Key points

  • This briefing presents the findings of an evaluation into the early effects on hospital use from the first phase of an enhanced support initiative for older people living in 15 nursing or residential care homes in Wakefield between February 2016 and March 2017.
  • The enhanced support was commissioned by Wakefield Enhanced Health in Care Homes and was rolled out in two phases. The first phase involved 15 care homes in the area covered by Wakefield Clinical Commissioning Group (CCG) between February 2016 and March 2017. The enhanced support had three main strands: voluntary sector engagement, a multidisciplinary team (MDT) and enhanced primary care support. It aimed to improve coordination of care, reduce unnecessary hospital admissions, shorten time spent in hospital, reduce isolation, and make sure that all residents had an end-of-life care plan with a preferred place of dying.
  • The Improvement Analytics Unit examined the impact of the enhanced support initiative on hospital use among 526 residents aged 65 or over living in the 15 vanguard nursing and residential care homes in Wakefield between February 2016 and March 2017. The care home residents receiving enhanced support were compared with a local matched control group, which consisted of broadly similar individuals living in care homes of similar type in Wakefield CCG who were not receiving the enhanced support during the period of the evaluation. We examined the hospital use of care home residents for an average of six months.
  • We estimated that vanguard residents experienced 27% fewer potentially avoidable admissions than the matched control group. This effect was stronger looking at only those residents that had been resident in a care home for three months or longer, where we estimated that vanguard residents experienced 38% fewer potentially avoidable emergency admissions than the matched control group. However, there was no conclusive evidence that overall emergency admissions or A&E attendances differed between the groups.
  • We ensured that the matched control group was as similar as possible to the vanguard residents in the study on observed characteristics (eg demographic mix, co-morbidities and past hospital activity). Vanguard and control residents may, however, have still differed in unobservable ways (for instance in degree of family support). Furthermore, we did not identify as many care home residents as expected and we are unable to determine whether the missing residents (vanguard and non-vanguard) were different to the residents included the study. This could have affected the results.
  • The purpose of this evaluation was to explore whether there were any early signals of changes in hospital use to inform local learning and improvement. We did not see a significant difference in overall hospital admissions or A&E attendances among residents receiving the enhanced support although there were fewer potentially avoidable emergency admissions. It could be that the enhanced support initiative did not have an effect on overall hospital use or the study was not able to detect an effect due to the short study period. However, the results are promising on potentially avoidable admissions, which may reflect the MDT’s targeted care for residents who needed additional support that may otherwise result in hospital use, and training of care home staff on issues such as falls and pressure sore prevention.
  • It is important to remember that this evaluation was conducted approximately one year after the introduction of the enhanced support and does not evaluate the effect after March 2017. Research has highlighted that implementing complex interventions needs time to take effect. This is so that teams introducing these changes can be supported to work through implementation challenges and learn from experience and evaluation. For example, evidence on implementation of the GP local enhanced service (LES) suggests that during the period covered by the study it did not have much influence on the working patterns of the GP practices. It is also important to remember that this evaluation did not examine the impact of the enhanced support in improving the coordination of care or improving residents’ health, social isolation, experience of care and quality of life. These are all areas that the enhanced support was aiming to improve and the value of the enhanced support might relate to improving these other areas in addition to emergency hospital admissions.
  • Good quality data are essential for evaluation. Further analysis would benefit from access to further linked data sets, for example linking Secondary Uses Service (SUS) data to data on MDT referrals to improve the understanding of the effect of the MDT over and above the other elements of the vanguard, which would provide additional insight for policymakers. This should ideally be done in combination with qualitative research to better understand how MDTs, GP enhanced support and other elements interact with the local context in Wakefield.