Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis

What works in managing complex conditions in older people in primary and community care? A state-of-the-art review

The number of older people living with complex health conditions is increasing, with the majority of these managed in primary and community settings. Many models of care have been developed to support them, however, there is mixed evidence on their value and they include multiple overlapping components. We aimed to synthesise the evidence to learn what works for managing complex conditions in older people in primary and community care. We carried out a state-of-the-art review of systematic reviews. We searched three databases (January 2009 to July 2019) for models of primary and community care for long-term conditions, frailty, multimorbidity and complex neurological conditions common to older people such as dementia. We narratively synthesised review findings to summarise the evidence for each model type and identify components which influenced effectiveness. Out of 2,129 unique titles and abstracts, 178 full texts were reviewed and 54 systematic reviews were included. We found that the models of care were more likely to improve depressive symptoms and mental health outcomes than physical health or service use outcomes. Interventions including self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways had greater evidence of effectiveness. The level of healthcare service integration appeared to be more important than inclusion of specific professional types within a team. However, more experienced and qualified nurses were associated with better outcomes. These conclusions are limited by the overlap between reviews, reliance on vote counting within some included reviews and the quality of study reports. In conclusion, primary and community care interventions for complex conditions in older people should include: (a) clear intervention targets; (b) explicit theoretical underpinnings; and (c) elements of self-management and patient education, structured collaboration between healthcare professionals and professional support. Further work needs to determine the optimal intensity, length, team composition and role of technology in interventions.

Emergency admission risk stratification tools in UK primary care: a cross-sectional survey of availability and use

Background

Stratifying patient populations by risk of adverse events was believed to support preventive care for those identified, but recent evidence does not support this. Emergency admission risk stratification (EARS) tools have been widely promoted in UK policy and GP contracts.

Aim

To describe availability and use of EARS tools across the UK, and identify factors perceived to influence implementation.

Design and setting

Cross-sectional survey in UK.

Method

Online survey of 235 organisations responsible for UK primary care: 209 clinical commissioning groups (CCGs) in England; 14 health boards in Scotland; seven health boards in Wales; and five local commissioning groups (LCGs) in Northern Ireland. Analysis results are presented using descriptive statistics for closed questions and by theme for open questions.

Results

Responses were analysed from 171 (72.8%) organisations, of which 148 (86.5%) reported that risk tools were available in their areas. Organisations identified 39 different EARS tools in use. Promotion by NHS commissioners, involvement of clinical leaders, and engagement of practice managers were identified as the most important factors in encouraging use of tools by general practices. High staff workloads and information governance were identified as important barriers. Tools were most frequently used to identify individual patients, but also for service planning. Nearly 40% of areas using EARS tools reported introducing or realigning services as a result, but relatively few reported use for service evaluation.

Conclusion

EARS tools are widely available across the UK, although there is variation by region. There remains a need to align policy and practice with research evidence.

The Effectiveness of Patient-Centred Medical Home-Based Models of Care versus Standard Primary Care in Chronic Disease Management: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Controlled Trials

Patient-centred care by a coordinated primary care team may be more effective than standard care in chronic disease management. We synthesised evidence to determine whether patient-centred medical home (PCMH)-based care models are more effective than standard general practitioner (GP) care in improving biomedical, hospital, and economic outcomes. MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus were searched to identify randomised (RCTs) and non-randomised controlled trials that evaluated two or more principles of PCMH among primary care patients with chronic diseases. Study selection, data extraction, quality assessment using Joanna Briggs Institute (JBI) appraisal tools, and grading of evidence using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach were conducted independently. A quantitative synthesis, where possible, was pooled using random effects models and the effect size estimates of standardised mean differences (SMDs) and odds ratios (ORs) with 95% confidence intervals were reported. Of the 13,820 citations, we identified 78 eligible RCTs and 7 quasi trials which included 60,617 patients. The findings suggested that PCMH-based care was associated with significant improvements in depression episodes (SMD -0.24; 95% CI -0.35, -0.14; I2 = 76%) and increased odds of remission (OR 1.79; 95% CI 1.46, 2.21; I2 = 0%). There were significant improvements in the health-related quality of life (SMD 0.10; 95% CI 0.04, 0.15; I2 = 51%), self-management outcomes (SMD 0.24; 95% CI 0.03, 0.44; I2 = 83%), and hospital admissions (OR 0.83; 95% CI 0.70, 0.98; I2 = 0%). In terms of biomedical outcomes, with exception to total cholesterol, PCMH-based care led to significant improvements in blood pressure, glycated haemoglobin, and low-density lipoprotein cholesterol outcomes. The incremental cost of PCMH care was identified to be small and significantly higher than standard care (SMD 0.17; 95% CI 0.08, 0.26; I2 = 82%). The quality of individual studies ranged from "fair" to "good" by meeting at least 60% of items on the quality appraisal checklist. Additionally, moderate to high heterogeneity across studies in outcomes resulted in downgrading the included studies as moderate or low grade of evidence. PCMH-based care has been found to be superior to standard GP care in chronic disease management. Results of the review have important implications that may inform patient, practice, and policy-level changes.

Health and health service usage outcomes of case management for patients with long-term conditions: a review of reviews

Objective:

There have been plenty of articles published in recent decades on patient care in the form of case management (CM), but conclusions regarding health outcomes and costs have often been discordant. The objective of this study was to examine previous systematic reviews and meta-analyses with a view to assessing and pooling the overwhelming amount of data available on CM-based health outcomes and resource usage.

Methods:

We conducted a review of reviews of secondary studies (meta-analyses and systematic reviews) addressing the effectiveness of CM compared with usual care (or other organizational models) in adult (18+) with long-term conditions. PubMed, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects (DARE) were searched from 2000 to the end of December 2017. The outcomes of interest are related to process of care, health measures, and resource usage.

Results:

Twenty-two articles were ultimately considered: 4 meta-analyses and 18 systematic reviews. There is strong evidence of CM increasing adherence to treatment guidelines and improving patient satisfaction, but none of the secondary studies considered demonstrated any effect on patient survival. Based on the available literature, there is contrasting evidence regarding all the other health outcomes, such as quality of life (QOL), clinical outcomes, and functional status. Good-quality secondary studies consistently found nothing to indicate that CM prompts any reduction in the use of hospital resources.

Conclusion:

The source of variability in the literature on the consistency of the evidence for most outcomes is unclear. It may stem from the heterogeneity of CM programs in terms of what their intervention entails, the populations targeted, and the tools used to measure the results. That said, there was consistently strong evidence of CM being associated with a greater adherence to treatment guidelines and higher patient satisfaction, but not with a longer survival or better use of hospital resources.

New integrated care models in England associated with small reduction in hospital admissions in longer-term: A difference-in-differences analysis

Closer integration of health and social care services has become a cornerstone policy in many developed countries, but there is still debate over what population and service level is best to target. In England, the 2019 Long Term Plan for the National Health Service included a commitment to spread the integration prototypes piloted under the Vanguard `New Care Models' programme. The programme, running from 2015 to 2018, was one of the largest pilots in English history, covering around 9 % of the population. It was largely intended to design prototypes aimed at reducing hospital utilisation by moving specialist care out of hospital into the community and by fostering coordination of health, care and rehabilitation services for (i) the whole population ('population-based sites'), or (ii) care home residents ('care home sites'). We evaluate and compare the efficacy of the population-based and care home site integrated care models in reducing hospital utilisation. We use area-level monthly counts of emergency admissions and bed-days obtained from administrative data using a quasi-experimental difference-in-differences design. We found that Vanguard sites had higher hospital utilisation than non-participants in the pre-intervention period. In the post-intervention period, there is clear evidence of a substantial increase in emergency admissions among non-Vanguard sites. The Vanguard integrated care programme slowed the rise in emergency admissions, especially in care home sites and in the third and final year. There was no significant reduction in bed-days. In conclusion, integrated care policies should not be relied upon to make large reductions in hospital activity in the short-run, especially for population-based models.

The national implementation of 'Proactive Health Support' in Denmark since 2017: Expectations and challenges for the telephone-based self-management program

In Denmark, as in many other Western countries, a small group of people are major hospital users and account for a large proportion of health care spending. Proactive Health Support (PaHS) is the first national Danish program that aims to reduce health care consumption targeting people at risk of becoming major users of health services. PaHS was part of the government's The sooner-the better national health policy, which includes a focus on policy programs targeting the weakest and most complex chronic patients at risk of high health care consumption. PaHS is a telephone-based self-management support program that uses a prediction model to identify people at high risk of acute hospital admissions. Reducing preventable hospital admissions and enhancing quality of life are central policy goals. The Danish policy was inspired by a Swedish policy program, and PaHS has been implemented based on policy transfer with political expectations that the Swedish results can be replicated in Denmark. The effects of PaHS are currently under study, and time will show whether expectations can be met. This paper discusses institutional conditions and expectations related to replicating a policy program and its outcomes. In addition, it highlights implementation issues that may affect the success of the policy program.

Proactive health support (PaHS) - telephone-based self-management support for persons at risk of hospital admission: Study protocol for a randomized controlled trial

BACKGROUND

A small proportion of patients account for most of the healthcare costs. Previous studies of supportive interventions have several methodological limitations and results are mixed. This article describes the protocol for Proactive Health Support: a national randomized controlled trial of telephone-based self-management support (ClinicalTrials.gov, NCT03628469). The main aim of the intervention is to reduce hospital admissions and improve quality of life at six months.

METHODS

A sample size of 4400 is needed and individuals with the highest risk of hospital admission in Denmark are invited by electronic communication and telephone to participate in a 1:1 randomized controlled trial. The intervention group receives one face-to-face start-up session followed by telephone sessions about individual goals regarding participants' knowledge, coping and need of healthcare. Quality of life was assessed with the mental health composite score of the SF-36v2 questionnaire. Primary analyses are done using the intention-to-treat principle.

DISCUSSION

The trial has been approved by The Regional Committee on Health Research Ethics (SJ-677). Intervention nurses do not assume clinical responsibility for the participants and the intervention is an addition to the general healthcare services. The intervention is complex due to challenging skills and behaviors required by nurses, individual tailoring of the intervention, and interacting intervention components. The study therefore includes process evaluation. The research program comprises: 1. Development initiation, 2. Intervention effect, 3. Cost-effectiveness, 4. Organizational implementation, and 5. Participants' experiences. Inclusion to the trial began April 9th, 2018, was completed July 1st, 2019 and follow-up will be completed February 1st, 2020.

Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts

Policy Points Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. Policies to integrate care that facilitate person-centered, relationship-based care can potentially contribute to (but not determine) improved patient experiences. There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced.

CONTEXT

Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts.

METHODS

We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care.

FINDINGS

We identified four perspectives on integrated care: patients' perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other.

CONCLUSIONS

Those looking for universal answers to narrow questions about whether integrated care "works" are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review

BACKGROUND

Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations.

METHODS AND FINDINGS

We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management.

CONCLUSIONS

Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

A practical model for research with learning health systems: Building and implementing effective complex case management

For researchers to contribute meaningfully to the creation of learning health systems, practical tools are required to operationalize existing conceptual frameworks. We describe a model currently in use by the University of Wisconsin Health Innovation Program (HIP). The HIP model consolidates and enhances existing learning health system frameworks by defining specific steps needed to create sustainable change based on research conducted within the health system. As an example of the model's application, we describe its use to improve patient identification for the University of Wisconsin health system's case management program. Our case study shows the importance of culture, infrastructure, and strong leadership support in realizing a learning health systems research project and creating sustainable change within the health system. By articulating the foundational elements and steps to conduct research with learning health systems, our model supports researchers in achieving the challenge of moving learning health systems from concept to action.

Unknown makes unloved-A case study on improving integrated health and social care in the Netherlands using a participatory approach

Many initiatives integrating health and social care have been implemented in order to provide adequate care and support to older people living at home. Further development of existing initiatives requires iterative processes of developing, implementing and evaluating improvements to current practice. This case study provides insight into the process of improving an existing integrated care initiative in the Netherlands. Using a participatory approach, researchers and local stakeholders collaborated to develop and implement activities to further improve collaboration between health and social care professionals. Improvement activities included interprofessional meetings focussing on reflection and mutual learning and workplace visits. Researchers evaluated the improvement process, using data triangulation of multiple qualitative and quantitative data sources. According to participating professionals, the improvement activities improved their communication and collaboration by establishing mutual understanding and trust. Enabling factors included the safe and informal setting in which the meetings took place and the personal relationships they developed during the project. Different organisational cultures and interests and a lack of ownership and accountability among managers hindered the improvement process, whereas issues such as staff shortages, time constraints and privacy regulations made it difficult to implement improvements on a larger scale. Still, the participatory approach encouraged the development of partnerships and shared goals on the level of both managers and professionals. This case study highlights that improving communication between professionals is an important first step in improving integrated care. In addition, it shows that a participatory approach, in which improvements are co-created and tailored to local priorities and needs, can help in the development of shared goals and trust between stakeholders with different perspectives. However, stakeholders' willingness and ability to participate in such an improvement process is challenged by many factors.

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

Background

In 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice.

Objectives

To map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions.

Methods

For the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA).

Results

A total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights.

Limitations

The research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.

Conclusions

Overall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services.

Future work

Research should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

State of Science: Bridging the Science-Practice Gap in Aging, Dementia and Mental Health

The workforce available to care for older adults has not kept pace with the need. In response to workforce limitations and the growing complexity of healthcare, scientists have tested new models of care that redesign clinical practice. This article describes why new models of care in aging, dementia, and mental health diffuse inadequately into the healthcare systems and communities where they might benefit older adults. We review a general framework for the diffusion of innovations and highlight the importance of other features of innovations that deter or facilitate diffusion. Although scientists often focus on generating evidence-based innovations, end-users apply their own criteria to determine an innovation's value. In 1962, Rogers suggested six features of an innovation that facilitate or deter diffusion suggested: relative advantage, compatibility with the existing environment, ease or difficulty of implementation, trial-ability or ability to "test drive", adaptability, and observed effectiveness. We describe examples of models of care in aging, dementia and mental health that enjoy a modicum of diffusion into practice and place the features of these models in the context of deterrents and facilitators for diffusion. Developers of models of care in aging, dementia, and mental health typically fail to incorporate the complexities of health systems, the barriers to diffusion, and the role of emotion into design considerations of new models. We describe agile implementation as a strategy to facilitate the speed and scale of diffusion in the setting of complex adaptive systems, social networks, and dynamic macroenvironments.

Exploring improvement plans of fourteen European integrated care sites for older people with complex needs

Integrated care programmes are increasingly being put in place to provide care to older people living at home. However, knowledge about further improving integrated care is limited. In fourteen integrated care sites in Europe, plans to improve existing ways of working were designed, implemented and evaluated to enlarge the understanding of what works and with what outcomes when improving integrated care. This paper provides insight into the existing ways that the sites were working with respect to integrated care, their perceived difficulties and their plans for working towards improvement. The seven components of the Expanded Chronic Care Model provided a conceptual framework for describing the fourteen sites. Although sites were spread across Europe and differed in basic characteristics and existing ways of working, a number of difficulties in delivering integrated care were similar. Existing ways of working and improvement plans mostly focused on three components of the Expanded Chronic Care Model: delivery system design; decision support; self-management. Two components were represented less frequently in existing ways of working and improvement plans: building healthy public policy; building community capacity. These findings suggest that broadly-based prevention efforts, population health promotion and community involvement remain limited. From the Expanded Chronic Care Model perspective, therefore, opportunities for improving integrated care outcomes may continue to be restricted by the narrow focus of developed improvement plans.

"We Want to Build a Network": Professional Experiences of Case Managers Working With Military Families

Optimizing case management (CM) services increases service member readiness at home and abroad. However, little research has been conducted on the experiences of case managers providing services to military families within the Military Health System. Semistructured qualitative interviews were conducted to explore the professional experiences of case managers to identify factors that may affect care to military families. A total of 53 case managers from military medical treatment facilities (MTFs) varying in size, location, and branch of service were interviewed by telephone to explore their perspectives. Qualitative content analysis was performed. Case managers serve a variety of functions, but specific roles vary between MTFs. Factors that affect CM services for military families were identified: (1) need for pediatric specialization, (2) heavy workload, (3) appropriate staff, (4) patient handoffs, and (5) the role of CM. Recommendations for improving CM services to facilitate the well-being of military families are discussed.

Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review

PURPOSE

Case management (CM) interventions are effective for frequent users of health care services, but little is known about which intervention characteristics lead to positive outcomes. We sought to identify characteristics of CM that yield positive outcomes among frequent users with chronic disease in primary care.

METHODS

For this systematic review of both quantitative and qualitative studies, we searched MEDLINE, CINAHL, Embase, and PsycINFO (1996 to September 2017) and included articles meeting the following criteria: (1)population: adult frequent users with chronic disease, (2)intervention: CM in a primary care setting with a postintervention evaluation, and (3)primary outcomes: integration of services, health care system use, cost, and patient outcome measures. Independent reviewers screened abstracts, read full texts, appraised methodologic quality (Mixed Methods Appraisal Tool), and extracted data from the included studies. Sufficient and necessary CM intervention characteristics were identified using configurational comparative methods.

RESULTS

Of the 10,687 records retrieved, 20 studies were included; 17 quantitative, 2 qualitative, and 1 mixed methods study. Analyses revealed that it is necessary to identify patients most likely to benefit from a CM intervention for CM to produce positive outcomes. High-intensity intervention or the presence of a multidisciplinary/interorganizational care plan was also associated with positive outcomes.

CONCLUSIONS

Policy makers and clinicians should focus on their case-finding processes because this is the essential characteristic of CM effectiveness. In addition, value should be placed on high-intensity CM interventions and developing care plans with multiple types of care providers to help improve patient outcomes.

Low-income homebound older adults receiving home-delivered meals: Physical and mental health conditions, incidence of falls and hospitalisations

Significant differences in health across racial/ethnic and socioeconomic groups in the US signal increasing numbers of low-income homebound older adults in a rapidly ageing society. The purpose of this study was to examine physical and psychiatric conditions and their association with incidence of self-reported falls and hospitalisations among largely low-income and racial/ethnic minority adults age 50+ (N = 2,224), clients from a home-delivered meals programme in Central Texas. Data came from comprehensive, in-home assessments done in 2017 by these older adults' case managers. We used bivariate analyses to compare those with and without incidence of self-reported past-year falls and those with and without a hospitalisation episode with respect to their sociodemographic and clinical characteristics. We used multivariable logistic regression analysis to examine sociodemographic and clinical correlates of any incidence of falls and negative binomial regression analysis to examine these correlates of the number of hospitalisations in the preceding 12 months. The rates of chronic physical illnesses, including cardiovascular disease, diabetes, gastrointestinal disease, lung disease and renal failure, were extremely high. The 41% of reported falls among the study sample was also higher than the rate among US older adults in general. More diagnosed physical illnesses, depression, chewing/swallowing problems, chronic/severe pain, activities and instrumental activities of daily living (ADL/IADL) impairments and ambulation assistive device use were associated with greater odds of falling. The rate of past-year hospitalisation was 26%, and more diagnosed physical illnesses, ADL/IADL impairments, ambulation assistive device use and any fall incidence were positively associated with the number of hospitalisations. These findings indicate the need for fall prevention programmes for frail homebound older adults as well as health and social care services that help older adults better manage physical/mental health problems and reduce preventable health crises and hospitalisations.

Assessing system-based trainings for primary care teams and quality-of-life of patients with multimorbidity in Thailand: patient and provider surveys

Background

Strengthening primary care is considered a global strategy to address non-communicable diseases and their comorbidity. However, empirical evidence of the longer-term benefits of capacity building programmes for primary care teams contextualised for low- and middle-income countries is scanty. In Thailand, a series of system-based capacity building programmes for primary care teams have been implemented for a decade. An analysis of the relationship between these systems-based trainings in diverse settings of primary care and quantified patient outcomes was needed.

Methods

Facility-based and community-based cross-sectional surveys were used to obtain data on exposure of primary care team members to 11 existing training programmes in Thailand, and health profiles and health-related quality of life of their patients measured in EuroQol-5 Dimension (EQ-5D) scale. Using a multilevel modelling, the associations between primary care provider’s training and patient’s EQ-5D score were estimated by a generalized linear mixed model (GLMM).

Results

While exposure to training programmes varied among primary care teams nationwide, District Health Management Learning (DHML) and Contracting Unit of Primary Care (CUP) Leadership Training Programmes, which put more emphasis on bundling of competencies and contextualising of applying such competencies, were positively associated with better health-related quality of life of their multimorbid patients.

Conclusions

Our report provides systematic feedback to a decade-long investment on system-based capacity building for primary care teams in Thailand, and can be considered as new evidence on the value of human resource development in primary care systems in low- and middle-income countries. Building multiple competencies helps members of primary care teams collaboratively manage district health systems and address complex health problems in different local contexts. Coupling contextualised training with ongoing programme implementation could be a key entity to the sustainable development of primary care teams in low and middle income countries which can then be a leverage for improving patients outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0951-6) contains supplementary material, which is available to authorized users.

Impact of the Case Management Model through Community Liaison Nurses

The objective of the present study is to assess the model’s impact on patients and their families in terms of outcomes and the efficiency results for the health system in Tenerife, Canary Islands, selecting a period of eight years from the time interval 2002–2018. The employed indicators were collected on a monthly basis. They referred to home care and its impact on clinical outcomes and on the use of resources. The comparison between the indicators’ tendencies with and without the liaison nurse model was done with the F-test by Snedecor. All these tests are bilateral, with a level of significance of p < 0.05. In those areas with community liaison nurse (CLN), improvements have been found in indicators that describe: (1) the management of the clinical status of patients, (2) the efficiency of the use of resources, and (3) the quality and compliance with the process that also includes home visits and social risk detection and management. It can be said that in the basic areas of primary health care where the work of the CLN develops there are improvements in the management of the patients’ clinical condition as well as in the quality and efficiency of care.

The impact of a combinatorial digital and organisational intervention on the management of long-term conditions in UK primary care: a non-randomised evaluation

BACKGROUND

Better management of long-term conditions remains a policy priority, with a focus on improving outcomes and reducing use of expensive hospital services. A number of interventions have been tested, but many have failed to show benefit in rigorous comparative research. In 2016, the NHS Test Beds scheme was launched to implement and test interventions combining digital technologies and pathway redesign in routine health care settings, with each intervention comprising multiple innovations to better realise benefit from their 'combinatorial' effect. We present the evaluation of one of the NHS Test Beds, which combined risk stratification algorithms, practice-based quality improvement and health monitoring and coaching to improve management of long-term conditions in a single health economy in the north-west of England.

METHODS

The NHS Test Bed was implemented in one clinical commissioning group in the north-west of England (patient population 235,800 served by 36 general practices). Routine administrative data on hospital use (the primary outcome) and a selection of secondary outcomes (data from both hospital and primary care) were collected in the intervention site, and from a comparator area in the same region. We used difference-in-differences analysis to compare outcomes in the NHS Test Bed area and the comparator after initiation of the combinatorial intervention.

RESULTS

Tests confirmed the existence of parallel trends in the intervention and comparator sites for hospital outcomes for the period April 2016 to March 2017, and for some of the planned primary care outcomes. Based on 10 months of post-intervention secondary care data and 13 months post-intervention primary care data, we found no significant impact on primary outcomes between the intervention and comparator site, and a significant impact on only one secondary outcome.

CONCLUSION

A combinatorial digital and organisational intervention to improve the management of long-term conditions was implemented across a whole health economy, but we found no evidence of a positive impact on health care utilisation outcomes in hospital and primary care.

Impact of the Southwark and Lambeth Integrated Care Older People's Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis

OBJECTIVES

To estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation.

DESIGN

Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values.

SETTING

94 practices in Southwark and Lambeth and 263 control practices from other parts of England.

MAIN OUTCOME MEASURES

Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay.

RESULTS

By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM.

CONCLUSIONS

The Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.

Characteristics of the provision of case management services in the community setting in Andalusia based on the RANGECOM registry

OBJECTIVE

To describe the characteristics of case management in terms of population served, interventions, use of services and outcomes such as mortality, readmissions, pressure ulcers, falls, drug problems and institutionalization.

METHOD

Follow-up study of a cohort, from the RANGECOM Multicentric Registry of Andalusia. The study population were patients included in the case management services of Health Centres and their family caregivers.

RESULTS

Data from 835 patients with a mean age of 76.8years (SD:12.1), 50.24% women, are presented. They had an important comorbidity (Charlson 3.1, SD:2.5) and high dependence (Barthel 37.5, SD:31.4). Sixty-two point two percent of the interventions deployed by the case managers were grouped into three domains: behavioural (26.0%), health system (20.2%) and safety (14.1%). Mortality was 34.4% and hospital admissions 38.1%. Patients with more hospital readmissions had more visits to the Emergency Department (OR:1.41; 95%CI: 1.22-1.63), more telephone interventions by case managers (OR:1.12; 95%CI: 1.02-1.24) and imaging tests (OR:1.37; 95%CI: 1.17-1.60), together with greater caregiver burden (OR:1.31; 95%CI: 1.08-1.59), the presence of medical devices at home (OR:1.69; 95%CI: 1.00-2.87) and received less "Case Management" intervention.

CONCLUSIONS

The patients who absorb the demand of case management nurses present high complexity, for which they deploy behavioural interventions, navigation through the health system and clinical safety.

The (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people: A systematic review

Integrated care is increasingly promoted as an effective and cost-effective way to organise care for community-dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost-effectiveness of preventive, integrated care for community-dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost-effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk-of-bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom-reported outcomes such as well-being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost-effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost-effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected.

Influence of fungal endophytes on plant physiology is more pronounced under stress than well-watered conditions: a meta-analysis

A meta-analysis of published articles shows that the influence of fungal endophytes on plant performance is dependent on plant water status. The magnitude of endophytic effects is higher in plants grown in water-limiting environments than those in adequate watering environments. The outcome of plant-endophyte interactions depends on the identity of the plant host and fungal symbionts. Water limitation often hinders plant productivity in both natural and agricultural settings. Endophytic fungal symbionts can mediate plant water stress responses by enhancing drought tolerance and avoidance, but these effects have not been quantified across plant-endophyte studies. A meta-analysis of published studies was performed to determine how endophytic fungal symbionts influence plant response under non-stressed versus water-stressed conditions. A significantly positive or neutral overall effect of fungal endophyte was noted under water-stressed conditions. In contrast, under non-stressed conditions, the overall effect of fungi on plants was mostly neutral. In general, the presence of fungal endophytes increased plant's total biomass, chlorophyll content, and stomatal conductance irrespective of water availability. In addition, plant shoot biomass, tiller density, plant height, maximum quantum yield (Fv/Fm), net photosynthesis, relative water content (RWC), amounts of ascorbate peroxidase (APX), glutathione (GSH), polyphenol oxidase (PPO), superoxide dismutase (SOD), and phenolics were significantly increased by endophyte colonisation under stressed conditions. Malondialdehyde (MDA) and hydrogen peroxide (H₂O₂) were reduced in endophytic plants under stress as compared with non-endophytic counterparts. Categorical analysis revealed that accumulation in plant biomass is influenced by factors such as host and fungi identity, the magnitude of which is greater under stressed than non-stressed conditions.

Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trial

Aim

We evaluated the introduction of a predictive risk stratification model (PRISM) into primary care. Contemporaneously National Health Service (NHS) Wales introduced Quality and Outcomes Framework payments to general practices to focus care on those at highest risk of emergency admission to hospital. The aim of this study was to evaluate the costs and effects of introducing PRISM into primary care.

Methods

Randomised stepped wedge trial with 32 general practices in one Welsh health board. The intervention comprised: PRISM software; practice-based training; clinical support through two ‘general practitioner (GP) champions’ and technical support. The primary outcome was emergency hospital admissions.

Results

Across 230 099 participants, PRISM implementation increased use of health services: emergency hospital admission rates by 1 % when untransformed (while change in log-transformed rate Δ_L=0.011, 95% CI 0.010 to 0.013); emergency department (ED) attendance rates by untransformed 3 % (while Δ_L=0.030, 95% CI 0.028 to 0.032); outpatient visit rates by untransformed 5 % (while Δ_L=0.055, 95% CI 0.051 to 0.058); the proportion of days with recorded GP activity by untransformed 1 % (while Δ_L=0.011, 95% CI 0.007 to 0.014) and time in hospital by untransformed 3 % (while Δ_L=0.029, 95% CI 0.026 to 0.031). Thus NHS costs per participant increased by £76 (95% CI £46 to £106).

Conclusions

Introduction of PRISM resulted in a statistically significant increase in emergency hospital admissions and use of other NHS services without evidence of benefits to patients or the NHS.

Outpatient Complex Case Management: Health System-Tailored Risk Stratification Taxonomy to Identify High-Cost, High-Need Patients

BACKGROUND

U.S. health systems, incentivized by financial penalties, are designing programs such as case management to reduce service utilization among high-cost, high-need populations. The major challenge is identifying patients for whom targeted programs are most effective for achieving desired outcomes.

OBJECTIVE

To evaluate a health system's outpatient complex case management (OPCM) for Medicare beneficiaries for patients overall and for high-risk patients using system-tailored taxonomy, and examine whether OPCM lowers service utilization and healthcare costs.

DESIGN

Retrospective case-control study using Medicare data collected between 2012 and 2016 for Ochsner Health System.

PARTICIPANTS

Super-utilizers defined as Medicare patients with at least two hospital/ED encounters within 180 days of the index date including the index event.

INTERVENTION

Outpatient complex case management.

MAIN MEASURES

Propensity score-adjusted multivariable logistic regression analysis was conducted for primary outcomes (90-day hospital readmission; 90-day ED re-visit). A difference-in-difference analysis was conducted to examine changes in per membership per month (PMPM) costs based on OPCM exposure.

KEY RESULTS

Among 18,882 patients, 1197 (6.3%) were identified as "high-risk" and 470 (2.5%) were OPCM participants with median enrollment of 49 days. High-risk OPCM cases compared to high-risk controls had lower odds of 90-day hospital readmissions (0.81 [0.40-1.61], non-significant) and lower odds of 90-day ED re-visits (0.50 [0.32-0.79]). Non-high-risk OPCM cases compared to non-high-risk controls had lower odds of 90-day hospital readmissions (0.20 [0.11-0.36]) and 90-day ED re-visits (0.66 [0.47-0.94]). Among OPCM cases, high-risk patients compared to non-high-risk patients had greater odds of 90-day hospital readmissions (4.44 [1.87-10.54]); however, there was no difference in 90-day ED re-visits (0.99 [0.58-1.68]). Overall, OPCM cases had lower total cost of care compared to controls (PMPM mean [SD]: - $1037.71 [188.18]).

CONCLUSIONS

Use of risk stratification taxonomy for super-utilizers can identify patients most likely to benefit from case management. Future studies must further examine which OPCM components drive improvements in select outcome for specific populations.

SMASH! The Salford medication safety dashboard

BACKGROUND

Patient safety is vital to well-functioning health systems. A key component is safe prescribing, particularly in primary care where most medications are prescribed. Previous research demonstrated that the number of patients exposed to potentially hazardous prescribing can be reduced by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners in a pharmacist-led intervention. We aimed to develop and roll out an online dashboard application that delivers this audit and feedback intervention in a continuous fashion.

METHOD

Based on initial system requirements we designed the dashboard's user interface over 3 iterations with 6 general practitioners (GPs), 7 pharmacists and a member of the public. Prescribing safety indicators from previous work were implemented in the dashboard. Pharmacists were trained to use the intervention and deliver it to general practices.

RESULTS

A web-based electronic dashboard was developed and linked to shared care records in Salford, UK. The completed dashboard was deployed in all but one (n=43) general practices in the region. By November 2017, 36 pharmacists had been trained in delivering the intervention to practices. There were 135 registered users of the dashboard, with an average of 91 user sessions a week.

CONCLUSION

We have developed and successfully rolled out of a complex, pharmacist-led dashboard intervention in Salford, UK. System usage statistics indicate broad and sustained uptake of the intervention. The use of systems that provide regularly updated audit information may be an important contributor towards medication safety in primary care.

Unplanned Readmission prevention by Geriatric Emergency Network for Transitional care (URGENT): protocol of a prospective single centre quasi-experimental study

BACKGROUND

International guidelines recommend adapting the classic emergency department (ED) management model to the needs of older adults in order to ameliorate post-ED outcomes among this vulnerable group. To improve the care for older ED patients and especially prevent unplanned ED readmissions, the URGENT care model was developed.

METHODS

The URGENT care model is a nurse-led, comprehensive geriatric assessment based care model in the ED with geriatric follow-up after ED discharge. A prospective single centre quasi-experimental study (sequential design with two cohorts) is used to evaluate its effectiveness on unplanned ED readmission compared to usual ED care. Secondary outcome measures are hospitalization rate, ED length of stay, in-hospital length of stay, higher level of care, functional decline and mortality.

DISCUSSION

URGENT builds on previous research with adaptations tailored to the local context and addresses the needs of older patients in the ED with a special focus on transition of care. Although the selected approaches have been tested in other settings, evidence on this type of innovative care models in the ED setting is inconclusive.

TRIAL REGISTRATION

The study protocol is registered retrospectively with ISRCTN ( ISRCTN91449949 ).

Health care costs of case management for frequent users of the emergency department: Hospital and insurance perspectives

BACKGROUND

In most emergency departments (EDs), few patients account for a relatively high number of ED visits. To improve the management of these patients, the university hospital of Lausanne, Switzerland, implemented an interdisciplinary case management (CM) intervention. This study examined whether the CM intervention-compared with standard care (SC) in the ED-reduced costs generated by frequent ED users, not only from the hospital perspective, but also from the third-party payer perspective, that is, from a broader perspective that takes into account the costs of health care services used outside the hospital offering the intervention.

METHODS

In this randomized controlled trial, 250 frequent ED users (>5 visits during the previous 12 months) were allocated to either the CM or the SC group and followed up for 12 months. Cost data were obtained from the hospital's analytical accounting system for the entire sample and from health insurance companies for a subgroup (n = 140). Descriptive statistics and multivariate regressions were used to make comparisons between groups and assess the contribution of patient characteristics to the main cost components.

RESULTS

At the end of the 12-month follow-up, 115 patients were in the CM group and 115 in the SC group (20 had died). Despite differences in economic costs between patients in the CM intervention and the SC groups, our results do not show any statistically significant reduction in costs associated with the intervention, either for the hospital that housed the intervention or for the third-party payer. Frequent ED users were big users of health services provided by both the hospital and community-based services, with 40% of costs generated outside the hospital that housed the intervention. Higher age, Swiss citizenship, and having social difficulty increased costs significantly.

CONCLUSIONS

As the role of the CM team is to guide patients through the entire care process, the intervention location is not limited to the hospital but often extends into the community.

Effectiveness of case management performed by nurses for blood pressure control in adults with hypertension: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The question of this review is: what is the effectiveness of nurse case management in primary healthcare for improving blood pressure, in adults over 18 years with hypertension?The objective of this review is to synthesize the best available evidence regarding the effectiveness of nurse case management in primary healthcare, compared to usual care, in improving blood pressure in adults over 18 years with hypertension.

Self-management capability in patients with long-term conditions is associated with reduced healthcare utilisation across a whole health economy: cross-sectional analysis of electronic health records

Objective

To quantify the association between patient self-management capability measured using the Patient Activation Measure (PAM) and healthcare utilisation across a whole health economy.

Results

12 270 PAM questionnaires were returned from 9348 patients. In the adjusted analyses, compared with the least activated group, highly activated patients (level 4) had the lowest rate of contact with a general practitioner (rate ratio: 0.82, 95% CI 0.79 to 0.86), emergency department attendances (rate ratio: 0.68, 95% CI 0.60 to 0.78), emergency hospital admissions (rate ratio: 0.62, 95% CI 0.51 to 0.75) and outpatient attendances (rate ratio: 0.81, 95% CI 0.74 to 0.88). These patients also had the lowest relative rate (compared with the least activated) of ‘did not attends’ at the general practitioner (rate ratio: 0.77, 95% CI 0.68 to 0.87), ‘did not attends’ at hospital outpatient appointments (rate ratio: 0.72, 95% CI 0.61 to 0.86) and self-referred attendance at emergency departments for conditions classified as minor severity (rate ratio: 0.67, 95% CI 0.55 to 0.82), a significantly shorter average length of stay for overnight elective admissions (rate ratio 0.59, 95% CI 0.37 to 0.94), and a lower likelihood of 30- day emergency readmission (rate ratio: 0.68, 95%  CI 0.39 to 1.17), though this did not reach significance.

Conclusions

Self-management capability is associated with lower healthcare utilisation and less wasteful use across primary and secondary care.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Improving care for older people with long-term conditions and social care needs in Salford: the CLASSIC mixed-methods study, including RCT

Background

The Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness.

Objectives

To explore the process of implementation of the SICP and the impact on patient outcomes and costs.

Design

Qualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies.

Setting

Salford in the north-west of England.

Participants

Older people aged ≥ 65 years, carers, and health and social care professionals.

Interventions

A large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’).

Main outcome measures

Patient self-management, care experience and quality of life, and health-care utilisation and costs.

Data sources

Professional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation.

Results

The SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776).

Limitations

The Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were < 40%.

Conclusions

The SICP has been implemented in a way that is consistent with the original vision. However, there has been more rapid success in establishing new integrated structures (such as a formal integrated care organisation), rather than in delivering mechanisms of integration at sufficient scale to have a large impact on patient outcomes.

Future work

Further research could focus on each of the mechanisms of integration. The multidisciplinary groups may require improved targeting of patients or disease subgroups to demonstrate effectiveness. Development of a proven model of health coaching that can be implemented at scale is required, especially one that would provide cost savings for commissioners or providers. Similarly, further exploration is required to assess the longer-term benefits of community assets and whether or not health impacts translate to reductions in care use.

Trial registration

Current Controlled Trials ISRCTN12286422.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 6, No. 31. See the NIHR Journals Library website for further project information.

Targeting the 'right' patients for integrated care: stakeholder perspectives from a qualitative study

Objective To explore the perceptions of relevant stakeholders in terms of targeting the 'right' patients for integrated care. Methods Secondary analysis of qualitative interviews with relevant stakeholders (including programme managers, programme initiators, a representative of the payers, medical and social care professionals and allied health services staff) from two integrated care sites in England. A thematic analysis was conducted of cross-cutting themes. Results Both sites focused on individualized management of 'high-risk' patients through multidisciplinary team case management. The data-driven approach to targeting patients, recommended in the policy literature, did not align with stakeholders' experience of selecting patients in practice. The 'right' patients were at lower risk than those recommended by policy, and their complexities were identified as comprising mostly social rather than medical issues. Conclusions These findings raise timely questions about the individualized management approach. They potentially explain why management of high-risk patients has not been found to be effective using quantitative measures, undermining the assumption that this approach will lead to cost savings. There is a need to expand beyond an individually targeted approach to incorporate prevention and to address social issues.

Change in health care use after coordinated care planning: a quasi-experimental study

BACKGROUND

We sought to determine whether patients with a coordinated care plan developed using the Health Links model of care in the Hamilton Niagara Haldimand Brant Local Health Integration Network differed in their use of health care (no. of emergency department visits, inpatient admissions, length of inpatient stay) when compared with a matched control group of patients with no care plans.

METHODS

We performed a propensity score-matched study of 12 months pre- and 12 months post-health care use. Patients who had a coordinated care plan that started between 2013 and 2015 were propensity score matched to patients in a control group. Patient information was obtained from Client Health and Related Information System, National Ambulatory Care Reporting System and Discharge Abstract Database. Differences in health care use pre- and post-index date were compared using the Wilcoxon signed-rank test. A negative binomial regression model was fit for each health care use outcome at 6 and 12 months post-index date.

RESULTS

Six hundred coordinated care plan enrollees and 25 449 potential control patients were included in the matching algorithm, which resulted in 548 matched pairs (91.3%). Both groups showed decreases in health care use post-index date. Matched care plan enrollees had significantly fewer emergency department visits at 6 (incidence rate ratio [IRR] 0.81, 95% confidence interval [CI] 0.72-0.91, p < 0.01) and 12 months post-index date (IRR 0.88, 95% CI 0.79-0.99, p < 0.05) compared with the matched controls. Other use parameters were not significantly different between care plan enrollees and the control group.

INTERPRETATION

Care plan enrollees show a decrease in the number of times they visit emergency departments, which may be attributed to integrated and coordinated care planning. This association should be examined to see whether these reductions persist for more than 1 year.

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND

Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context.

METHODS

The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence.

RESULTS

One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users.

CONCLUSIONS

Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand.

TRIAL REGISTRATION

Prospero registration number: 42016037725 .

Effectiveness of Nurse-Led Case Management in Cancer Care: Systematic Review

Cancer survivors need accountable, patient-centered and lifelong care. Case management has been shown effective at providing quality care and at reducing both hospital access and health care costs. However, how effective case management in cancer care is to date unclear. This systematic review examines recent evidence of the effectiveness of nurse-led case management in adults with cancer. The Cochrane processes and PRISMA statements guided this systematic review. The methodological risk of bias was assessed. From four electronic databases, nine experimental studies published from 2008 to 2017 were retrieved. Synthesized results show positive case management effectively improved patients' quality of life and significantly reduced hospital readmission rates. However, there were mixed results of health care costs and other hospital access outcomes. There is some evidence that nurse-led case management is effective in cancer care. Further research applying rigorous design to large populations of cancer patients is recommended.

Case Management in Primary Care for Frequent Users of Health Care Services: A Mixed Methods Study

PURPOSE

This study aimed to evaluate the effects of the V1SAGES case management intervention (Vulnerable Patients in Primary Care: Nurse Case Management and Self-management Support) for frequent users of health care services with chronic disease and complex care needs on psychological distress and patient activation.

METHODS

We used a 2-phase sequential mixed methods design. The first phase was a pragmatic randomized controlled trial with intention-to-treat analysis that measured the effects of the intervention compared with usual care on psychological distress and patient activation before and after 6 months. The second phase had a qualitative descriptive design and entailed thematic analysis of in-depth interviews (25 patients, 6 case management nurses, 9 health managers) and focus groups (8 patients' spouses, 21 family physicians) to understand stakeholders' perceived effects of the intervention on patients.

RESULTS

A total of 247 patients were randomized into the intervention group (n = 126) or the control group (n = 121). Compared with usual care, the intervention reduced psychological distress (odds ratio = 0.43; 95% CI, 0.19-0.95, P = .04), but did not have any significant effect on patient activation (P = .43). Qualitative results suggested that patients and their spouses benefitted from the case management intervention, gaining a sense of security, and stakeholders noted better patient self-management of health.

CONCLUSIONS

Together, our study's quantitative and qualitative results suggest that case management reduces psychological distress, making patients and caregivers feel more secure, whereas impact on self-management is unclear. Case management is a promising avenue to improve outcomes among frequent users of health care with complex needs.

Validation of the What Matters Index: A brief, patient-reported index that guides care for chronic conditions and can substitute for computer-generated risk models

INTRODUCTION

Current health care delivery relies on complex, computer-generated risk models constructed from insurance claims and medical record data. However, these models produce inaccurate predictions of risk levels for individual patients, do not explicitly guide care, and undermine health management investments in many patients at lesser risk. Therefore, this study prospectively validates a concise patient-reported risk assessment that addresses these inadequacies of computer-generated risk models.

METHODS

Five measures with well-documented impacts on the use of health services are summed to create a "What Matters Index." These measures are: 1) insufficient confidence to self-manage health problems, 2) pain, 3) bothersome emotions, 4) polypharmacy, and 5) adverse medication effects. We compare the sensitivity and predictive values of this index with two representative risk models in a population of 8619 Medicaid recipients.

RESULTS

The patient-reported "What Matters Index" and the conventional risk models are found to exhibit similar sensitivities and predictive values for subsequent hospital or emergency room use. The "What Matters Index" is also reliable: akin to its performance during development, for patients with index scores of 1, 2, and ≥3, the odds ratios (with 95% confidence intervals) for subsequent hospitalization within 1 year, relative to patients with a score of 0, are 1.3 (1.1-1.6), 2.0 (1.6-2.4), and 3.4 (2.9-4.0), respectively; for emergency room use, the corresponding odds ratios are 1.3 (1.1-1.4), 1.9 (1.6-2.1), and 2.9 (2.6-3.3). Similar findings were replicated among smaller populations of 1061 mostly older patients from nine private practices and 4428 Medicaid patients without chronic conditions.

SUMMARY

In contrast to complex computer-generated risk models, the brief patient-reported "What Matters Index" immediately and unambiguously identifies fundamental, remediable needs for each patient and more sensibly directs the delivery of services to patient categories based on their risk for subsequent costly care.

Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC)

Background

With a higher proportion of older people in the UK population, new approaches are needed to reduce emergency hospital admissions, thereby shifting care delivery out of hospital when possible and safe.

Study aim

To evaluate the introduction of predictive risk stratification in primary care.

Objectives

To (1) measure the effects on service usage, particularly emergency admissions to hospital; (2) assess the effects of the Predictive RIsk Stratification Model (PRISM) on quality of life and satisfaction; (3) assess the technical performance of PRISM; (4) estimate the costs of PRISM implementation and its effects; and (5) describe the processes of change associated with PRISM.

Design

Randomised stepped-wedge trial with economic and qualitative components.

Setting

Abertawe Bro Morgannwg University Health Board, south Wales.

Participants

Patients registered with 32 participating general practices.

Intervention

PRISM software, which stratifies patients into four (emergency admission) risk groups; practice-based training; and clinical support.

Main outcome measures

Primary outcome – emergency hospital admissions. Secondary outcomes – emergency department (ED) and outpatient attendances, general practitioner (GP) activity, time in hospital, quality of life, satisfaction and costs.

Data sources

Routine anonymised linked health service use data, self-completed questionnaires and staff focus groups and interviews.

Results

Across 230,099 participants, PRISM implementation led to increased emergency admissions to hospital [ΔL = 0.011, 95% confidence interval (CI) 0.010 to 0.013], ED attendances (ΔL = 0.030, 95% CI 0.028 to 0.032), GP event-days (ΔL = 0.011, 95% CI 0.007 to 0.014), outpatient visits (ΔL = 0.055, 95% CI 0.051 to 0.058) and time spent in hospital (ΔL = 0.029, 95% CI 0.026 to 0.031). Quality-of-life scores related to mental health were similar between phases (Δ = –0.720, 95% CI –1.469 to 0.030); physical health scores improved in the intervention phase (Δ = 1.465, 95% CI 0.774 to 2.157); and satisfaction levels were lower (Δ = –0.074, 95% CI – 0.133 to –0.015). PRISM implementation cost £0.12 per patient per year and costs of health-care use per patient were higher in the intervention phase (Δ = £76, 95% CI £46 to £106). There was no evidence of any significant difference in deaths between phases (9.58 per 1000 patients per year in the control phase and 9.25 per 1000 patients per year in the intervention phase). PRISM showed good general technical performance, comparable with existing risk prediction tools (c-statistic of 0.749). Qualitative data showed low use by GPs and practice staff, although they all reported using PRISM to generate lists of patients to target for prioritised care to meet Quality and Outcomes Framework (QOF) targets.

Limitations

In Wales during the study period, QOF targets were introduced into general practice to encourage targeting care to those at highest risk of emergency admission to hospital. Within this dynamic context, we therefore evaluated the combined effects of PRISM and this contemporaneous policy initiative.

Conclusions

Introduction of PRISM increased emergency episodes, hospitalisation and costs across, and within, risk levels without clear evidence of benefits to patients.

Future research

(1) Evaluation of targeting of different services to different levels of risk; (2) investigation of effects on vulnerable populations and health inequalities; (3) secondary analysis of the Predictive Risk Stratification: A Trial in Chronic Conditions Management data set by health condition type; and (4) acceptability of predictive risk stratification to patients and practitioners.

Trial and study registration

Current Controlled Trials ISRCTN55538212 and PROSPERO CRD42015016874.

Funding

The National Institute for Health Research Health Services Delivery and Research programme.

Senior high-cost healthcare users' resource utilization and outcomes: a protocol of a retrospective matched cohort study in Canada

INTRODUCTION

Senior high-cost users (HCUs) are estimated to represent 60% of all HCUs in Ontario, Canada's most populous province. To improve our understanding of individual and health system characteristics related to senior HCUs, we will examine incident senior HCUs to determine their incremental healthcare utilisation and costs, characteristics of index hospitalisation episodes, mortality and their regional variation across Ontario.

METHODS AND ANALYSIS

A retrospective, population-based cohort study using administrative healthcare records will be used. Incident senior HCUs will be defined as Ontarians aged ≥66 years who were in the top 5% of healthcare cost users during fiscal year 2013 but not during fiscal year 2012. Each HCU will be matched to three non-HCUs by age, sex and health planning region. Incremental healthcare use and costs will be determined using the method of recycled predictions. We will apply multivariable logistic regression to determine patient and health service factors associated with index hospitalisation and inhospital mortality during the incident year. The most common causes of admission will be identified and contrasted with the most expensive hospitalised conditions. We will also calculate the ratio of inpatient costs incurred through admissions of ambulatory care sensitive conditions to the total inpatient expenditures. The magnitude of variation in costs and health service utilisation will be established by calculating the extremal quotient, the coefficient of variation and the Gini mean difference for estimates obtained through multilevel regression analyses.

ETHICS AND DISSEMINATION

This study has been approved by Hamilton Integrated Research Ethics Board (ID#1715-C). The results of the study will be distributed through peer-reviewed journals. They also will be disseminated at research events in academic settings, national and international conferences as well as with presentations to provincial health authorities.

Introducing care management to Brazil's alcohol and substance use disorder population

Brazil has a sizable alcohol and substance use disorder (ASUD) population, yet there are considerable gaps in treatment access and retention. ASUD, a chronic medical condition, is highly comorbid with medical and behavioral health disorders. This indicates a need for more targeted interventions in order to achieve health care integration (a major goal of Brazil's health care system). Care management - that is, the organization of patient care by an institution - is a viable strategy to engage individuals with ASUD who might benefit from treatment but are not aware of or do not use the available resources, as well as to help maintain patients in treatment. Care management is considered an essential supplement to the treatment of chronic disease. The objective of this article is to discuss the applicability of care management for the treatment of ASUD within the public health care system in Brazil. We describe models of care management that have been adopted internationally and identify the feasibility and advantages for its adoption in Brazil.