Interpretation of the findings

Older people living in care homes that participated in the enhanced support programme attended A&E departments 29% less often than a matched comparison group (95% confidence interval: 11–43%), and were admitted to hospital as an emergency 23% less frequently (95% confidence interval: 3–39%). These findings require careful interpretation, informed by a discussion of the strengths and limitations of the analysis.

In the absence of randomisation, residents of the participating care homes were compared with a retrospectively matched comparison group. These two groups had similar age, gender, health care conditions and previous hospital utilisation, and they lived in care homes that were similar in terms of size and provision of nursing care. Moreover, the matched comparison residents lived in local authority areas that were comparable to Rushcliffe in terms of demographic and socioeconomic characteristics and historic, per capita rates of emergency hospital admission. Notwithstanding these similarities, unmeasured differences may have existed between the Principia residents and the matched comparison group, for example in the availability of informal care support or local authority funding. Also, although we ensured that the comparison areas had similar overall emergency admission rates to Rushcliffe, we could not assess whether they had similar levels of admissions from care homes in the period running up to the introduction of the Principia enhanced support in April 2014. These unmeasured differences might explain some or all of the difference we observed in the utilisation of emergency care. However, although we cannot be definitive, some reassurance is available. For example, the Principia and matched comparison groups had similar mortality rates, lending support to the notion that neither group had more severe health conditions than the other. In fact, the two groups appeared similar even before matching, which might mean there was limited scope for bias through unobserved variables. More information is available in the technical appendix.

If the lower use of emergency care does not reflect differences in the characteristics of the individuals, care homes or areas, then the most likely explanation is that it reflects the care provided to care home residents. However, we could not determine definitively whether the enhanced support produced the lower levels of emergency care utilisation, or some other innovation in care delivery. Here, it would help to have data on admissions from care homes before April 2014. This would enable comparisons to be made between new residents in Principia care homes and people who moved to the same care homes earlier, before the start of the enhanced support, in a ‘difference-in-difference’ style analysis. Such analysis would reveal whether the reductions in emergency care utilisation occurred at the same time as the introduction of the enhanced support, potentially leading to stronger evidence about attribution.

It would also be helpful to combine quantitative with qualitative evaluation. Based on our own discussions with Principia, we have described the enhanced support as including regular visits from a named GP, improved support from community nurses, independent advocacy and support from the third sector, and a programme of work to engage and support care home managers. However, we could not observe how these elements operated in practice, or examine the mechanisms through which the enhanced support might have interacted with contextual factors to produce the lower rates of A&E attendance and emergency admission. Such insights would be helpful because complex interventions such as these often evolve over time in response to experience and changing priorities and needs. Understanding these dynamics is important when considering whether to replicate the enhanced support, since the effects might be different in other contexts. Certain elements of the enhanced support package may be more significant determinants of emergency care utilisation than others.

The effect of the enhanced support package might vary according to the characteristics of the residents involved. By using linked data sets, the Improvement Analytics Unit could examine both local authority and privately funded residents. However, the analysis was restricted to residents aged 65 or over who moved to a care home following the introduction of the enhanced support. Therefore, it did not consider impacts on existing residents. Furthermore, the unit considered only people who experienced at least one inpatient hospital admission in the two years before moving to the care home.

This analysis focused on hospital care. This is an important consideration for people with social care needs, who report fragmentation in services, with frequent handovers between care teams often leading to duplication and confusion. However, lower admission rates do not always indicate better patient outcomes and lower cost. Therefore, further analysis is needed regarding impacts on clinical metrics, patient outcomes and the cost of care (which should include the cost of providing the enhanced support to care home residents). Further data linkage, beyond that already performed, might provide a fuller picture. This could draw on information recorded by local authorities when assessing individuals for social care support, or on clinical diagnostic data recorded in the primary care electronic medical record. Ideally, digitally mature health and social care systems would begin to record the outcomes reported by individual service users on a routine basis – this information could then inform improvements to service delivery, as well as direct care. Qualitative studies might also explore the perceptions and experiences of care home residents, their families, and health and social care practitioners.

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