Title: Establishing and implementing best practice to reduce unplanned admissions in those aged 85+ through system change (ESCAPE 85+): a mixed method case study approach
Funder: Department of Health (England)

Abstract: Our conceptual framework is that emergency admissions are one outcome in a complex system which includes a range of inter-related services. Additionally improvements will emerge not just from reconfiguration of services but also from effective leadership and implementation. We define the system of interest as an acute hospital trust and its catchment area including commissioners GPs intermediate care services care homes ambulance service and social care. The principal method proposed is a multiple explanatory case study.[18] This approach is designed not to be generalisable to a population but to develop and test theory. Multiple cases strengthen the results by replicating pattern-matching thus increasing confidence in the robustness of the theory. We propose examining three cases at each extreme of changes in admission rates a sample large enough to develop and test theory while being small enough to be feasible. Other multiple case studies including the national evaluation of intermediate care to which several applicants contributed have used a similar number of sites. [19] We will use a multiple case study approach to investigate three sites where the increase in rates of admission for those 85+ has been highest and three where it has been lowest. At each site the ‘system’ to be examined will be the main acute hospital trust in the locality its major commissioning organisations and health and social services provision within its catchment area. In workstream 1 we will analyse routine HES and population data to calculate changes in admission rates for those aged 85+ at potential study sites identified by the Nuffield Trust as showing the highest and lowest changes in the number of unplanned admissions and select six sites for inclusion.In workstream 2 we will map and quantify the pathways of care leading to unplanned admissions in those aged 85+ at each site taking a whole systems perspective. We will use qualitative methods including interviews focus groups and documentary analysis to examine what changes have been attempted to reduce admissions in the 85+ the extent of adoption their outcome and reasons for success of failure from the perspectives of commissioners and providers.In workstream 3 we will develop recommendations to reduce unplanned admissions in the 85+ from our findings and further develop these with the help of an expert panel. Finally in workstream 4 we will examine the challenges of implementation at two sites in the East Midlands with which members of the study team are already working through their involvement with the East Midlands Collaborative for health services management research. This is chaired by the chief executive of a major acute trust in the region who has agreed to join the project steering group. At each site we will establish a quality improvement collaborative the primary output from which will be a business plan for system change to reduce unplanned admissions in those aged 85+ signed off by commissioners and providers. At each implementation site we will use a systems approach to describe and understand the process of starting implementation so at the end of the project we will have a package of tried and tested recommendations as well as experience of the issues involved in their implementation. This will be widely disseminated to GP commissioners and chief executives of acute Trusts in England in both summary and detailed versions.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE