Title: Identifying models of care to improve outcomes for older people with emergency and urgent care needs
Funder: Department of Health and Social Care

Abstract: Introduction Emergency and Urgent care (EUC) is a major international issue. Older people with EUC needs, in particular those with frailty, are especially vulnerable to harms that can arise in this care pathway. The first hours of an EUC episode can have a powerful influence on patient outcomes. We will undertake a series of linked studies, with a focus on implementation, which will provide robust, practical and focussed guidance about how best to organise care pathways in Emergency Departments, so as to improve outcomes for older people with EUC needs. Methods Workpackage (WP) 1 Identifying best practice WP1.1 Review of reviews of EUC interventions for older people, their outcomes and costs and any implementation factors identified. WP1.2 Interviews of older people and their carers with recent experience of EUC, using the findings to ensure that the patient’s voice is at the centre of this study. WP1.3 Clinician interviews about emerging interventions and key elements of high quality care. WP2 Qualitative study of delivery of exemplar EUC pathways Qualitative fieldwork (interviews, ethnography, documentary analysis) in 4-6 sites exemplifying promising pathways, to identify aspects relevant to transfer and adaptation of these models to other settings. WP3 Individual patient level data analysis to describe EUC pathways and outcomes Analysis of linked databases to describe EUC pathways experienced by people aged 75+ across the Yorkshire and Humber region, 2010-2017. The aims are to assess which pathways deliver better patient outcomes and lower costs than others, how pathways have changed over time, and what patient characteristics, demand factors and supply factors explain differences in outcomes and costs between patients, from place to place, and over time. WP4 Modelling changes to EUC pathways We will develop a family of System Dynamics (SD) computer simulation models representing patient flow through the entire care process (attendance through to transfer home) for different EUC pathways, using evidence from WP1 and WP2 and data from WP3. We will use these models to evaluate different EUC interventions in different settings, in terms of their impact on patient outcomes and their knock-on effects in the wider care system. PPI PPI input will include high level strategic oversight of the study progress, assured by quarterly briefings to the PPI leads at the Executive Management Team meetings, complimented by ‘deep dive’ reviews of specific aspects of the project, and quarterly consultations with the broader Leicester PPI forum to bring wider perspectives to the research. Dissemination A comprehensive dissemination strategy (evidence summaries, high impact papers, press releases, and national dissemination events) will be developed and targeted to key audiences who will be interested in the findings of this research. Impact The primary output will be a validated, patient-centred, SD model with guidance adaptable to health care systems through an easy to use interface, allowing modelling of emergency department interventions on the whole system. We will provide outputs relevant to teams planning and delivering EUC for older people, and to academics. These will include a user-friendly classification of the different types of care pathway, summarising the strengths and limitations of different approaches and key points of information about optimising their delivery.

Lay abstract: Older people accessing urgent care are amongst the most vulnerable in society. Despite efforts by the NHS and social care systems to provide more care at home, many older people still need to attend emergency departments. Older people in emergency and urgent care (EUC) settings have higher risks of developing complications in hospital such as falls, fractures, confusion, and pressure sores. These harms lead to longer hospital stays, increased readmissions, and need for long term care. These risks are highest in the 20% of people aged 75+ who are frail, making them vulnerable to harm and poor outcomes when exposed to a stressful event. We know that older people with frailty benefit from care which takes account of all their problems rather than just the reason for their arrival in hospital (such as a fall). This care includes considering all their clinical conditions, including their future wishes, involving their family and care organisations, and planning for what happens when they leave. What we do not know is how to deliver this frail-friendly care in busy emergency departments. To answer this, our team of clinicians, health services researchers, health economists, and simulation experts will collect existing evidence, observe and describe current best practice and apply state-of-the-art computer modelling. We will start by carefully reviewing existing evidence of what might work alongside patient, carer and staff perspectives about best practice in emergency care. From this, we will describe a range of care models and their impact on patient outcomes. We will then seek out examples that closely represent the different care models that are likely to be reproducible, making use of a recent survey of 14 acute hospitals across the region. We will undertake detailed fieldwork (interviews, focus groups and observations) within several hospitals to understand what works (and what does not), and to identify the necessary conditions that facilitate or inhibit the delivery of care, including resource implications. We will also analyse a database of patient information in the Yorkshire and Humber region (covering over 5.3 million people) that bring together NHS 111, ambulance, emergency departments and hospital records that will allow us to track patient journeys through urgent care pathways over a six-year period. Our focus will be older people’s use of and experience of emergency departments, described in the context of the whole urgent care system. We will then model the potential impact (on patient, staff, services and costs) of implementing different types of emergency interventions for older people within a system using computer simulation (‘System Dynamics’) that allows the interventions to be modelled, looking not only at the impact at specific points in the pathway, but the consequences for the rest of the system. At the end of this study, we will have a rich description of what ‘frail-friendly’ urgent care looks like. We will know the strengths and limitations of different approaches to providing EUC for frail older people and we will provide service planners with our simulation software and user-guidance, to allow them to see what might happen if they implement changes. We will disseminate this knowledge through national stakeholder groups that will allow the findings to be rapidly implemented, as well as via lay, academic and policy papers.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE