THE ESSENCE PROJECT

Integration: Inter-professional working

Case studies

Read the full case study for 'Integrated housing with care and support for older people: economic evidence' here (PDF)
Michela Tinelli, Martin Knapp, Danielle Guy 2019

KEY POINTS

  • Extra care housing is diverse. Key elements include self-contained accommodation, 24-hour accessible on-site care and support, some collective meal provision and a range of leisure and communal facilities on site.
  • There is evidence to suggest that extra-care housing can be cost-effective.
  • However, research has focused on comparison with the cost of living in a residential care home, which may not always be the relevant comparator. More research is required to examine the cohort of people in extra-care housing schemes to establish how their needs would otherwise be met.
  • Most of the research evidence to date derives from schemes in England where government funding has promoted greater development of extra care. People are motivated to use extra care housing for physical and emotional security, availability of support and an accessible environment, and social contact.
  • People living in extra care housing value the opportunities for friendship and social interaction. Carers value that it enables them to carry on leading an active life and enhances their relationship with their spouse.
  • There is evidence that extra care housing produces health benefits and increases life expectancy. It also reduces needs for care and use of health and social care resources, which can reduce costs and generate economic value.
  • The government should look at innovative ways to make sure that health, housing and social care sectors work together and support each other in planning and funding of extra care housing schemes.

Read the full case study for 'Person-centred support for people living with dementia in care homes: economic evidence' here (PDF)
Michela Tinelli, Renee Romeo, Martin Knapp, Danielle Guy 2019

KEY POINTS

  • Almost all (95%) of the average cost of care home residence (£792 per week) is accounted for by room and board charges. Hospital contacts contribute the largest proportion of the additional healthcare costs. The absence of an association between cost and needs emphasizes the importance of a more needs-based service system which could result in clinical and economic advantages.
  • Person-centred, integrated, and in-reach care home services responding to the needs of individual residents may improve health outcomes and quality of life at reasonable costs.
  • Interventions providing good value for money, similar to the Wellbeing and Health for People with Dementia or Enhanced Care Home Outcomes interventions are good value for money.

Evidence

A Review of the Evidence Assessing Impact of Social Prescribing on Healthcare Demand and Cost Implications
Polley M, et al University of Westminster, London. 2017

This paper critically appraises the current evidence as to whether social prescribing reduces the demand for health services and is cost effective. It draws on the results of a systematic review of online databases which identified 94 reports, 14 of which met the selection criteria. They included studies on the effect of social prescribing on demand for general practice, the effect on attendance at accident and emergency (A&E) and value for money and social return on investment assessments. The evidence broadly supports the potential for social prescribing to reduce demand on primary and secondary care, however, the quality of the evidence is weak. It also identifies encouraging evidence that social prescribing delivers cost savings to the health service, but this is not proven or fully quantified. In conclusion, the paper looks at the possible reasons for the growth in scale and scope of social prescribing across the UK and makes recommendations for more evaluations of on-going projects to assess the effectiveness of social prescribing.

Building Wellbeing and Resilience - Living Well
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2016

The Living Well scheme aims to improve prevention and resilience amongst older people with multiple long-term conditions by providing low-level support to day-to-day living and utilising asset-based resources to promote empowerment and wellbeing.

The process begins with a conversation between the person and the voluntary sector coordinator, who helps them to identify their goals and coordinate a management plan. Trained volunteers provide support to build social networks around the individual to help them become better connected to their community, be more physically and socially active and subsequently have better health outcomes. Practical support, navigation and coordination are provided in order to boost self-confidence and self-reliance, leading to reduced adult social care spend and primary/community health benefits.

Cost-effectiveness of an Integrated Care Home Support Service in Oxfordshire, England.
Tsiachristas A, et al International Journal of Integrated Care, 17, 1-8. 2017

Background: Multi-morbidity is an increasing threat to population health and healthcare systems. A high proportion of people living in care homes have dementia, mental illness and/or physical frailty. Thus, this population has high and complex care needs, which require substantial healthcare expenditure.

Intervention: An Integrated Care Home Support Service (CHSS) in Oxfordshire, England, combined two evidence based approaches to deliver a stepped care and treatment to meet both physical and mental health needs, called the BRIghTER DAWN programme. These evidenced based approaches trained staff to deliver Dementia Assessment of Wellbeing and Needs (DAWN) and/or a personalised intervention focusing on Building Relationships and Individually Tailored Evaluation and Responses (BRIghTER).

Methods: Different data sources and methods were combined in this observational study to perform an economic evaluation of the CHSS. Individual patient data (IPD) on two-year community care utilisation and time alive since admission to a care home were used to calculate community care costs and Life Years (LYs) per patient. Mahalanobis one-to-one propensity score matching (PSM) was used to match 443 residents who received DAWN and/or BrighTER with residents from a control cohort of 5,339 residents with respect to community care costs at baseline, date admitted to a care home, date of birth, mental health cluster codes, gender, and care home. Multiple imputation by predictive mean matching was used to impute missing observations in community care cost at baseline. To reduce remaining confounding, 5,000 bootstrapped samples were generated from the paired dataset and for each one, Generalised Linear Models were specified to estimate incremental community care costs and incremental Lys adjusting for confounders. Difference-in-differences analysis supplemented with inverse probability weighting for propensity score matching was performed to estimate incremental non-elective hospital costs based. A decision model was built to combine the incremental costs and effects from the two different analyses to estimate costs per LY gained and to perform probabilistic sensitivity analysis. Uncertainty was displayed in cost-effectiveness acceptability curves.

Results: The CHSS resulted to £575 higher costs and 0.04 more Lys than usual care resulting to an ICER of £13,886, which is considered to be cost-effective under conventional NICE thresholds (i.e. £20,000-£30,000). Looking at the interventions separately, DAWN was even more cost-effective (ICER=£2,081), while DAWN was less cost-effective (ICER=14,837) but still under NICE’s threshold. The probability of the interventions to be cost-effective at £20.000 ceiling ration was more than 80%.

Discussion: This study demonstrated a series of methods to be used by health economists when dealing with Murphy’s law in the economic evaluation of complex interventions.

Conclusion: The Integrated Care Home Support Service implemented in Oxfordshire was very likely to be cost-effective.

Lessons learned: Evidence-based, integrated, and in-reach care home services improve health outcomes at reasonable costs. These value-for-money interventions can improve efficiency in elderly care and meet the complex needs of an rapidly increasing part of the population.

Limitations: The impact of the CHSS on quality of life is not included in the economic evaluation.

Suggestions for future research: Investigate whether the cost-effectiveness results are sustainable in time and replicable in other settings.

Dementia care costs and outcomes: a systematic review
Knapp M, Iemmi V, Romeo R International Journal of Geriatric Psychiatry, 28:, 551-556. 2013

Abstract
OBJECTIVE:
We reviewed evidence on the cost-effectiveness of prevention, care and treatment strategies in relation to dementia.

METHODS:
We performed a systematic review of available literature on economic evaluations of dementia care, searching key databases and websites in medicine, social care and economics. Literature reviews were privileged, and other study designs were included only to fill gaps in the evidence base. Narrative analysis was used to synthesise the results.

RESULTS:
We identified 56 literature reviews and 29 single studies offering economic evidence on dementia care. There is more cost-effectiveness evidence on pharmacological therapies than other interventions. Acetylcholinesterase inhibitors for mild-to-moderate disease and memantine for moderate-to-severe disease were found to be cost-effective. Regarding non-pharmacological treatments, cognitive stimulation therapy, tailored activity programme and occupational therapy were found to be more cost-effective than usual care. There was some evidence to suggest that respite care in day settings and psychosocial interventions for carers could be cost-effective. Coordinated care management and personal budgets held by carers have also demonstrated cost-effectiveness in some studies.

CONCLUSION:
Five barriers to achieving better value for money in dementia care were identified: the scarcity and low methodological quality of available studies, the difficulty of generalising from available evidence, the narrowness of cost measures, a reluctance to implement evidence and the poor coordination of health and social care provision and financing.

Dying Well at Home: The Case for Integrated Working
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2013

The NHS should have a better evidence-based understanding of the relative costs of specialist and generalist care at the end of life, analysed according to place of care delivery.
Time spent in hospital in the last year of life is the most expensive factor in end of life care. Policy makers and commissioners should concentrate on interventions to keep people out of hospital if they do not need to be there, and to discharge them as early as possible.
Economic analyses should reflect the ‘cost’ to family members of caring, and should consider how savings to the state can be harnessed to support carers to continue to care at home.

Effectiveness and Cost-effectiveness of 'Usual Care' versus 'Specialist Integrated Care': A Comparative Study of Hospital Discharge Arrangements for Homeless People in England
Cornes M Forthcoming.

Purpose
To explore specialist services set up to improve homeless people’s experiences of leaving hospital. It is investigating different types of services; for example, some put patients in touch with a specially trained GP, others might employ a housing support worker to ensure people do not return to living on the streets after hospital discharge. We want to know what homeless people think of specialist services, how they help them tackle the range of problems they may have, and if this support prevents them returning to hospital. To compare effectiveness and costs we will also study hospital discharge arrangements where no specialist support for homeless people is in place.

Evaluation of Integrated Personal Commissioning (IPC)
Thom G SQW Limited, London. 2018

The Department of Health has commissioned a summative evaluation of the Integrated Personal Commissioning (IPC) programme. The evaluation will be carried out by a consortium led by SQW, in partnership with Bryson Purdon Social Research (BPSR), Social Care Institute for Excellence (SCIE), the Social Policy Research Unit (SPRU) and the Centre for Health Economics (CHE) both at the University of York, and Mott MacDonald.

Integrated Personal Commissioning (IPC) was launched in April 2015. It is a partnership between NHS England and the Local Government Association.

IPC is an approach to joining up health and social care, and other services where appropriate. The purpose is to enable people, with help from carers and families, to combine the resources available to them in order to control their care. This is achieved through personalised care planning and personal budgets. IPC also aims to support people to develop the skills and confidence needed to self-manage their care in partnership with carers, the voluntary, community and social enterprise (VCSE) sector, community capacity and peer support.

Evidence to Inform the Commissioning of Social Prescribing
Centre for Reviews and Dissemination, University of York Centre for Reviews and Dissemination, York. 2015

Summarises the findings of a rapid appraisal of available evidence on the effectiveness of social prescribing. Social prescribing is a way of linking patients in primary care with sources of support within the community, and can be used to improve health and wellbeing. For the review searches were conducted on the databases: DARE, Cochrane Database of Systematic Reviews and NHS EED for relevant systematic reviews and economic evaluations. Additional searches were also carried out on MEDLINE, ASSIA, Social Policy and Practice, NICE, SCIE and NHS. Very little good quality evidence was identified. Most available evidence described evaluations of pilot projects but failed to provide sufficient detail to judge either success or value for money. The briefing calls for better evaluation of new schemes. It recommends that evaluation should be of a comparative design; examine for whom and how well a scheme works; the effect it has and its costs.

Factors that promote and hinder joint and integrated working between health and social care services
Cameron A, Lart R, Bostock L, et al Health and Social Care in the Community, 22, 225-233. 2012

Key messages

This is an update of a previous systematic review on the factors that promote and hinder joint working between health and social care services. It demonstrates some positive outcomes of such an approach for people who use services, carers and organisations delivering services.
Three broad themes are used to organise the factors that support or hinder joint or integrated working: organisational issues; cultural and professional issues; and contextual issues.
There is significant overlap between positive and negative factors, with many of the organisational factors identified in research as promoting joint working also being identified as hindering collaboration when insufficient attention is paid to their importance.
Securing the understanding and commitment of staff to the aims and desired outcomes of new partnerships is crucial to the success of joint working, particularly among health professionals.
Defining outcomes that matter to service users and carers is important. Outcomes defined by service users may differ from policy and practice imperatives but are a crucial aspect of understanding the effectiveness of joint or integrated services.
Although most service users and carers report high levels of satisfaction, more can be done to involve them in care planning and influencing future care options. Joint and integrated services work best when they promote increased user involvement, choice and control.
The evidence base underpinning joint and integrated working remains less than compelling. It largely consists of small-scale evaluations of local initiatives which are often of poor quality and poorly reported. No evaluation studied for the purpose of this briefing included an analysis of cost-effectiveness.
There is an urgent need to develop high-quality, large-scale research studies that can test the underpinning assumptions of joint and integrated working in a more robust manner and assess the process from the perspective of service users and carers as well as from an economic perspective.

Going Home Alone: Counting the Cost to Older People and the NHS
Royal Voluntary Service Royal Voluntary Service, Cardiff. 2014

Assesses the impact of home from hospital services, which focus on supporting older people in their homes following a stay in hospital and seek to reduce the likelihood that they will need to be readmitted to hospital. The report brings together the findings of a literature review (as well as discussions with relevant experts), the results of the survey of 401 people aged 75 or over who had spent at least one night in hospital on one or more occasions within the past five years, and the outputs from a cost-impact analysis using national data and results from the survey. It sets out the policy context in England, Scotland and Wales, with its focus on preventive care, better integration of health and care services, and on shifting care away from the hospital into homes and communities. It then discusses the demand drivers for these schemes, including the ageing population, the growth in hospital readmissions, and decreasing length of stay. The report examines the experiences of older people after leaving hospital, looking at admissions, discharge, need for support following discharge, and type and duration of support. It suggests that home from hospital schemes can help to improve the well-being of their users and to reduce social isolation and loneliness and the number of hospital readmissions, as well as demand for other health and care services. The results of the cost-impact analysis suggest that, were home from hospital schemes appropriately targeted and effective in addressing ‘excess admissions’, they may produce a saving for the NHS of £40.4m per year

Growing Innovative Models of Health, Care and Support for Adults
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2018

Key Messages: Innovation is needed more than ever as our challenges grow. Innovation does not only mean technological breakthroughs or large restructures. New and better ways of delivering relationship-based care are needed, and already exist, but are inconsistently implemented or poorly scaled.
For innovation to flourish, we need to find better ways to help people bring good ideas from the margins into core business. The keys to success are:
a shared ambition to ‘embed person- and community-centred ways of working across the system, using the best available tools and evidence’
co-production: planning with the people who have the greatest stake in our services from the beginning
a new model of leadership which is collaborative and convening
investment and commissioning approaches which transfer resources from low quality, low outcomes into approaches which work effectively
effective outcomes monitoring and use of data to drive change
a willingness to learn from experience.

Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: a cluster randomised controlled trial.
Ballard C, Corbett A, Orrell M, et al Public Library of Science: Medicine, 15, e1002500. 2018

Abstract
Background

Agitation is a common, challenging symptom affecting large numbers of people with dementia and impacting on quality of life (QoL). There is an urgent need for evidence-based, cost-effective psychosocial interventions to improve these outcomes, particularly in the absence of safe, effective pharmacological therapies. This study aimed to evaluate the efficacy of a person-centred care and psychosocial intervention incorporating an antipsychotic review, WHELD, on QoL, agitation, and antipsychotic use in people with dementia living in nursing homes, and to determine its cost.
Methods and findings

This was a randomised controlled cluster trial conducted between 1 January 2013 and 30 September 2015 that compared the WHELD intervention with treatment as usual (TAU) in people with dementia living in 69 UK nursing homes, using an intention to treat analysis. All nursing homes allocated to the intervention received staff training in person-centred care and social interaction and education regarding antipsychotic medications (antipsychotic review), followed by ongoing delivery through a care staff champion model. The primary outcome measure was QoL (DEMQOL-Proxy). Secondary outcomes were agitation (Cohen-Mansfield Agitation Inventory [CMAI]), neuropsychiatric symptoms (Neuropsychiatric Inventory–Nursing Home Version [NPI-NH]), antipsychotic use, global deterioration (Clinical Dementia Rating), mood (Cornell Scale for Depression in Dementia), unmet needs (Camberwell Assessment of Need for the Elderly), mortality, quality of interactions (Quality of Interactions Scale [QUIS]), pain (Abbey Pain Scale), and cost. Costs were calculated using cost function figures compared with usual costs. In all, 847 people were randomised to WHELD or TAU, of whom 553 completed the 9-month randomised controlled trial. The intervention conferred a statistically significant improvement in QoL (DEMQOL-Proxy Z score 2.82, p = 0.0042; mean difference 2.54, SEM 0.88; 95% CI 0.81, 4.28; Cohen’s D effect size 0.24). There were also statistically significant benefits in agitation (CMAI Z score 2.68, p = 0.0076; mean difference 4.27, SEM 1.59; 95% CI −7.39, −1.15; Cohen’s D 0.23) and overall neuropsychiatric symptoms (NPI-NH Z score 3.52, p < 0.001; mean difference 4.55, SEM 1.28; 95% CI −7.07,−2.02; Cohen’s D 0.30). Benefits were greatest in people with moderately severe dementia. There was a statistically significant benefit in positive care interactions as measured by QUIS (19.7% increase, SEM 8.94; 95% CI 2.12, 37.16, p = 0.03; Cohen’s D 0.55). There were no statistically significant differences between WHELD and TAU for the other outcomes. A sensitivity analysis using a pre-specified imputation model confirmed statistically significant benefits in DEMQOL-Proxy, CMAI, and NPI-NH outcomes with the WHELD intervention. Antipsychotic drug use was at a low stable level in both treatment groups, and the intervention did not reduce use. The WHELD intervention reduced cost compared to TAU, and the benefits achieved were therefore associated with a cost saving. The main limitation was that antipsychotic review was based on augmenting processes within care homes to trigger medical review and did not in this study involve proactive primary care education. An additional limitation was the inherent challenge of assessing QoL in this patient group.
Conclusions

These findings suggest that the WHELD intervention confers benefits in terms of QoL, agitation, and neuropsychiatric symptoms, albeit with relatively small effect sizes, as well as cost saving in a model that can readily be implemented in nursing homes. Future work should consider how to facilitate sustainability of the intervention in this setting.
Trial registration

ISRCTN Registry ISRCTN62237498
Author summary
Why was this study done?

People with dementia living in care homes often experience agitation and other symptoms that are difficult to treat and distressing for the individual.

What did the researchers do and find?

We tested the WHELD programme, which combined staff training, social interaction, and guidance on use of antipsychotic medications, in 69 UK care homes in a 9-month clinical trial.
We showed that care homes receiving the WHELD programme saw improvements in quality of life as well as other important symptoms including agitation, behaviour, and pain in people with dementia.
The WHELD programme was also shown to be cost-effective.

What do these findings mean?

The findings show that the WHELD approach is beneficial for people with dementia living in care homes.
WHELD could be provided in an affordable way to improve the lives of these individuals, who often do not receive the care they need.

Integrated care experiences and outcomes in Germany, the Netherlands, and England
Busse R and Stahl J Health Affairs, 33, 1549-1558. 2014

Care for people with chronic conditions is an issue of increasing importance in industrialized countries. This article examines three recent efforts at care coordination that have been evaluated but not yet included in systematic reviews. The first is Germany’s Gesundes Kinzigtal, a population-based approach that organizes care across all health service sectors and indications in a targeted region. The second is a program in the Netherlands that bundles payments for patients with certain chronic conditions. The third is England’s integrated care pilots, which take a variety of approaches to care integration for a range of target populations. Results have been mixed. Some intermediate clinical outcomes, process indicators, and indicators of provider satisfaction improved; patient experience improved in some cases and was unchanged or worse in others. Across the English pilots, emergency hospital admissions increased compared to controls in a difference-in-difference analysis, but planned admissions declined. Using the same methods to study all three programs, we observed savings in Germany and England. However, the disease-oriented Dutch approach resulted in significantly increased costs. The Kinzigtal model, including its shared-savings incentive, may well deserve more attention both in Europe and in the United States because it combines addressing a large population and different conditions with clear but simple financial incentives for providers, the management company, and the insurer.

Integrating assessments of older people: examining evidence and impact from a randomised controlled trial
Clarkson P, Brand C, Hughes J, et al Age and Ageing, 40, 3, 388-391. 2011

SIR—The needs of older people are often multiple, complex and are at times experienced in combination, which require closely targeted services [1] and necessitate the collaboration of several professional groups. However, care has often been disjointed and compartmentalised [2]. One response to this has been a call for integration, between health and social care. Integrated care can operate at the organisational level, in terms of structures [3, 4] or the professional level, in terms of shared working arrangements, multidisciplinary teams and case management [5, 6]; an issue being that integrated structures, although conducive to inter-professional working, do not necessarily guarantee it [7].

Integration is assumed to produce benefits in terms of better co-ordination of services, better outcomes and greater efficiency [8]. Integration remains an aim pursued by successive governments [9]. Policies in several countries call for integration at the assessment stage; a key phase in terms of ensuring care closely matches older people’s needs [10, 11]. In England, examples are the single assessment process (SAP), offering a common structure through shared tools and processes [12], and the common assessment framework (CAF) for adults, advocating technical solutions for information sharing [13]. However, while evidence identifies potential benefits of integrating assessment information from different professionals [5, 14] and of more comprehensive geriatric assessment [15], there remains a need to examine the cost-effectiveness of such approaches to guide future policy.

We reanalysed data from a randomised controlled trial of integrated assessment between specialist clinicians and social services care managers in England [14] to offer evidence of the costs and benefits of integration. We evaluated the experiment’s impact on changes in functioning, admissions to care homes and use and costs of health and social services for frail older people at risk of entering care homes

Integrating funds for health and social care: an evidence review
Mason A, Goddard M, Weatherly H, et al Journal of Health Services Research and Policy, 20, 177-188. 2015

OBJECTIVES:
Integrated funds for health and social care are one possible way of improving care for people with complex care requirements. If integrated funds facilitate coordinated care, this could support improvements in patient experience, and health and social care outcomes, reduce avoidable hospital admissions and delayed discharges, and so reduce costs. In this article, we examine whether this potential has been realized in practice.

METHODS:
We propose a framework based on agency theory for understanding the role that integrated funding can play in promoting coordinated care, and review the evidence to see whether the expected effects are realized in practice. We searched eight electronic databases and relevant websites, and checked reference lists of reviews and empirical studies. We extracted data on the types of funding integration used by schemes, their benefits and costs (including unintended effects), and the barriers to implementation. We interpreted our findings with reference to our framework.

RESULTS:
The review included 38 schemes from eight countries. Most of the randomized evidence came from Australia, with nonrandomized comparative evidence available from Australia, Canada, England, Sweden and the US. None of the comparative evidence isolated the effect of integrated funding; instead, studies assessed the effects of ‘integrated financing plus integrated care’ (i.e. ‘integration’) relative to usual care. Most schemes (24/38) assessed health outcomes, of which over half found no significant impact on health. The impact of integration on secondary care costs or use was assessed in 34 schemes. In 11 schemes, integration had no significant effect on secondary care costs or utilisation. Only three schemes reported significantly lower secondary care use compared with usual care. In the remaining 19 schemes, the evidence was mixed or unclear. Some schemes achieved short-term reductions in delayed discharges, but there was anecdotal evidence of unintended consequences such as premature hospital discharge and heightened risk of readmission. No scheme achieved a sustained reduction in hospital use. The primary barrier was the difficulty of implementing financial integration, despite the existence of statutory and regulatory support. Even where funds were successfully pooled, budget holders’ control over access to services remained limited. Barriers in the form of differences in performance frameworks, priorities and governance were prominent amongst the UK schemes, whereas difficulties in linking different information systems were more widespread. Despite these barriers, many schemes – including those that failed to improve health or reduce costs – reported that access to care had improved. Some of these schemes revealed substantial levels of unmet need and so total costs increased.

CONCLUSIONS:
It is often assumed in policy that integrating funding will promote integrated care, and lead to better health outcomes and lower costs. Both our agency theory-based framework and the evidence indicate that the link is likely to be weak. Integrated care may uncover unmet need. Resolving this can benefit both individuals and society, but total care costs are likely to rise. Provided that integration delivers improvements in quality of life, even with additional costs, it may, nonetheless, offer value for money

Integration of Health and Social Care. A Review of Literature and Models Implications for Scotland
Robertson H Royal College of Nursing Scotland, Glasgow. 2011

Summary: This exploration of integrated health and social care reviews the literature on models of integration from six European countries and New Zealand, assessesthe factors which help orhinder integration and considersthe implications for Scotland.An unequivocal message from the literature is that there is no single, agreed definition of integrated care. Integration can take place at a number of levels: team, service or organisation. It can apply to a small number of specialist services or to the full range of health and social care services. The body of information on integration is extensive but contains surprisingly little evidence of improved outcomes for patients. Most measures of the success of integration concentrate on criteriasuch as admissions to hospital, reduced waiting times or service responsiveness and infer benefits to service users.However, robust evidence of the impact on health outcomes is lacking.There are a large number of different models of integration. Some are based on multi-disciplinaryteam working and networks. Others involve structural reform to create single,integrated organisations. Two recent examples ofstructural integration are the TioHundra municipal company in Sweden(Norrtälje)and the Care Trusts Plus in England.Factors helping or hindering integrated working fall into three categories:Organisational issuesVision and cultureUnified budgets or structuresCommunication and ITProfessional issuesStatus and stereotypesPatient focusTraining and educationPolicy and legal issues Policy environment LegislationEmployment contracts, terms and conditions.Scotlandalreadyhas experiencein integrating health and social care services through joint future bodies, community health (and care) partnerships and managed clinical/care networks. A track record of joint working is a marker for success in integration so this previous experience bodes well. However, integration is not a quick or cheap option so if the drivers for integration are a need to reduce costs and ease pressure on secondary care, it may fail.

Is integrated care associated with service costs and admission rates to institutional settings? An observational study of community mental health teams for older people in England
Wilberforce M, Tucker S, Brand C, et al International Journal of Geriatric Psychiatry, 31, 11, 1208-1216. 2016

Objectives:To evaluate the association between the degree of integration in community mental healthteams (CMHTs) and: (i) the costs of service provision; (ii) rates of mental health inpatient and carehome admission.Methods:An observational study of service use and admissions to institutional care was undertaken for aprospectively-sampled cohort of patients from eight CMHTs in England. Teams were chosen to repre-sent‘high’or‘low’levels of integrated working practice and patients were followed-up for seven months.General linear models were used to estimate service costs and the likelihood of institutional admission.Results:Patients supported by high integration teams received services costing an estimated 44% morethan comparable patients in low integration teams. However, after controlling for case mix, no signif-icant differences were found in the likelihood of admission to mental health inpatient wards or carehomes between team types.Conclusions:Integrated mental health and social care teams appeared to facilitate greater access tocommunity care services, but no consequent association was found with community tenure. Furtherresearch is required to identify the necessary and sufficient components of integrated community men-tal health care, and its effect on a wider range of outcomes using patient-reported measures.

LGA Adult Social Care Efficiency Programme: The Final Report
Local Government Association Local Government Association, London. 2014

This is the concluding report from the LGA Adult Social Care Efficiency (ASCE) programme. The programme was launched in 2011 in response to the significant cuts to council budgets and their impact on adult social care. The aim of the programme is to support councils to develop transformational approaches to making the efficiency savings required to meet the challenge of reduced funding. The report shares innovative and transformational examples of how councils are bringing together businesses, public sector partners and communities to develop lower-cost solutions to support the most vulnerable in our society. In particular, it outlines some key lessons around developing a new contract with citizens and communities, managing demand, transformation, commissioning, procurement and contract management, and integration. It looks at efficiency approaches in practice, with specific reference to assessment, advice and information, delivering preventative services, avoiding admissions and reducing costs of residential care, reducing costs in domiciliary care and transforming learning disability services. In addition, it considers local approaches to developing effective internal management, reshaping the service and working with partners, customers and suppliers.

Living Well for Longer: The Economic Argument for Investing in the Health and Wellbeing of Older People in Wales
Edwards RT, Spencer LH, Bryning L, et al Centre for Health Economics and Medicines Evaluation, Bangor. 2018

This report by the University of Bangor makes the economic argument for investing in prevention at different stages of the life course, in particular, older people.

Commissioned by Public Health Wales, it brings together robust international and UK evidence on the relative cost-effectiveness and return on investment of devoting public sector resources to programmes and practices supporting older people.

In relation to housing, it notes that the Welsh Government spends around £50 million per year on adapting the homes of older and disabled people, helping them to live safely and independently.

For every £1 invested in Care & Repair there is £7.50 savings to the taxpayer. It comes to the conclusion that it is cost-effective to improve housing by providing heating and insulation for high risk groups of over 65s.

Living, Not Existing: Putting Prevention at the Heart of Care for Older People in Wales
Royal College of Occupational Therapists Royal College of Occupational Therapists, London. 2017

This report focuses on the important contribution that occupational therapists can make to support further integration of health and social care in Wales. It looks at the role of occupational therapy in helping older people to remain independent and live in their own communities for as long as possible, preventing or delaying the need for expensive care long-term. The report focuses on three key areas: prevention or delaying the need for care and support; helping older people to remain in their communities; and ensuring equality of access to occupational therapy. It provides recommendations to improve the design and delivery of services and examples of best practice and individual case studies to how occupational therapists can contribution to integrated, person-centred services. These include for occupational therapists to work more closely with general practitioners, take on leadership roles to provide expertise to community providers on the development of person and community centred services; and the development of formal partnership agreements across local housing, health and social care sectors to ensure all older people have access to occupational therapy services.

Money Matters: Reviews of Cost-effective Initiatives
Institute of Public Care The Institute for Research and Innovation in Social Services, Glasgow. 2011

This set of eight case studies, produced by the Institute of Public Care on behalf of IRISS (the Institute for Research and Innovation in Social Services), provides detailed analysis of the cost-effectiveness of a series of recent social care initiatives, ranging from nationwide and relatively high-profile schemes such as individual budgets to those thus far unique to one country, city or local authority area in the UK.

In each case, the report provides an overview of the initiative – its origins, including previous variants of the scheme, who it is intended to help, and how it works in practice – before justifying claims of cost-effectiveness by reference to detailed comparative costings, using one illustrative implementation of the scheme where the initiative is nationwide. Based on the analysis, the report sets out the initiative’s applicability to other settings as well as potential impediments to broader implementation.

The eight initiatives scrutinised are:

A study of Shared Lives schemes in south east England for providing care in the carer’s own home for individuals placed there by the local authority.
An extra-care housing scheme completed in Bradford.
Health in mind – social inclusion support for people with mental health needs in Bradford based round a series of mental health “well-being cafes”.
LinkAge Plus – analysis of nationwide DWP-funded pilot schemes for an holistic approach to provision of services for older people.
The Rapid Response Adaptations Programme – a Welsh initiative for providing adaptations such as ramps to let people return to their own homes.
A project in north west England to guide older people with low-level needs through a self-assessment process.
Analysis of various pilot sites taking different approaches to individual budgets, based on a broader evaluation conducted in 2008.
A project in two acute trusts in London to reconfigure hospital discharge procedures to emphasise rehabilitation.

National Evaluation of Partnerships for Older People Projects: Final Report
Windle K, Wagland R, Forder J, et al Personal Social Services Research Unit, Kent. 2009

The Partnership for Older People Projects (POPP) were funded by the Department of Health to
develop services for older people, aimed at promoting their health, well‐being and independence
and preventing or delaying their need for higher intensity or institutional care. The evaluation found
that a wide range of projects resulted in improved quality of life for participants and considerable
savings, as well as better local working relationships.
 Twenty‐nine local authorities were involved as pilot sites, working with health and voluntary
sector partners to develop services, with funding of £60m
 Those projects developed ranged from low level services, such as lunch‐clubs, to more formal
preventive initiatives, such as hospital discharge and rapid response services
 Over a quarter of a million people (264,637) used one or more of these services
 The reduction in hospital emergency bed days resulted in considerable savings, to the extent
that for every extra £1 spent on the POPP services, there has been approximately a £1.20
additional benefit in savings on emergency bed days. This is the headline estimate drawn from a
statistically valid range of £0.80 to £1.60 saving on emergency bed days for every extra £1 spent
on the projects.
 Overnight hospital stays were seemingly reduced by 47% and use of Accident & Emergency
departments by 29%. Reductions were also seen in physiotherapy/occupational therapy and
clinic or outpatient appointments with a total cost reduction of £2,166 per person
 A practical example of what works is pro‐active case coordination services, where visits to A&E
departments fell by 60%, hospital overnight stays were reduced by 48%, phone calls to GPs fell
by 28%, visits to practice nurses reduced by 25% and GP appointments reduced by 10%
 Efficiency gains in health service use appear to have been achieved without any adverse impact
on the use of social care resources
 The overwhelming majority of the POPP projects have been sustained, with only 3% being closed
– either because they did not deliver the intended outcomes or because local strategic priorities
had changed
 PCTs have contributed to the sustainability of the POPP projects within all 29 pilot sites.
Moreover, within almost half of the sites, one or more of the projects are being entirely
sustained through PCT funding – a total of 20% of POPP projects. There are a further 14% of
projects for which PCTs are providing at least half of the necessary ongoing funding
 POPP services appear to have improved users’ quality of life, varying with the nature of
individual projects; those providing services to individuals with complex needs were particularly
successful, but low‐level preventive projects also had an impact
 All local projects involved older people in their design and management, although to varying
degrees, including as members of steering or programme boards, in staff recruitment panels, as
volunteers or in the evaluation
 Improved relationships with health agencies and the voluntary sector in the locality were
generally reported as a result of partnership working, although there were some difficulties
securing the involvement of GPs

Report of the Annual Social Prescribing Network Conference
Social Prescribing Network Social Prescribing Network, University of Westminster, London. 2016

Report of the annual social prescribing network conference, which sets out a definition of social prescribing, outlines principles for effective service provision and the steps needed to evaluate and measure the impact of social prescribing. It also includes an analysis of a pre-conference survey, completed by 78 participants to explore their experience of social prescribing. Key ingredients identified that underpin social prescribing included: funding, healthcare professional buy-in, simple referral process, link workers with appropriate training, patient centred care, provision of services, patient buy-in and benefits of social prescribing. The benefits of social prescribing fell into six broad headings: physical and emotional health and wellbeing; behaviour change; cost effectiveness and sustainability; capacity to build up the voluntary community; local resilience and cohesion; and tackling the social determinants of ill health. Afternoon sessions covered the following topics: obtaining economic data on social prescribing; engaging different stakeholders in social prescribing; standards and regulations that could be applied to social prescribing services; qualities and skills necessary to commission high quality social prescribing services; designing research studies on social prescribing. Short case studies are included. There was consensus from participants that social prescribing provides potential to reduce pressures on health and care services through referral to non-medical, and often community-based, sources of support.

Social Prescribing and Health and Well-being
Welsh NHS Confederation Welsh NHS Confederation, Cardiff. 2017

This briefing paper sets out the important role that social prescribing has on the health and well-being of the population in Wales and highlights some of the social prescribing initiatives already in place which show how patients are benefiting from integrated, person-centred and non-medical services. The initiatives include the Valleys Steps programme which considers alternatives for seeking medical treatment for ongoing mental health issues; Gofal Community Food Co-ops, which provide opportunities for mental health patients to interact with members of the local community; and Care and Repair Cymru’s Warm Homes Prescription Scheme. It also highlights existing evidence which shows the effectiveness and cost effectiveness of social prescribing.

Social prescribing: less rhetoric and more reality. A systematic review of the evidence
Bickerdike L, et al BMJ Open, 7, e013384. 2017

Objectives: Social prescribing is a way of linking patients in primary care with sources of support within the community to help improve their health and well-being. Social prescribing programmes are being widely promoted and adopted in the UK National Health Service and this systematic review aims to assess the evidence for their effectiveness. Setting/data sources: Nine databases were searched from 2000 to January 2016 for studies conducted in the UK. Relevant reports and guidelines, websites and reference lists of retrieved articles were scanned to identify additional studies. All the searches were restricted to English language only. Participants: Systematic reviews and any published evaluation of programmes where patient referral was made from a primary care setting to a link worker or facilitator of social prescribing were eligible for inclusion. Risk of bias for included studies was undertaken independently by two reviewers and a narrative synthesis was performed. Primary and secondary outcome measures: Primary outcomes of interest were any measures of health and well-being and/or usage of health services. Results: A total of 15 evaluations of social prescribing programmes were included. Most were small scale and limited by poor design and reporting. All were rated as a having a high risk of bias. Common design issues included a lack of comparative controls, short follow-up durations, a lack of standardised and validated measuring tools, missing data and a failure to consider potential confounding factors. Despite clear methodological shortcomings, most evaluations presented positive conclusions. Conclusions: Social prescribing is being widely advocated and implemented but current evidence fails to provide sufficient detail to judge either success or value for money. If social prescribing is to realise its potential, future evaluations must be comparative by design and consider when, by whom, for whom, how well and at what cost.

Social Value of Local Area Coordination in Derby
Marsh H Kingfishers (Project Management) Ltd, Manchester. 2016

A Social Return on Investment Analysis for Derby City Council (SROI) has found that for a three year forecast period with 10 Local Area Coordinators, £4.00 of social value would be earned for every £1.00 invested. The report was commissioned by Think Local Act Personal and developed from our work with a number of health and wellbeing boards to embed our earlier ‘Strong and Inclusive Communities Framework'”.

The analysis was initially completed for Thurrock Council based on nine Local Area Coordinators (LAC) in July 2015. Then followed by an analysis for Derby based on ten LAC in November 2015.

The findings our available in two reports: Social Value of Local Area Coordination in Derby – Social Return on Investment (SROI) Analysis, and the Learning Outcomes from Thurrock Council & Derby City Council SROI Analyses.

Technical Guide: Building a Business Case for Prevention
Social Finance Social Finance, London. 2014

This guide sets out the issues that need to be considered when developing a business case to invest in preventive services and to ensure that any decision are based on robust and reliable data. The guide focuses on the following arguments: the importance of ‘investing to save’, arguing that prevention is cheaper in the long term; promotion of service innovation; placing the focus of commissioning on outcomes rather than outputs; and managing a shift in spending from acute to prevention to reduce demand over time. The guide outlines key four activities required to build a business case: understanding needs; understanding current costs; assessing possible interventions; and deciding how to measure the value and outcome of the interventions. It also provides a summary business case for prevention and using a Social Impact Bond (SBI) to finance a business case for prevention. An example case study of making a business case for prevention services in early years services in Greater Manchester is included.

The (cost‐)effectiveness of preventive, integrated care for community‐dwelling frail older people: a systematic review
Looman WM, Huijsman R, Fabbricotti IN Health and Social Care in the Community, 27, 1-30 2018

Integrated care is increasingly promoted as an effective and cost‐effective way to organise care for community‐dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost‐effectiveness of preventive, integrated care for community‐dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost‐effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk‐of‐bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom‐reported outcomes such as well‐being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost‐effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost‐effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected. (Edited publisher abstract)

The effectiveness of inter-professional working for older people living in the community: a systematic review
Trivedi D, Goodman C, Gage H, et al Health and Social Care Community, 21, 113-128. 2013

Abstract
Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.

The Lightbulb project: switched on to integration in Leicestershire
Moran A Housing Learning and Improvement Network, London. 2017

A case study of the Lightbulb project, which brings together County and District Councils and other partners in Leicestershire to help people stay in their homes for as long as possible. The approach includes GPs and other health and care professionals and relies on early at home assessment process at key points of entry. This is delivered through a ‘hub and spoke’ model with an integrated Locality Lightbulb Team in each District Council area and covers: minor adaptations and equipment; DFGs; wider housing support needs (warmth, energy, home security); housing related health and wellbeing (AT, falls prevention); planning for the future (housing options); and housing related advice, information, and signposting. The Lightbulb service also includes a cost effective specialist Hospital Housing Enabler Team based in acute and mental health hospital settings across Leicestershire. The team work directly with patients and hospital staff to identify and resolve housing issues that are a potential barrier to hospital discharge and also provide low level support to assist with the move home from hospital to help prevent readmissions.

What is the Evidence on the Economic Impacts of Integrated Care?
Nolte E and Pitchforth E King's Fund, London. 2014

The rising burden of chronic disease, and the number of people with complex
care needs in particular, require the development of delivery systems that bring
together a range of professionals and skills from both the cure (health-care) and
care (long-term and social-care) sectors. Failure to better integrate or coordinate
services along the care continuum may result in suboptimal outcomes and
available evidence of integrated care programmes points to a positive impact
on the quality of patient care and improved health or patient satisfaction
outcomes. However, uncertainty remains about the relative effectiveness of
different system-level approaches on care coordination and outcomes, with
particular scarcity of robust evidence on the economic impacts of integrated
care approaches.
This report provides a summary of published reviews on the economic
impacts of integrated care approaches. Given the wide range of defi nitions
and interpretations of the concept, we propose a working defi nition that
builds on the goal of integrated care and which considers initiatives seeking to
improve outcomes for those with (complex) chronic health problems and needs
by overcoming issues of fragmentation through linkage or coordination of
services of different providers along the continuum of care.
Based on a systematic search of Pubmed, Embase and the Cochrane Library,
we identifi ed a total of 963 references, of which 19 reviews were identifi ed
as eligible for inclusion. We analysed reviews for three economic outcomes:
utilization, cost–effectiveness and cost or expenditure. The latter were
combined because most studies used these interchangeably. For completeness,
we also extracted data on core health outcomes such as health status, quality
of life or mortality, as well as process measures.
None of the reviews identifi ed by our searches explicitly defi ned
‘integrated care’ as the topic of review.
The most common concepts or terms were case management, care
coordination, collaborative care or a combination of these; four reviews focused
on disease management interventions. The majority of reviews iconsidered
a wide range of approaches and typically only about half of primary studies
included in individual reviews could be considered as integrated care under
our defi nition. Care initiatives frequently targeted the hospital-primary care or
community services interface, while several reviews examined the coordination
of primary care and community services, often, although not always, involving
medical specialists, or extending further into social care services. Utilization and cost were the most common economic outcomes
assessed by reviews but reporting of measures was inconsistent
and the quality of the evidence was often low.
The majority of economic outcomes focused on hospital utilization through
(re)admission rates, length of stay or admission days and emergency department
visits. Findings tended to be mixed within each review, which makes it diffi cult
to draw fi rm conclusions. Also, results were commonly not quantifi ed, making
an overall assessment of the size of possible effects problematic. Seventeen
reviews reported cost and/or expenditure data in some form, typically reporting
cost in terms of health-care cost savings resulting from the intervention, most
frequently in relation to hospital costs. There was some evidence of cost
reduction in a number of reviews; however, fi ndings were frequently based on
a small number of original studies only, or studies that only used a before–after
design without control, or both.
There is evidence of cost–effectiveness of selected integrated care
approaches but the evidence base remains weak. Eight of the nineteen
studies reported on cost–effectiveness.
There was some evidence from one review of approaches targeting frequent
hospital emergency department users that found one trial to report the
intervention to be cost-effective. Based on one economic evaluation, one other
review concluded that there was little or no evidence of incremental QALY gain
over usual care of structured home-based, nurse-led health promotion for older
people at risk of hospital or care home admission. Six reviews reported on cost
per QALY as a measure of cost–utility, suggesting increased cost associated
with the integrated care approach in question in some studies but not others.
Overall the evidence was diffi cult to interpret.
The majority of studies reviewed echo the concerns reported in earlier
assessments of the evidence of integrated care interventions. Thus, it remains
challenging to interpret the evidence from existing primary studies, which tend
to be characterized by heterogeneity in the defi nition and description of the
intervention and components of care under study. Variation in defi nitions and
components of care, and failure to recognize these variations, might lead to
inappropriate conclusions about programme effectiveness and the application
of fi ndings.
Based on the evidence presented here, there may be a need to revisit our
understanding of what integrated care is and what it seeks to achieve, and
the extent to which the strategy lends itself to evaluation in a way that would
allow for the generation of clear-cut evidence, given its polymorphous nature.
Fundamentally, it is important to understand whether integrated care is to be
considered an intervention that, by implication, ought to be cost-effective and support fi nancial sustainability, or whether it is to be interpreted and evaluated
as a complex strategy to innovate and implement long-lasting change in the
way services in the health and social-care sectors are being delivered and
that involve multiple changes at multiple levels. Evidence presented here and
elsewhere strongly points to the latter, and initiatives and strategies underway
will require continuous evaluation over extended periods of time enabling
assessment of their impacts both economic and on health outcomes if we are
to generate appropriate conclusions about programme effectiveness and the
application of fi ndings to inform decision making.

What is the Evidence on the Economic Impacts of Integrated Care? Technical Report
Nolte E and Pitchforth E World Health Organization, Geneva. 2014

This new policy summary reviews the existing evidence on the economic impact of integrated care approaches. Whereas it is generally accepted that integrated care models have a positive effect on the quality of care, health outcomes and patient satisfaction, it is less clear how cost effective they are. As the evidence-base in this field is rather weak, the authors suggest that we may have to revisit our understanding of the concept and our expectations in terms of its assessment. Integrated care should rather be seen as a complex strategy to innovate and implement long-lasting change in the way services in the health and social-care sectors are delivered. This policy summary (number 11) is based on a report for the European Commission to inform the discussions of the EU’s Reflection process on modern, responsive and sustainable health systems on the objective of integrated care models and better hospital management. Both authors are affiliated to RAND Europe.

What Works in Community Led Support? Findings and Lessons from Local Approaches and Solutions for Transforming Adult Social Care (and Health) Services
Brown H, et al National Development Team for Inclusion, Bath. 2017

The first evaluation report of the Community Led Support (CLS) programme, which supported nine authorities across England, Wales and Scotland to develop and implement a new model of delivering community based care and support. The findings show what can be achieved when applying core principles associated with asset based approaches. CLS involves local authorities working collaboratively with their communities, partner organisations and staff to design a health and social care service that works for everyone. Its core principles include co-production; a focus on communities; preventing crises by enabling people to get support and advice when they need it; a culture based on trust and empowerment; and treating people as equals, and building on their strengths. The evaluation found evidence that CLS resulted in better experiences and outcomes for local people, improved access to services; greater efficiencies in services; reduced waiting times and lists; increased signposting and resolution through community services; improvement in staff morale; and a potential for cost savings. Sites achieved these changes by adopting a variety of approaches to implementing CLS – from implementing CLS across an entire authority area at the same time, to implementing in one innovation site and encouraging others to adopt aspects of the service. The report identifies six priority areas for action to further develop and embed community led support over the next 12-18 months.

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