Title: The CIRACT (Community In-reach Rehabilitation And Care Transition) Clinical and Cost Effectiveness study
Funder: Department of Health (England)

Abstract: Older people represent a significant proportion of patients admitted to hospital as an emergency. Their care compared to younger patients is much more challenging their stay in hospital much longer the risk of hospital acquired problems much higher and the risk of being re-admitted within 28 days much greater. NHS Nottingham City Clinical Commissioning Group (Nottingham City CCG) currently delivers two rehabilitation services for older people admitted to hospital. One service is the traditional hospital based rehabilitation (THB-rehab) service. In the THB-rehab service patients are assessed and managed by the hospital based multidisciplinary team for the duration of their hospital stay and on hospital discharge they are referred to the community rehabilitation service and social service for personal care. The other service is a community in-reach rehabilitation and care transition (CIRACT) service. This is delivered by an occupational therapist a junior physiotherapist and two assistant practitioners. They provide more intensive hospital rehabilitation work closely with the patient and their carers while in hospitals and allow a more seamless integrated discharge back to the home where they follow up the patient. A pilot trial comparing the two services showed that the CIRACT service resulted in a reduction in the length of stay in hospital and re-admission rates when analysed over the 4 month period. This trial will evaluate the clinical and cost-effectiveness of the CIRACT service. This will be conducted as a randomised controlled trial with an integral i) qualitative mechanism and action study designed to provide the explanatory and theoretical components on how the CIRACT service compares to current practice and ii) Health Economic Study to provide a detailed cost-analysis of the service. The primary outcome will be hospital length of stay from admission to the general medical elderly care ward Secondary outcomes will be assessed at 28 and 91 days post discharge and include: 1.Super spell bed days (total time in NHS care (hospital care+ community care / intermediate care)2.Hospital re-admission3.Disability (Barthel ADL Index) at 91 days post discharge 4.Health related quality of life (EQ-5D-3L) at 91 days post dischargei) the main aims of the Qualitative Mechanism and Action Study will be to understand the situated activities and interactions that constitute the CIRACT service in comparison to THB-rehab service and to understand how these mechanics of care interact with other organisational and occupational factors located in the wider care system. The Qualitative Mechanism and Action study will involve a systematic programme of organisational profiling observations of work processes interviews with key informants and care providers and tracking of participants. a.Organisational profilingThis involves acquiring factual information with regards to each ward/service i.e. staffing levels resources patient throughput commissioning arrangements and performance levels. b.Observations of work processesThis involves describing the general organisation and delivery of care within the two ward areas. This will involve being provided tours of the facilities shadowing of representatives of key individuals (nurses care assistants therapists) observing management meetings rest areas and clinical interactions to understand how care is organised. c.Participant trackingThis part of the study involves close direct observations of patient care processes and interactions with different clinicians. It also involves small conversation type interviews with participants and their carers. The observations are to describe and explain how the service is organised managed and delivered. ii) the main aims of the Health Economic study will undertake a within-trial cost utility analysis of the CIRACT service compared to the THB-rehab service from a NHS and PSS perspective. The cost of the two services to the NHS will be considered from a detailed time and motion study and compared against cost estimates based on standard methods of collecting resource use information. The Health Economics Study will be done in three phases:a. A detailed structured literature review (phase 1)The review will provide information on how to conduct the Time and Motion study b. Observation and semi structured interviews (Phase 2)The observations and interviews will provide information on how to conduct the Time and Motion studyc. Micro-costing study (phase 3)Using the information from phase 1 and 2 a Time and Motion study will be conducted in 10 patients in each arm recruited through purposive sampling over a 6 month period. The precise time spent on each patient related activity will be recorded in detail.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: GENERIC HEALTH RELEVANCE