NIHR CLAHRC e-newsletter Reducing admissions/care planning

Welcome to the community e-newsletter for the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) bringing you the latest news and interesting developments from across the thirteen collaborations and the health service research community. The NIHR CLAHRCs are funded by the NIHR and form part of the NIHR infrastructure. This newsletter looks at the work NIHR CLAHRCs are doing on reducing admissions/care planning.

A whole system approach to avoiding hospital admissions
Avoiding hospital admissions is central to the future sustainability of the NHS. In Bristol the Integration to Avoid Hospital Admissions Healthntegration Team (ITHAcA HIT) is bringing decision makers from across the urgent care system together to reduce complexity and develop new research. Part of Bristol Health Partners, a strategic collaboration of the region’s major health institutions, from universities to hospitals, and commissioners to public health, ITHAcA HIT has three priority themes: avoidable hospital admissions (with a focus on chronic obstructive disease (COPD), dementia and childhood asthma), the management of risk around avoidable admissions and using evidence and data to inform commissioning.  Studies that ITHAcA is working on with NIHR CLAHRC West include an investigation of discharge from secondary into primary care for elderly patients and developing a ‘rule’ for managing abnormal test results in out-of-hours primary care. Find out more.Release of Greater Manchester primary care demonstrator findings
NHS England (Greater Manchester) funded a programme of six ‘demonstrator communities’ to test new ways of delivering primary care services, with a key focus on increased access to general practice, reduced secondary care admissions, integration and the use of technology. The NIHR CLAHRC Greater Manchester was commissioned to conduct an independent, academic evaluation of the programme. View the key findings.Analysing emergency and urgent care system demand: a data linkage study of pre-hospital and emergency hospital data
A better understanding of the causes of increasing service pressures in the emergency and urgent care (EUC) system is fundamental to the delivery of more appropriate and better quality care for patients.  Currently there is a lack of detailed information on how patients use the EUC system, from the point of access to point of discharge. The NIHR CLAHRC Yorkshire and Humber Avoidable Attendances and Admissions Theme is undertaking a pilot of the region’s first EUC routine dataset linking pre-hospital and hospital data.  All 14 acute hospitals NHS trusts in Yorkshire and Humber have agreed to participate. Data has been collected so far from nine acute trusts, collating data for over 10 million patient attendances to hospital.  Data from the Yorkshire Ambulance Service for NHS 111 and 999 calls will be linked with these hospital episodes to provide a complete picture of the patient journey from time of call through to discharge.  Analysis of this dataset will provide crucial intelligence on how best to target interventions to provide better quality and appropriate care for patients at different parts of the EUC pathway.

Collaboration with local NHS partners to reduce hospital readmissions in the West Midlands
Researchers in NIHR CLAHRC West Midlands Theme 4 (Chronic Diseases) are undertaking two projects aimed at reducing hospital readmission. The first involves collaboration with Sandwell and West Birmingham NHS Trust to identify effective ways to reduce high levels of 30-day emergency hospital readmissions following a hospital stay. The first stage of the work is to assess whether the ‘LACE’ risk prediction tool, which uses information on patient length of stay, admission type, other health conditions and previous emergency admissions, can predict accurately whether or not a patient is likely to be readmitted to hospital after being discharged. If the tool is successful, NIHR CLAHRC West Midlands will work with the Trust to design and test interventions to offer enhanced inpatient care and more intensive management after discharge to improve patient outcomes and reduce the number of emergency readmissions for high-risk patients. The second project is outlined below.

Project to evaluate a supported integrated discharge service in the West Midlands
NIHR CLAHRC West Midlands is also collaborating with the Heart of England NHS Foundation Trust (HEFT) on a project to evaluate a supported integrated discharge service to identify whether its objectives are being met, and to understand the impact it has on patients, carers, staff and costs. HEFT has implemented a system of supported integrated discharge for patients aged over 65, admitted to hospital as an emergency, with a length of stay of 14 days or more. This patient group often has multiple chronic conditions and needs intensive rehabilitation, reablement and longer-term social care services input after their hospital stay. The aim is to reduce the length of hospital stay by providing specialist, multidisciplinary rehabilitation and support services in the patient’s home, improve the co-ordination of care across settings and care providers, reduce readmissions to hospital, make resource savings for the Trust, and help patients to improve their quality of life and stay independent for as long as possible. The integrated discharge service offers up to 14 days of therapy from the hospital Trust in the patient’s home, up to six weeks reablement from the local authority, a full community social work assessment, and managed handover to community therapy services if needed.  Find out more about the West Midlands chronic diseases theme.

Patient-Initiated Clinics
Patients with long-term chronic conditions are often required to attend clinic appointments at regular intervals, say three or six months. This has been shown to be ineffective for the patient and inefficient for the NHS – not all chronic conditions are consistent in the way in which they affect patients, which means that the allocated appointment may not fall when their condition is at its worst or where the patient feels the need for consultation. In association with the South West Academic Health Science Network, NIHR CLAHRC for South West Peninsula (PenCLAHRC) is working to systematically review the effectiveness of a number of patient-initiated clinics (PICs) for conditions such as rheumatoid arthritis. Find out more.

Rapid diagnostic kits can help prevent unnecessary hospital admission
NIHR CLAHRC South London research testing ‘rapid diagnostic kits’ is helping doctors to identify the cause of symptoms quickly and ensure patients aren’t admitted to hospital unnecessarily. The CLAHRC’s infection research team is evaluating different types of rapid diagnostic devices to find out whether they can help reduce the number of people admitted to hospital and cut down on the amount of unnecessary antibiotics prescribed. The research also includes a cost-effective analysis. The research team has been working with three different companies – Alere, BioFire Defense and Enigma Diagnostics. Each one has donated scores of diagnostic kits that have been road-tested in accident and emergency departments and admission wards in south London. Because of the time taken by laboratories to process diagnostic tests, doctors may admit patients to hospital pending the results, and may prescribe broad-spectrum antibiotics in the first instance. Find out more here and here.

Reducing acute kidney injury admissions
The EDucational Intervention to Prevent Acute Kidney Injury in Primary Care (ED-AKI-P) Implementation Study and clinical audit is supported by NIHR CLAHRC East Midlands. The study combines a novel informatics solution to help clinicians identify patients at risk of Acute Kidney Injury in the community, along with a multifaceted educational program to help health care staff understand the condition better. Patients who develop AKI suffer from significantly higher mortality and morbidity. The aim of the study is develop new ways to tackle the condition in the community before patients are admitted to hospital, and if possible prevent the onset of AKI in high-risk population groups.

ACE methods to explore hospital admissions of end-of-life patients
Admitting dying patients to hospital can be distressing for their families, frustrating for healthcare staff and expensive for the NHS. Researchers from the University of Cambridge and NIHR CLAHRC East of England are using innovative research methods to better understand these admissions.  TheAdmissions Close to the End of life (ACE) study focuses on patients with dementia, cancer and chronic chest disease who died shortly after admission to hospital. Patients are identified retrospectively after death and include those not labelled as ‘end-of-life’ on admission. Hospital records are used to identify hospital and community healthcare staff involved in the patients’ admission. Despite being interviewed up to a month after the patients’ death, staff give useful accounts of admissions. Patients’ next-of-kin are interviewed later after the death and provide valuable insights into admission circumstances.  Interview analysis is ongoing; ambulance staff seem to be central to many admissions but often feel unable to prevent them. For further information please contact Sarah Hoare – eh91@medschl.cam.ac.uk.

Kidney injury prevention card delivered to pharmacists and GPs
A sick day rules card, listing medicines that should be temporarily stopped during illness to avoid acute kidney injury (AKI), has been delivered to 47 practices and 59 pharmacies in Salford. One in five people admitted to hospital in the UK each year as an emergency has AKI; this NIHR CLAHRC Greater Manchester project aims to help patients understand which medicines they should stop taking when they’re ill to avoid AKI. Read more.

Alternative pre-hospital pathways for mental health patients
A collaboration between NIHR CLAHRC Yorkshire and Humber Avoidable Attendances and Admissions Theme and Yorkshire Ambulance Service is exploring the care provided for 999 patients with mental health problems. This includes a pilot study evaluating mental health nurse triage within the Emergency Operations Centre where calls are handled. This new service provides front-line call-handlers, clinicians and patients with access to specialist mental health support. The aims of the evaluation are to assess the impact of the service on outcomes for patients and on the working practices of Ambulance Service staff. It will also examine the costs and benefits associated with the service and any lessons learned from its implementation.  The study is collecting routine data on calls to the new service as well as qualitative data from staff and patients.  Early indications from routine data suggest a reduction in ambulance transport for patients with mental health problems and improved response time performance as a result for high priority calls.

Avoidable Acute Admissions
A research team supported by NIHR PenCLAHRC and led by Plymouth University Peninsula Schools of Medicine and Dentistry is working on a national report which addresses the question: how can frontline expertise and models of care best contribute to safely reducing acute hospital admissions? With analysis of working practice and patient experience in four NHS acute hospital trusts in the South West of England, the report will be published in the foreseeable future. Find out more.

Improving the mental health and wellbeing of young people leaving public care
The NIHR CLAHRC West Midlands Theme 2 (Youth Mental Health) is developing work alongside ‘LYNC’, an NIHR Programme Development Grant, to understand the mental health, social care needs and service use of young people leaving the social care system. Qualitative interviews with 12 care leavers and local authority staff have been completed and the findings form the basis of a full NIHR Programme Grant.  Young people in public care are a well-recognised vulnerable group. As these young people move into adulthood (become care leavers) they often continue to have problems: many are not in employment, education or training and are more likely to be involved in substance misuse, offending behaviour and be homeless. Poor mental health is a key impediment to young people in care achieving a successful transition to meaningful adult roles and personal wellbeing. The LYNC study is investigating how health services can effectively improve the mental health and wellbeing of young people leaving care within a research programme of four high-quality linked studies.  The first study will examine the literature and identify what constitutes effective transition. The second is a national census of transition across England, with four to five distinct models of transitional care identified, and involves a longitudinal assessment tracking young people’s care and outcomes within these models. In the third study, in collaboration with care leavers, a package will be developed to improve transition and promote mental health and wellbeing. The fourth study will be a feasibility test of the transition package as an intervention which can be rigorously tested in a randomised controlled trial. Find out more.

Reducing acute paediatric admissions
The number of acute admissions to hospital is rising, with around 20 percent of the increase made up of children and young people aged 19 and under. Of that number, 25 percent are aged four and younger. NIHR PenCLAHRC have led on a systematic review which clarifies the effectiveness of interventions used to reduce acute paediatric hospital admissions. See more on the project and access the paper.

Reducing urgent care admissions
NHS services spend an estimated £3 billion per year on providing inappropriate care for health anxiety that has little benefit for patients and can make the problem worse.  Despite the availability of effective treatment, few people with health anxiety take it up, due to aspects such as stigma or previous negative experiences with psychological/mental health services. Previous research suggests that remote delivery of therapy for anxiety and depression is just as effective as face-to-face, is more cost effective and can help overcome current engagement difficulties.  The NIHR CLAHRC East Midlands Urgent Care Study will test the effectiveness of a Cognitive Behavioural Therapy (CBT) delivered via telephone or video calling to people with high health anxiety that have had two or more emergency/urgent care attendances in the last 12 months. It will investigate whether remotely delivered CBT can relieve symptoms causing distress, improve physical and emotional health and reduce unscheduled/urgent care use. It will also explore the best way to deliver and put the intervention into practice. Find out more about the study.

Radiographer-led discharge
A research team from the Peninsula Collaboration for Health Operational Research and Development (PenCHORD), part of NIHR PenCLAHRC, has worked with Yeovil District Hospital to develop a visual pathway model and simulation model of the Emergency Department which could be used to train radiographers to either admit patients to hospital or discharge them. This would mean that the radiographer would interpret the diagnostic image without the need for consultant input. Find out more.

Advance care planning and health service utilisation for care home residents
In 2011, NIHR CLAHRC East Midlands PhD candidate Dr Gill Garden, Consultant in Older People’s Services at United Lincolnshire Hospitals NHS Trust, set up a care home service in Boston, Lincolnshire which delivered staff training, assessment of residents with reference to Gold Standards Framework prognostic indicators and advance care planning. Evaluation showed significant improvements in staff confidence in recognition, prevention and management of delirium and recognition and management of dysphagia, as well as a reduction in hospital admissions of 37 percent in the first and 55 percent in the second and third years. Although there was considerable satisfaction with the Boston service, approximately 10 percent of residents or their carers did not wish to participate in advance care planning. Gill’s NIHR CLAHRC East Midlands PhD will help to develop a similar service delivering comprehensive geriatric assessment for residents of care homes in Lincoln. This will allow escalation planning for all residents and provide opportunity to examine attitudes of residents and their carers to care planning and the impact of those views on subsequent health service utilisation. See the NIHR CLAHRC East Midlands SOPRANO study for more on assessing older people’s needs.

Further information
Further information on the NIHR can be found at www.nihr.ac.uk. Further information on the CLAHRCs, including links to their own web resources, is available at www.clahrcpp.co.uk. This newsletter is produced by the CLAHRC Partnership Programme based at Universities UK on behalf of the CLAHRC community. If you have any ideas or suggestions for the newsletter please contactChristina.heap@universitiesuk.ac.uk. For past issues of this newsletter and to join the mailing list please visit the CPP website.

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