ObjectiveOlder people and people with complex needs often require both health and social care services, but there is limited insight into individual journeys across these services. To help inform ...joint health and social care planning, we aimed to assess the relationship between hospital admissions and domiciliary care receipt.DesignRetrospective cohort study, using linked data on primary care activity, hospital admissions and social care records.SettingLondon Borough of Barking and Dagenham, England.ParticipantsAdults aged 19 and over who lived in the area on 1 April 2018 and who were registered at a general practice in East London between 1 April 2018 and 31 March 2020 (n=140 987).Outcome measuresThe outcome was initiation of domiciliary care. We estimated the rate of hospital-associated care package initiation, and of care packages unrelated to hospital admission. We also described the characteristics of hospital admissions that preceded domiciliary care, including primary diagnosis codes.Results2041/140 987 (1.4%) participants had a domiciliary care package during a median follow-up of 1.87 years. 32.6% of packages were initiated during a hospital stay or within 7 days of discharge. The rate of new domiciliary care packages was 120 times greater (95% CI 110 to 130) during or after a hospital stay than at other times, and this association was present for all age groups. Primary admission reasons accounting for the largest number of domiciliary care packages were hip fracture, pneumonia, stroke, urinary tract infection, septicaemia and exacerbations of long-term conditions (chronic obstructive pulmonary disease and heart failure). Admission reasons with the greatest likelihood of a subsequent domiciliary care package were fractures and strokes.ConclusionHospitals are a major referral route into domiciliary care. While patients admitted due to new and acute illnesses account for many domiciliary care packages, exacerbations of long-term conditions and age-related and frailty-related conditions are also important drivers.
The International Consortium for Health Outcomes Measurement (ICHOM) was founded in 2012 to propose consensus-based measurement tools and documentation for different conditions and populations.This ...article describes how the ICHOM Older Person Working Group followed a consensus-driven modified Delphi technique to develop multiple global outcome measures in older persons. The standard set of outcome measures developed by this group will support the ability of healthcare systems to improve their care pathways and quality of care. An additional benefit will be the opportunity to compare variations in outcomes which encourages and supports learning between different health care systems that drives quality improvement. These outcome measures were not developed for use in research. They are aimed at non researchers in healthcare provision and those who pay for these services.
A modified Delphi technique utilising a value based healthcare framework was applied by an international panel to arrive at consensus decisions.To inform the panel meetings, information was sought from literature reviews, longitudinal ageing surveys and a focus group.
The outcome measures developed and recommended were participation in decision making, autonomy and control, mood and emotional health, loneliness and isolation, pain, activities of daily living, frailty, time spent in hospital, overall survival, carer burden, polypharmacy, falls and place of death mapped to a three tier value based healthcare framework.
The first global health standard set of outcome measures in older persons has been developed to enable health care systems improve the quality of care provided to older persons.
ObjectivesHousehold factors can affect the level and type of health and social care a person with long-term conditions needs. Information on household composition and health needs within households ...is not easily available in routine health records but linked data from health providers and local government can address this gap.
ApproachIndividual-level linked data from local government services, health providers and health commissioners in Barking and Dagenham was used. This provided sociodemographic, health and household information alongside activity data for five care settings (primary care, hospital, community, inpatient and outpatient mental health services, and social care). We identified 9222 residents aged 50+ living in two-person households between April 2016 and March 2018. Their long-term conditions were counted using primary care data. Annualised use and cost of care services were compared for households with one versus both residents having two or more long-term conditions (known as “multimorbidity”).
ResultsOver 45% of multimorbid people in two-person households were co-resident with another multimorbid person. This percentage was higher in the most deprived areas. In households where both residents were multimorbid, each resident had higher use of some types of care. After adjustment for age, gender and area deprivation, those co-resident with another multimorbid person were 1.14 (95% CI 1.00, 1.30) times as likely to have any community care activity and 1.24 (95% CI 0.99,1.54) times as likely to have any mental health care activity compared to those co-resident with a healthy person. They had more primary care visits (8.5 (95% CI 8.2,8.8) vs 7.9 (95% CI 7.7,8.2)) and higher primary care costs. Outpatient care and elective admissions did not differ between these groups.
ConclusionsCare use for people with multimorbidity depends on the health of others in their household. Use of household health data could inform local planning for health and other community services. Its use for delivering individual or household level care could be explored, if acceptable to patients. Future research could examine larger households.
Background
Pressure ulcers are areas of skin damage resulting from sustained pressure. Informal carers play a central role in preventing pressure ulcers among older and disabled people living at ...home. Studies highlight the paucity of pressure ulcer training for informal carers and suggest that pressure ulcer risk is linked to high levels of carer burden.
Objective
This pilot study evaluated a smartphone app with a specific focus on pressure ulcer prevention education for informal carers. The app was developed based on the principles of microlearning. The study aimed to explore carer perspectives on the acceptability of the app and determine whether the app increased knowledge and confidence in their caring role.
Methods
In this concurrent mixed methods study, participants completed quantitative questionnaires at baseline and at the end of weeks 2 and 6, which examined caregiving self-efficacy, preparedness for caregiving, caregiver strain, pressure ulcer knowledge, and app acceptability and usability. A subsample of participants participated in a “think aloud” interview in week 1 and semistructured interviews at the end of weeks 2 and 6.
Results
Of the 32 participants, 23 (72%) participants completed the week 2 and 16 (50%) completed the week 6 questionnaires; 66% (21/32) of carers participated in qualitative “think aloud” interviews, and 18 (56%) also participated in semistructured interviews at week 2, and 13 (41%) at week 6. Pressure ulcer knowledge scores significantly changed (F1,6.112=21.624; P=.001) from baseline (mean 37.5; SE 2.926) to the second follow-up (mean 59.72, SE 3.985). Regarding the qualitative data, the theme “I’m more careful now and would react to signs of redness” captured participants’ reflections on the new knowledge they had acquired, the changes they had made to their caring routines, their increased vigilance for signs of skin damage, and their intentions toward the app going forward. There were no significant results pertaining to improved preparedness for caregiving or caregiving self-efficacy or related to the Caregiver Strain Index. Participants reported above average usability scores on a scale of 0 to 100 (mean 69.94, SD 18.108). The app functionality and information quality were also rated relatively high on a scale of 0 to 5 (mean 3.84, SD 0.704 and mean 4.13, SD 0.452, respectively). Overall, 2 themes pertaining to acceptability and usability were identified: “When you’re not used to these things, they take time to get the hang of” and “It’s not a fun app but it is informative.” All participants (n=32, 100%) liked the microlearning approach.
Conclusions
The iCare app offers a promising way to improve informal carers’ pressure ulcer knowledge. However, to better support carers, the findings may reflect the need for future iterations of the app to use more interactive elements and the introduction of gamification and customization based on user preferences.
The daily management of long-term conditions falls primarily on individuals and informal carers, but the impact of household context on health and social care activity among people with multiple ...long-term conditions (MLTCs) is understudied.
To test whether co-residence with a person with MLTCs (compared with a co-resident without MLTCs) is associated with utilisation and cost of primary, community, secondary health care, and formal social care.
Linked data from health providers and local government in Barking and Dagenham for a retrospective cohort of people aged ≥50 years in two-person households in 2016-2018.
Two-part regression models were applied to estimate annualised use and cost of hospital, primary, community, mental health, and social care by MLTC status of individuals and co-residents, adjusted for age, sex, and deprivation. Applicability at the national level was tested using the Clinical Practice Research Datalink (CPRD).
Forty-eight per cent of people with MLTCs in two-person households were co-resident with another person with MLTCs. They were 1.14 (95% confidence interval CI = 1.00 to 1.30) times as likely to have community care activity and 1.24 (95% CI = 0.99 to 1.54) times as likely to have mental health care activity compared with those co-resident with a healthy person. They had more primary care visits (8.5 95% CI = 8.2 to 8.8 versus 7.9 95% CI = 7.7 to 8.2) and higher primary care costs. Outpatient care and elective admissions did not differ. Findings in national data were similar.
Care utilisation for people with MLTCs varies by household context. There may be potential for connecting health and community service input across household members.
ObjectivesOlder people and people with complex needs often require both health and social care services, but there is limited insight into individual journeys across these services. To help inform ...joint health and social care planning, we aimed to assess the relationship between hospital admissions and domiciliary care receipt.
ApproachWe used an individually linked dataset of primary care activity, hospital admissions and local authority-held social care records for adults living in Barking and Dagenham, a borough in London, England, on 1 April 2018, and followed them up until 31 March 2020. The outcome was initiation of a new domiciliary care package. We estimated the rate of hospital-associated care package initiation, and of care packages unrelated to hospital admissions. We also described the characteristics of hospital admissions that preceded domiciliary care and examined which primary diagnoses codes were associated with receiving domiciliary care after discharge.
ResultsIn our cohort, 1.4 of participants had a domiciliary care package during a median follow-up of 1.87 years. One in three domiciliary care packages were initiated during a hospital stay or within 7 days of discharge. The rate of new domiciliary care packages was 120 times greater (95% CI 110-130) during or after a hospital stay than at other times, and this association was present for all age groups. Primary admission reasons accounting for the largest number of domiciliary care packages were hip fracture, pneumonia, urinary tract infection, septicaemia, and exacerbations of long-term conditions (COPD and heart failure). Admission reasons with the greatest likelihood of a subsequent domiciliary care package were fractures and strokes.
ConclusionHospitals are a major referral route into domiciliary care. While new and acute illnesses account for many domiciliary care packages, exacerbations of long-term conditions and age- and frailty-related conditions are also an important driver. National-level linked datasets are needed for a better understanding of the relationship between health and social care receipt.
The mental health and wellbeing of children and young people is deteriorating. It is increasingly recognised that mental health is a systemic issue, with a wide range of contributing and interacting ...factors. However, the vast majority of attention and resources are focused on the identification and treatment of mental health disorders, with relatively scant attention on the social determinants of mental health and wellbeing and investment in preventative approaches. Furthermore, there is little attention on how the social determinants manifest or may be influenced at the local level, impeding the design of contextually nuanced preventative approaches. This paper describes a major research and design initiative called Kailo that aims to support the design and implementation of local and contextually nuanced preventative strategies to improve children's and young people's mental health and wellbeing. The Kailo Framework involves structured engagement with a wide range of local partners and stakeholders - including young people, community partners, practitioners and local system leaders - to better understand local systemic influences and support programmes of youth-centred and evidence-informed co-design, prototyping and testing. It is hypothesised that integrating different sources of knowledge, experience, insight and evidence will result in better embedded, more sustainable and more impactful strategies that address the social determinants of young people's mental health and wellbeing at the local level.
Objective
To assess service use and associated expenditure across a range of care settings in one local authority in London, United Kingdom.
Methods
An analysis of linked electronic health and ...council records of adults living in the borough of Barking and Dagenham, east London, for the financial year 2016/17. Unit costs were applied to individual service use to provide expenditure at an individual and population level for five settings of care. Population and expenditure volumes were compared for 32 possible combinations of service use.
Results
The total expenditure for the cohort (114,393 residents) for 2016/17 was £180.1 million. Almost half (47%) of total expenditure was incurred by community care, social care and mental health services, with hospital care and primary care incurring, respectively, 35% (£63.3 m) and 18% (£32.6 m). The two most common combinations in terms of total population volume and expenditure were primary and hospital care, and primary, hospital and community care. Primary care was present in all combinations. Mental health service use accounted for just over a tenth of all expenditure in the borough, but using mental health services substantially increased mean expenditure per patient.
Conclusions
A whole system perspective across all settings of care improves understanding of service user patterns. Setting-level analysis remains important, particularly for mental health users.
Purpose
Structural integration is increasingly explored as a means of achieving efficiency gains alongside improved health outcomes. In 2015, three boroughs in London, England began working together ...to develop an Accountable Care Organisation for the 750,000 population they serve. The purpose of this paper is to understand the experiences of working across organisational and sectoral boundaries for the benefit of the population, including enablers and barriers encountered, the role of financial incentives and perspectives on Accountable Care Organisations.
Design/methodology/approach
A single site instrumental case study involving 35 semi-structured interviews using a topic guide, with key leaders and decision makers from the site and nationally, between April 2016 and August 2016.
Findings
There are differences in levels of autonomy and operational priorities between councils and the NHS. Existing financial mechanisms can be used to overcome sectoral boundaries, but require strong leadership to implement. There are challenges associated with primary care participating in integration, including reluctance for small organisations to adopt the risk associated with large scale programmes. Interviewees were aligned on espoused ambitions for the Accountable Care Organisation but not on whether one organisation was needed to deliver these in practice.
Research limitations/implications
Progressing the integration agenda requires consideration of the context of primary care and the core differences between health and government. Further, research into ACOs is required as they may not be required to deliver the anticipated integration and system outcomes. Understanding if there are specific population groups for whom cross-organisation and cross-sector working could have particular benefits would help to target efforts.
Originality/value
This paper highlights some of the challenges associated with cross-sector collaboration.
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