Title: STRETCHED: STRategies to manage Emergency ambulance Telephone Callers with sustained high needs - an Evaluation using linked Data
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Over recent years, more people are phoning 999 but ambulance services cannot see everyone promptly when they are very busy. A small number of people phone 999 a lot – more than five times a month or 12 times in three months. But they don’t always have a medical problem which will cause death or disability if not treated immediately. If someone’s life is not in danger, the time the ambulance crew spends seeing them may mean paramedics cannot see someone else who might die without immediate help. It may be better for people with less urgent needs to get the right help without having to phone 999. One possible way of getting the right help for these people is called ‘case management’. This approach means the person is referred to a team from different agencies - including social services, primary care (GP), community mental health and the Emergency Department who work together with the ambulance service to consider what the caller may need. These professionals and the person agree what will happen and how – this is called a treatment plan. The aim is to help such people so they don’t need to contact emergency services again._x000D_ _x000D_ UK ambulance services are trying out new ways of responding to people who call 999 frequently, with local case management initiatives in place in some areas. In this research, we want to understand the characteristics of people who call frequently, what is currently being done for this group and what helps them to stay well and not need to call 999 or other emergency services._x000D_ We want to look at how well case management helps people who phone 999 a lot_x000D_ • Do they have fewer emergency episodes if a ‘case management’ service is available?_x000D_ • Is this help safe?_x000D_ • How much does case management cost to deliver and what costs if any are saved?_x000D_ • How do people feel about this help?_x000D_ • How easy or difficult is it for services to give this kind of help?_x000D_ _x000D_ How will we do this?_x000D_ We will work with four ambulance services where the new case management approach has been introduced in partnership with local agencies, and in other areas where the standard 999 service is still in operation. We will then be able to see what difference the new partnership approach makes. We expect to include 1200 people who have been classified by the service as a 'frequent caller' - 600 in areas where case management is in place and 600 where it is not. _x000D_ _x000D_ We will use NHS information which is automatically collected to find out whether case management reduces further emergency calls. We will interview some patients who are treated through case management (and who have agreed to be contacted), to hear about their experiences and how they feel about the care offered to them, whether it has helped - or not. We will interview health, social care and other professionals who are involved in case management initiatives so that we can understand what helps or hinders service delivery. _x000D_ _x000D_ Involving people who phone 999 in our research_x000D_ People who call 999 and who also have illnesses of the mind are included in our research team. Two people will come to our meetings, representing a wider group, and be involved in running this study by giving their views and sharing in decision-making. _x000D_ _x000D_ Telling people about what we learn_x000D_ We will print what we learn in the magazines that experts read. We will go to meetings with people_x000D_ who plan and run health services, meet with people who phone 999 and with people who work in_x000D_ ambulances to talk about what we find.

Lay abstract: Background_x000D_ The NHS is under sustained pressure, particularly in emergency and urgent care, with 999 calls increasing by 6% every year, although fewer than 10% relate to patients with life threatening conditions. All UK ambulance services have identified a clinical and operational problem with persistent high users of the 999 service and have set up 'Frequent Callers' services, ranging from within-service to cross-sectoral multi-disciplinary case management approaches. These callers are known to be at high risk of mental health crises, such as self harm and other crises of a varied nature. Current responses can be punitive and may simply shift unmet demand from one part of the system to another. There is a lack of evidence about what works in this setting and how._x000D_ _x000D_ Aim_x000D_ To evaluate effectiveness, safety and efficiency of case management approaches to the care of people who frequently call the emergency ambulance service; and gain understanding of barriers and facilitators to implementation._x000D_ _x000D_ Research questions_x000D_ For high 999 service users:_x000D_ What are the demographics, casemix and patterns of use?_x000D_ What are the costs and effects of case management across the emergency care system?_x000D_ What are the facilitators and barriers to implementation?_x000D_ _x000D_ Study design_x000D_ We propose a mixed methods evaluation using anonymised linked routine data outcomes in a 'natural experiment' cohort design in four UK ambulance services, with 1 case management intervention site and 1 control site within each service._x000D_ _x000D_ WP1 Development of a logic model building on national survey of current practice and new models of care to underpin evaluation_x000D_ WP2 Natural experiment evaluation in 4 ambulance services using anonymised routine linked data to describe and assess:_x000D_ *epidemiology of 'frequent calling'_x000D_ *effects of new cross-sector 'case management' models of care on processes, outcomes, safety and costs up to 6 months_x000D_ *views and experiences of stakeholders regarding acceptability, successes and challenges_x000D_ - commissioners, emergency and non-acute care providers (interviews/focus groups, n=36)_x000D_ - callers (patient stories, n=32)_x000D_ WP3 Synthesis of quantitative and qualitative findings informed by logic model_x000D_ _x000D_ Primary outcome_x000D_ *Further emergency events (999 calls, ED attendances, emergency admissions to hospital) or death up to 6 months_x000D_ Secondary outcomes_x000D_ *'frequent caller' declassification and reclassification_x000D_ *costs_x000D_ Safety outcomes_x000D_ *Adverse events e.g. self-harm incident; police arrest_x000D_ _x000D_ Sample size_x000D_ We expect to recruit 300 high users per service (n=1200), allowing us to detect a change in rate of further emergency events/death of +/- 20% with 90% power and 95% confidence._x000D_ _x000D_ PPI_x000D_ We have had strong service user involvement in this study throughout planning stages. PPI research team members have participated in all decisions about study design including primary outcome selection and judgement of meaningful difference between study arms. We will need to widen PPI links during the study to better reflect the diverse patient population. _x000D_ _x000D_ Impact_x000D_ With a very strong record of working closely with ambulance services and multi-disciplinary teams, we are able to demonstrate impact on policy and practice from previous projects nationally and internationally. We expect to be able to translate findings from this study into real world clinical practice through publication in high impact journals as well as dissemination through clinical and practitioner networks.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE