Identifying models of care

Improving outcomes for older people with emergency and urgent care needs

Principal Investigator: Andrew Street
Start Date: 01 September 2018
End Date: 30 September 2021
Regions: Europe
Countries: UK
Keywords: Older people, emergency care, hospitals, A&E, readmission, community care

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 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.

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