US scheme prevents some hospital admissions
http://www.100md.com
《英国医生杂志》
The final UK evaluation of a US designed system to manage the care of vulnerable elderly people says that care has improved and the project will continue.
However, it may take more than a year for the Evercare programme to reduce the number of unnecessary hospital admissions, says the final report, which was commissioned by the Department of Health from UnitedHealth Europe, the company that piloted the programme together with nine NHS primary care trusts in England over 17 months. The pilots covered 1333 patients.
The Evercare programme identifies vulnerable elderly patients, who are then allocated to an advanced practice nurse who manages their cases and coordinates all aspects of the patients?care, working with GPs, geriatricians, each patient抯 family, and social services. The nurse also advises patients in managing their own care.
The report, published last week, looks at the initial outcome of the pilot scheme, which was introduced into the trusts from April 2003. Using hospital data, they identified people for the scheme who were aged 65 and over, had had two or more unplanned hospital admissions in the past 12 months, and were therefore considered high risk. Some additional people were nominated by GPs as being at high risk of hospitalisation.
The period over which people were evaluated varied from trust to trust and patients stayed on the scheme for varying lengths of time, averaging eight months. The data were therefore compared using an annualised rate per 100 patients.
Among the 793 patients who were identified as having had previous unplanned admissions, unplanned admissions fell by 38% (from an annualised rate of 174 per 100 prior to the scheme being introduced to an annualised rate of 108 per 100).
However, according to Richard Smith, chief executive of UnitedHealth Europe, it is not possible to say whether this is entirely due to the programme, or is merely regression to the mean.
In a smaller group of 183 patients, who were predicted by general practitioners to be at high risk of admission, admissions rose from an annualised rate of ?1 per 100 to 62 per 100.
Some of the findings of a survey of patients, carers, and NHS staff conducted as part of the assessment were:
Nearly two thirds of patient and carers said that the overall quality of health care was better under the programme;
95% of all patients and carers saw improvement in patients?ability to cope with health problems and that patients and carers felt involved in decisions about care and treatment;
Four fifths of GPs reported that the advanced practice nurse helped to deliver care that was more centred on patients and helped the GPs manage time more effectively.
Despite primary care trusts?hopes that the programme would result in resource savings, the report warns that evidence from the United States indicates that it would take more than a year of running at full strength for the programme to reduce unnecessary hospital admissions.
The report also identifies shortcomings in the NHS. It says that better methods to identify patients at high risk are needed and that ways must be found to provide nurse cover all the time or to improve coordination with out of hours services.
"The healthcare system does not yet have enough capacity in the community for optimal results of a case management programme to be realised," says the report. It adds that patients and GPs noted a breakdown in continuity of services on weekends and during periods when nurses were on holiday or ill.
The nurses reported that the programme improved their skills and their care of patients. GPs thought their care improved and their workload lightened.
In November the independent health think tank the King抯 Fund expressed concern about a lack of evidence showing that Evercare and other long term schemes could save money through reducing hospital admissions.
All the trusts involved in the Evercare pilot plan to continue the programme.
However, Dr Jerry Playfer, chairman of the Joint Specialty Committee for Geriatrics (set up by the Royal College of Physicians and the British Geriatric Society) said the assessment did not seem to be particularly "scientific or rigorous."
He said, "Obviously, targeting patients at risk, anticipating problems, and having structured nursing care is valuable, but there would be some concern that this is too dissociated from geriatric services. It seems to be very separate from that provision. It is also very consuming on skilled nurses.
"If this was to be applied across the country, it would put a lot of pressure on nursing services."(Adrian O扗owd)
However, it may take more than a year for the Evercare programme to reduce the number of unnecessary hospital admissions, says the final report, which was commissioned by the Department of Health from UnitedHealth Europe, the company that piloted the programme together with nine NHS primary care trusts in England over 17 months. The pilots covered 1333 patients.
The Evercare programme identifies vulnerable elderly patients, who are then allocated to an advanced practice nurse who manages their cases and coordinates all aspects of the patients?care, working with GPs, geriatricians, each patient抯 family, and social services. The nurse also advises patients in managing their own care.
The report, published last week, looks at the initial outcome of the pilot scheme, which was introduced into the trusts from April 2003. Using hospital data, they identified people for the scheme who were aged 65 and over, had had two or more unplanned hospital admissions in the past 12 months, and were therefore considered high risk. Some additional people were nominated by GPs as being at high risk of hospitalisation.
The period over which people were evaluated varied from trust to trust and patients stayed on the scheme for varying lengths of time, averaging eight months. The data were therefore compared using an annualised rate per 100 patients.
Among the 793 patients who were identified as having had previous unplanned admissions, unplanned admissions fell by 38% (from an annualised rate of 174 per 100 prior to the scheme being introduced to an annualised rate of 108 per 100).
However, according to Richard Smith, chief executive of UnitedHealth Europe, it is not possible to say whether this is entirely due to the programme, or is merely regression to the mean.
In a smaller group of 183 patients, who were predicted by general practitioners to be at high risk of admission, admissions rose from an annualised rate of ?1 per 100 to 62 per 100.
Some of the findings of a survey of patients, carers, and NHS staff conducted as part of the assessment were:
Nearly two thirds of patient and carers said that the overall quality of health care was better under the programme;
95% of all patients and carers saw improvement in patients?ability to cope with health problems and that patients and carers felt involved in decisions about care and treatment;
Four fifths of GPs reported that the advanced practice nurse helped to deliver care that was more centred on patients and helped the GPs manage time more effectively.
Despite primary care trusts?hopes that the programme would result in resource savings, the report warns that evidence from the United States indicates that it would take more than a year of running at full strength for the programme to reduce unnecessary hospital admissions.
The report also identifies shortcomings in the NHS. It says that better methods to identify patients at high risk are needed and that ways must be found to provide nurse cover all the time or to improve coordination with out of hours services.
"The healthcare system does not yet have enough capacity in the community for optimal results of a case management programme to be realised," says the report. It adds that patients and GPs noted a breakdown in continuity of services on weekends and during periods when nurses were on holiday or ill.
The nurses reported that the programme improved their skills and their care of patients. GPs thought their care improved and their workload lightened.
In November the independent health think tank the King抯 Fund expressed concern about a lack of evidence showing that Evercare and other long term schemes could save money through reducing hospital admissions.
All the trusts involved in the Evercare pilot plan to continue the programme.
However, Dr Jerry Playfer, chairman of the Joint Specialty Committee for Geriatrics (set up by the Royal College of Physicians and the British Geriatric Society) said the assessment did not seem to be particularly "scientific or rigorous."
He said, "Obviously, targeting patients at risk, anticipating problems, and having structured nursing care is valuable, but there would be some concern that this is too dissociated from geriatric services. It seems to be very separate from that provision. It is also very consuming on skilled nurses.
"If this was to be applied across the country, it would put a lot of pressure on nursing services."(Adrian O扗owd)