Out of Hospital Care
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Integrated care – making positive impacts when it matters mostWe have been working together in a blended way with a common vision to ensure palliative and end of life care services provided in the home setting, inclusive of care homes, truly makes a difference to people known to be palliative – regardless of the stage of their disease. Our integrated, 24/7 rapid responsive care service, is not defined by an illness time point. Our vision was to provide an enhanced specialised team together. This team would do their utmost to ensure that any calls for help resulted in people remaining being cared for in their own home setting wherever possible – a wraparound service, ultimately avoiding unnecessary acute care admissions. Patients, family members, friends or professionals simply have to dial our direct mobile number and circa 90% of those calls for help will receive a visit from our team in person within 30 minutes of making their call overnight, 365 days a year. In the first full operational year (2018-19) of the service, 823 patients received 1479 visits between 8pm-8am. As the service extended to 24 hours in 2020-2021, our visit count reached 3628, with only 16 of these visits resulting in an acute admission for clinical need. Our team reported that 2216 of the 3628 visits, without their input, most likely the outcome would have been transmission to local A&E. In addition to people being able to receive care where they prefer to; our service costs us between £50-60 per hour to provide – considerably less than an onward ambulance journey and potential acute hospital admission. Working as a large NHS Foundation Trust – over 5000 employees and a small independent charity community hospice with just over 60 employees brought us several challenges as well as benefits. The benefits of integration for our local population have by far outweighed any challenges which we overcame together and will continue to do so going forwards.
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Working in TeamsThis excellent book on good teamwork is concise, easy to read and based on a thorough review of current research. It makes clear that no single model of leadership is ideal and that the emotional cost of caring must be recognised among team members for their work to be successful.
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Fall prevention interventions in primary care to reduce fractures and falls in people aged 70 years and over: the PreFIT three-arm cluster RCTBackground: Falls and fractures are a major problem. Objectives: To investigate the clinical effectiveness and cost-effectiveness of alternative falls prevention interventions. Design: Three-arm, pragmatic, cluster randomised controlled trial with parallel economic analysis. The unit of randomisation was the general practice. Setting: Primary care. Participants: People aged ≥ 70 years. Interventions: All practices posted an advice leaflet to each participant. Practices randomised to active intervention arms (exercise and multifactorial falls prevention) screened participants for falls risk using a postal questionnaire. Active treatments were delivered to participants at higher risk of falling. Main outcome measures: The primary outcome was fracture rate over 18 months, captured from Hospital Episode Statistics, general practice records and self-report. Secondary outcomes were falls rate, health-related quality of life, mortality, frailty and health service resource use. Economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit. Results: Between 2011 and 2014, we randomised 63 general practices (9803 participants): 21 practices (3223 participants) to advice only, 21 practices (3279 participants) to exercise and 21 practices (3301 participants) to multifactorial falls prevention. In the active intervention arms, 5779 out of 6580 (87.8%) participants responded to the postal fall risk screener, of whom 2153 (37.3%) were classed as being at higher risk of falling and invited for treatment. The rate of intervention uptake was 65% (697 out of 1079) in the exercise arm and 71% (762 out of 1074) in the multifactorial falls prevention arm. Overall, 379 out of 9803 (3.9%) participants sustained a fracture. There was no difference in the fracture rate between the advice and exercise arms (rate ratio 1.20, 95% confidence interval 0.91 to 1.59) or between the advice and multifactorial falls prevention arms (rate ratio 1.30, 95% confidence interval 0.99 to 1.71). There was no difference in falls rate over 18 months (exercise arm: rate ratio 0.99, 95% confidence interval 0.86 to 1.14; multifactorial falls prevention arm: rate ratio 1.13, 95% confidence interval 0.98 to 1.30). A lower rate of falls was observed in the exercise arm at 8 months (rate ratio 0.78, 95% confidence interval 0.64 to 0.96), but not at other time points. There were 289 (2.9%) deaths, with no differences by treatment arm. There was no evidence of effects in prespecified subgroup comparisons, nor in nested intention-to-treat analyses that considered only those at higher risk of falling. Exercise provided the highest expected quality-adjusted life-years (1.120), followed by advice and multifactorial falls prevention, with 1.106 and 1.114 quality-adjusted life-years, respectively. NHS costs associated with exercise (£3720) were lower than the costs of advice (£3737) or of multifactorial falls prevention (£3941). Although incremental differences between treatment arms were small, exercise dominated advice, which in turn dominated multifactorial falls prevention. The incremental net monetary benefit of exercise relative to treatment valued at £30,000 per quality-adjusted life-year is modest, at £191, and for multifactorial falls prevention is £613. Exercise is the most cost-effective treatment. No serious adverse events were reported. Limitations: The rate of fractures was lower than anticipated. Conclusions: Screen-and-treat falls prevention strategies in primary care did not reduce fractures. Exercise resulted in a short-term reduction in falls and was cost-effective. Future work: Exercise is the most promising intervention for primary care. Work is needed to ensure adequate uptake and sustained effects. Trial registration: Current Controlled Trials ISRCTN71002650. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 34. See the NIHR Journals Library website for further project information.
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Making a success of a place-based teamIn 2019, South Warwickshire NHS Foundation Trust implemented a pilot scheme to create place-based teams (PBTs) across the community under its leadership. These were to align themselves to the newly formed, geographically located, primary care networks (NHS England, 2019), and renamed integrated care systems (NHS White Paper, 2021). Their implementation and leadership was, as a result, devolved to these individual localities. In part, the drive behind this initiative was to address many of the social challenges that patients face, such as social isolation, anxiety and mental health problems -- situations that often lead patients to consult general practitioners and healthcare professionals, even when there are alternative interventions that would serve their needs more effectively. This article outlines how the setting up and implementation of a PBT, and its success in meeting patient needs, is attributed to a number of key elements and the committed organisational leadership and involvement of all those involved.