
South Warwickshire NHS Foundation Trust has a series of linked projects to improve outcomes and efficiency in the care of older people by developing more integrated care in partnership with social care, primary care and Age UK Warwickshire. We have now started to realise the benefits of this work with reduced mortality, reduced length of stay, reduced care home placements and improved patient experience.
Frail older people are now the largest group using acute hospital services, occupying more than two thirds of in-patient hospital beds. They also are the dominant group requiring care home services. It is not surprising therefore that it has been estimated that older people account for 46 per cent of NHS spend and 55 per cent of tax-funded social care spend in England. However, there have been concerns over many years about the quality of care, particularly about lack of respect for the dignity of older people in acute hospitals and there is considerable scope to provide better alternatives to acute hospital care, through reducing the need for admission and or providing early supportive discharge.
Evidence from randomised controlled trials with frail older people has shown the benefit of intermediate care services in providing alternatives to hospital admission (step-up intermediate care) or reducing length of hospital stay (step-down intermediate care) with at least as good health outcomes. Comprehensive geriatric assessment (multi-disciplinary care by old age specialists) has also been shown to deliver better health outcomes, reduced need for acute hospital beds and reduced or delayed need for long-term care services.
The challenges of introducing the new system were considerable. They included the need to develop better models of anticipatory care, rapid response to community crisis, the redesign of acute hospital pathways for frail older people, simplifying discharge processes and delivering comprehensive geriatric assessment within post-acute care.
Our approach to anticipatory care has been to identify older people at risk of adverse outcomes when they come into contact with primary health care, social care or Age UK services and offer them an assessment with the EASY-Care instrument 4, which covers 49 specific threats to health, independence and well-being. A summary is provided of the needs which have been identified and the priorities of the older person. Information is provided and referrals are made for the threats which are of highest concern to the older person. Information once collected is available to others who might be subsequently involved in the person’s care and data is collated and analysed to support population needs assessment.
We have redesigned our acute hospital care pathways for older people by ensuring that frail older people are identified in our Emergency Admissions Unit (EAU) and are assessed by a geriatrician, and we have converted step-down wards into additional geriatric assessment units so that all patients once transferred from EAU are managed on the correct ward without further transfers before discharge.
We have redesigned our community services so that we can provide a guarantee of early supported discharge for 50 patients per week from the acute hospital and provide an emergency community response within two hours of a frailty crisis in the community.
These changes to our hospital and community services have required a significant additional investment in old age specialist practitioners including the appointment of two additional Consultant Geriatricians.
We have agreed discharge pathways with our colleagues in social care so that patients transfer to social care responsibility at agreed end points.
We have coped with an 11 per cent increase in emergency presentations in all adults to Warwick Hospital because we have been able to manage the care of older people more efficiently, reducing the need for acute hospital care for this group. We have also seen a 24 per cent reduction in mortality in older people admitted to hospital, which gives us some assurance that our efficiency gains have not been achieved at the expense of quality of care. We have also seen a modest reduction in readmission rates and an increase in the proportion of older people able to return to their former residence. It is too early to gauge the impact of our work in anticipatory care for older people but we see this as a driver for extending healthy active life in old age and for compressing morbidity, which would allow us to mitigate the impact of further population ageing on the costs of providing care and improving the lives of older people in Warwickshire.
Lessons learnt and next steps
These improvements could only be achieved through building trusted relationships with colleagues across sectors of care at strategic, operational and clinical levels, through good and bad times, particularly when our services were struggling to cope with ever increasing demand and tight financial constraints. However we all believe that we are better working together than separately. Our next steps are focusing on integrating our electronic assessment and information systems and developing a contracting framework which will incentivise commissioners and providers to continue to work together, sharing risks and benefits.
1 Better health in old age. Department of Health: London 2004.
2 Helge Garåsen,Rolf Windspoll, Roar Johnsen, Intermediate care at a community hospital as an alternative to prolonged general hospital care for elderly patients: a randomised controlled trial, BMC Public Health, 2007; 7: 68.
3 A recent meta analysis of random controlled trials of CGAs for older adults to hospital suggested that undergoing a CGA increases the likelihood of their being alive, not suffering functional decline and living in their own homes within a year. Some argue CGA should be standard practice. Graham Ellis, Martin A Whitehead, David Robinson, Desmond O’Neill, Peter Langhorne, Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials, BMJ 2011 (doi: 10.1136/bmj.d6553).