'The Billion Dollar Question': embedding prevention in older people's services—Ten 'High-Impact' changes
Allen K and Glasby J British Journal of Social Work, 43, 904-924. 2013

With ageing populations, social changes and rising public expectations, many countries are exploring ways of developing a more preventative approach within their health and social care services. In England, this has become a growing priority over time—made even more significant by recent economic change and by the urgent need to reduce public sector spending. However, a key dilemma for policy makers and managers is the patchy nature of the evidence base—with a lack of certainty over how to reform services or prioritise spending in order to develop a more genuinely preventative approach. Against this background, this commentary reviews national and international evidence around ten policy measures and interventions, highlighting some of the most promising approaches as well as the fragmented and contested nature of the evidence base.

A community-based exercise and education scheme for stroke survivors: a randomized controlled trial and economic evaluation
Harrington R, Taylor G, Hollinghurst S, et al Clinical Rehabiliation, 24, 3-15. 2010

Abstract
OBJECTIVE:

The evaluation of a community-based exercise and education scheme for stroke survivors.
DESIGN:

A single blind parallel group randomized controlled trial.
SETTING:

Leisure and community centres in the south-west of England.
SUBJECTS:

Stroke survivors (median (IQR) time post stroke 10.3 (5.4-17.1) months). 243 participants were randomized to standard care (124) or the intervention (119).
INTERVENTION:

Exercise and education schemes held twice weekly for eight weeks, facilitated by volunteers and qualified exercise instructors (supported by a physiotherapist), each with nine participants plus carers or family members.
METHOD:

Participants were assessed by a blinded independent assessor at two weeks before the start of the scheme, nine weeks and six months. One-year follow-up was by postal assessment.
MAIN MEASURES:

PRIMARY OUTCOMES:

Subjective Index of Physical and Social Outcome (SIPSO); Frenchay Activities Index; Rivermead Mobility Index. NHS, social care and personal costs. Secondary outcomes included WHOQoL-Bref.
ANALYSIS:

Intention-to-treat basis, using non-parametric analysis to investigate change from baseline. Economic costs were compared in a cost-consequences analysis.
RESULTS:

There were significant between-group changes in SIPSO physical at nine weeks (median (95% confidence interval (CI)), 1 (0, 2): P = 0.022) and at one year (0 (-1, 2): P = 0.024). (WHOQol-Bref psychological (6.2 (-0.1, 9.1): P = 0.011) at six months. Mean cost per patient was higher in the intervention group. The difference, excluding inpatient care, was pound296 (95% CI: – pound321 to pound913).
CONCLUSION:

The community scheme for stroke survivors was a low-cost intervention successful in improving physical integration, maintained at one year, when compared with standard care.

A Cost Comparison of Supported Living in Wales: A Swansea Case Study
Nash P, Farr A, Phillips C Centre for Innovative Ageing, Swansea. 2013

The key findings from the data are: •The least expensive environment for delivery of care is in service users’ own homes with the most expensive being residential care. Caveats to this are that residential care supports older adults with higher levels of care needs, so type of care needs to be considered. Further, residential care includes housing costs where neither Extracare nor community based care include rent or mortgage payments, as these are not costs incurred by Social Services (Section 4.2). •The lowest equipment/modification costs were incurred by residents in Extracare with the highest by those receiving care and support in the community. This is reflective of the age of housing stock and support infrastructure, with Extracare having communal aides and ready modified flats, whereas this is not the case for community properties (Section 4.3) In-patient costs were significantly higher in residential care than in Extracare, again reflective of the underlying care need of older adults in each environment. The highest costs were associated with those in receipt of care in the community, which is likely because of delays in enacting assessments, re-ablement and new community support care packages (Section 4.4). •Outpatient admissions and A&E costs were relatively stable across each of the care environments (Section 4.5) •The most common GP services utilised by residents in each of the care environments were telephone consultations, home visits and GP surgery consultations (Section 4.7). •Overall, Residential care appears to be the most expensive for all costs relating to GP activity (Section 4.8).

Befriending of Older Adults
Bauer A, Knapp M, Perkins M Personal Social Services Research Unit, London. 2011

Befriending initiatives, often delivered by volunteers, provide an‘upstream’ intervention that is potentially of
value both to the person being befriended and the ‘befriender’. For those receiving the intervention,
particularly older people, it promotes social inclusion and reduces loneliness;
for the befriender, there is the personal satisfaction of contributing to the local community by offering support and skills. Specific potential
benefits include the improved mental well­being of the person receiving the intervention, a reduced risk of
depression, and associated savings in health care costs.

Better Housing, Better Health in London Lambeth: The Lambeth Housing Standard Health Impact Assessment and Cost Benefit Analysis
Ambrose A, Bashir N, Foden N, et al Centre for Regional Economic and Social Research, Sheffield. 2018

Main message: Our indicative cost-benefit analysis shows that Lambeth’s Housing Standard (LHS) investment programme will have a major impacton the health and quality of life of council tenants, with wider monetised benefits of £227million for individuals, for the National Health Service,social care services, the Criminal Justice System and the local economy

Better Lives, Health, Future: Key Findings of a Three-year Study by Aston Univerisity into The Extra Care Charitable Trust's Unique Model of Housing, Health and Social Care
Extra Care Charitable Trust Extra Care Charitable Trust, Coventry. 2015

Collaborative Research between Aston Research Centre for Healthy Ageing (ARCHA) and the ExtraCare Charitable Trust

Building community capital in social care: is there an economic case?
Knapp M, Bauer A, Perkins M, et al Community Development Journal, 48, 313-331. 2013

ABSTRACT
Current debates in many countries about the sustainability of public commitments include
discussion of the adequacy and affordability of collective health and social care responses to the
rapidly growing needs of ageing communities. A recurrent theme in England is whether
communities can play greater roles in preventing the emergence of social care needs and/or in
helping to meet them. A number of approaches have been suggested, employing a range of
concepts and terms, including community development, community capacity-building and
creating social capital. We investigated whether initiatives of this kind generate cost-savings to the
public purse and more broadly to society. We used a cost-benefit approach and decisionmodelling techniques to demonstrate potential costs and economic consequences in a context
where evidence is limited and there is little opportunity to collect primary data. We found that
there could be sizable savings to the public purse when investing in community capital-building
initiatives at relatively low cost. We discuss the limitations of our analysis and recommend
collection of better outcome data.

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.

Case management approaches to home support for people with dementia.
Reilly S, Miranda-Castillo C, Malouf R, et al Cochrane Database Systematic Review, 5, 1, CD008345. 2015

Abstract
BACKGROUND:
Over 35 million people are estimated to be living with dementia in the world and the societal costs are very high. Case management is a widely used and strongly promoted complex intervention for organising and co-ordinating care at the level of the individual, with the aim of providing long-term care for people with dementia in the community as an alternative to early admission to a care home or hospital.

OBJECTIVES:
To evaluate the effectiveness of case management approaches to home support for people with dementia, from the perspective of the different people involved (patients, carers, and staff) compared with other forms of treatment, including ‘treatment as usual’, standard community treatment and other non-case management interventions.

SEARCH METHODS:
We searched the following databases up to 31 December 2013: ALOIS, the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group,The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, LILACS, Web of Science (including Science Citation Index Expanded (SCI-EXPANDED) and Social Science Citation Index), Campbell Collaboration/SORO database and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group. We updated this search in March 2014 but results have not yet been incorporated.

SELECTION CRITERIA:
We include randomised controlled trials (RCTs) of case management interventions for people with dementia living in the community and their carers. We screened interventions to ensure that they focused on planning and co-ordination of care.

DATA COLLECTION AND ANALYSIS:
We used standard methodological procedures as required by The Cochrane Collaboration. Two review authors independently extracted data and made ‘Risk of bias’ assessments using Cochrane criteria. For continuous outcomes, we used the mean difference (MD) or standardised mean difference (SMD) between groups along with its confidence interval (95% CI). We applied a fixed- or random-effects model as appropriate. For binary or dichotomous data, we generated the corresponding odds ratio (OR) with 95% CI. We assessed heterogeneity by the I² statistic.

MAIN RESULTS:
We include 13 RCTs involving 9615 participants with dementia in the review. Case management interventions in studies varied. We found low to moderate overall risk of bias; 69% of studies were at high risk for performance bias.The case management group were significantly less likely to be institutionalised (admissions to residential or nursing homes) at six months (OR 0.82, 95% CI 0.69 to 0.98, n = 5741, 6 RCTs, I² = 0%, P = 0.02) and at 18 months (OR 0.25, 95% CI 0.10 to 0.61, n = 363, 4 RCTs, I² = 0%, P = 0.003). However, the effects at 10 – 12 months (OR 0.95, 95% CI 0.83 to 1.08, n = 5990, 9 RCTs, I² = 48%, P = 0.39) and 24 months (OR 1.03, 95% CI 0.52 to 2.03, n = 201, 2 RCTs, I² = 0%, P = 0.94) were uncertain. There was evidence from one trial of a reduction in the number of days per month in a residential home or hospital unit in the case management group at six months (MD -5.80, 95% CI -7.93 to -3.67, n = 88, 1 RCT, P < 0.0001) and at 12 months (MD -7.70, 95% CI -9.38 to -6.02, n = 88, 1 RCT, P < 0.0001). One trial reported the length of time until participants were institutionalised at 12 months and the effects were uncertain (hazard ratio (HR): 0.66, 95% CI 0.38 to 1.14, P = 0.14). There was no difference in the number of people admitted to hospital at six (4 RCTs, 439 participants), 12 (5 RCTs, 585 participants) and 18 months (5 RCTs, 613 participants). For mortality at 4 - 6, 12, 18 - 24 and 36 months, and for participants' or carers' quality of life at 4, 6, 12 and 18 months, there were no significant effects. There was some evidence of benefits in carer burden at six months (SMD -0.07, 95% CI -0.12 to -0.01, n = 4601, 4 RCTs, I² = 26%, P = 0.03) but the effects at 12 or 18 months were uncertain. Additionally, some evidence indicated case management was more effective at reducing behaviour disturbance at 18 months (SMD -0.35, 95% CI -0.63 to -0.07, n = 206, 2 RCTs I² = 0%, P = 0.01) but effects were uncertain at four (2 RCTs), six (4 RCTs) or 12 months (5 RCTs).The case management group showed a small significant improvement in carer depression at 18 months (SMD -0.08, 95% CI -0.16 to -0.01, n = 2888, 3 RCTs, I² = 0%, P = 0.03). Conversely, the case management group showed greater improvement in carer well-being in a single study at six months (MD -2.20 CI CI -4.14 to -0.26, n = 65, 1 RCT, P = 0.03) but the effects were uncertain at 12 or 18 months. There was some evidence that case management reduced the total cost of services at 12 months (SMD -0.07, 95% CI -0.12 to -0.02, n = 5276, 2 RCTs, P = 0.01) and incurred lower dollar expenditure for the total three years (MD= -705.00, 95% CI -1170.31 to -239.69, n = 5170, 1 RCT, P = 0.003). Data on a number of outcomes consistently indicated that the intervention group received significantly more community services. AUTHORS' CONCLUSIONS: There is some evidence that case management is beneficial at improving some outcomes at certain time points, both in the person with dementia and in their carer. However, there was considerable heterogeneity between the interventions, outcomes measured and time points across the 13 included RCTs. There was some evidence from good-quality studies to suggest that admissions to care homes and overall healthcare costs are reduced in the medium term; however, the results at longer points of follow-up were uncertain. There was not enough evidence to clearly assess whether case management could delay institutionalisation in care homes. There were uncertain results in patient depression, functional abilities and cognition. Further work should be undertaken to investigate what components of case management are associated with improvement in outcomes. Increased consistency in measures of outcome would support future meta-analysis.

Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people
Sahota O, Pulikottil-Jacob R, Marshall F, et al Health Services and Delivery Research, 4, 7. 2016

Background:
Older people represent a significant proportion of patients admitted to hospital as a medical emergency. Compared with the care of younger patients, their care is more challenging, their stay in hospital is much longer, their risk of hospital-acquired problems is much higher and their 28-day readmission rate is much greater.

Objective:
To compare the clinical effectiveness, microcosts and cost-effectiveness of a Community In-reach Rehabilitation And Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service in patients aged ≥ 70 years.

Methods:
A pragmatic randomised controlled trial with an integral health economic study and parallel qualitative appraisal was undertaken in a large UK teaching hospital, with community follow-up. Participants were individually randomised to the intervention (CIRACT service) or standard care (THB-Rehab service). The primary outcome was hospital length of stay; secondary outcomes were readmission within 28 and 91 days post discharge and super spell bed-days (total time in NHS care), functional ability, comorbidity and health-related quality of life, all measured at day 91, together with the microcosts and cost-effectiveness of the two services. A qualitative appraisal provided an explanatory understanding of the organisation, delivery and experience of the CIRACT service from the perspective of key stakeholders and patients.

Results:
In total, 250 participants were randomised (n = 125 CIRACT service, n = 125 THB-Rehab service). There was no significant difference in length of stay between the CIRACT service and the THB-Rehab service (median 8 vs. 9 days). There were no significant differences between the groups in any of the secondary outcomes. The cost of delivering the CIRACT service and the THB-Rehab service, as determined from the microcost analysis, was £302 and £303 per patient respectively. The overall mean costs (including NHS and personal social service costs) of the CIRACT and THB-Rehab services calculated from the Client Service Receipt Inventory were £3744 and £3603 respectively [mean cost difference £144, 95% confidence interval –£1645 to £1934] and the mean quality-adjusted life-years for the CIRACT service were 0.846 and for the THB-Rehab service were 0.806. The incremental cost-effectiveness ratio (ICER) from a NHS and Personal Social Services perspective was £2022 per quality-adjusted life-year. Although the CIRACT service was highly regarded by those who were most involved with it, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current established community services.

Conclusions:
The CIRACT service did not reduce hospital length of stay or short-term readmission rates compared with the standard THB-Rehab service, although it was highly regarded by those who were most involved with it. The estimated ICER appears cost-effective although it is subject to much uncertainty, as shown by points spanning all four quadrants of the cost-effectiveness plane. Microcosting work-sampling methodology provides a useful method to estimate the cost of service provision. Limitations in sample size, which may have excluded a smaller reduction in length of stay, and lack of blinding, which may have introduced some cross-contamination between the two groups, must be recognised. Reducing hospital length of stay and hospital readmissions remains a priority for the NHS. Further studies are necessary, which should be powered with larger sample sizes and use cluster randomisation (to reduce bias) but, more importantly, should include a more integrated community health-care model as part of the CIRACT team.

Cost-effectiveness of a community-based physical activity programme for adults (Be Active) in the UK: an economic analysis within a natural experiment
Frew EJ, Bhatti M, Win K, et al British Journal of Sports Medicine, 48, 207-212. 2014

Abstract
OBJECTIVE:

To determine the cost-effectiveness of a physical activity programme (Be Active) aimed at city-dwelling adults living in Birmingham, UK.
METHODS:

Very little is known about the cost-effectiveness of public health programmes to improve city-wide physical activity rates. This paper presents a cost-effectiveness analysis that compares a physical activity intervention (Be Active) with no intervention (usual care) using an economic model to quantify the reduction in disease risk over a lifetime. Metabolic equivalent minutes achieved per week, quality-adjusted life years (QALYs) gained and healthcare costs were all included as the main outcome measures in the model. A cost-benefit analysis was also conducted using ‘willingness-to-pay’ as a measure of value.
RESULTS:

Under base-case assumptions-that is, assuming that the benefits of increased physical activity are sustained over 5 years, participation in the Be Active programme increased quality-adjusted life expectancy by 0.06 years, at an expected discounted cost of £3552, and thus the cost-effectiveness of Be Active is £400 per QALY. When the start-up costs of the programme are removed from the economic model, the cost-effectiveness is further improved to £16 per QALY. The societal value placed on the Be Active programme was greater than the operation cost therefore the Be Active physical activity intervention results in a net benefit to society.
CONCLUSIONS:

Participation in Be Active appeared to be cost-effective and cost-beneficial. These results support the use of Be Active as part of a public health programme to improve physical activity levels within the Birmingham-wide population.

Costs and economic consequences of a help-at-home scheme for older people in England
Bauer A, Knapp M, Wistow G Health and Social Care in the Community, 25, 780-789. 2017

Abstract
Solutions to support older people to live independently and reduce the cost of an ageing population are high on the political agenda of most developed countries. Help-at-home schemes offer a mix of community support with the aim to address a range of well-being needs. However, not much is currently known about the costs, outcomes and economic consequences of such schemes. Understanding their impact on individuals’ well-being and the economic consequences for local and central government can contribute to decisions about sustainable long-term care financing. This article presents results from a mixed-methods study of a voluntary sector-provided help-at-home scheme in England for people of 55 years and older. The study followed a participatory approach, which involved staff and volunteers. Data were collected during 2012 and 2013. Social care-related quality of life was measured with the Adult Social Care Outcomes Toolkit for 24 service users (59% response rate) when they started using the scheme and 4-6 months later. A customised questionnaire that captured resource use and well-being information was sent to 1064 service users (63% response rate). The same tool was used in assessment with service users who started using the scheme between November 2012 and April 2013 (100% response rate). Costs of the scheme were established from local budget and activity data. The scheme was likely to achieve a mean net benefit of £1568 per person from a local government and National Health Service (NHS) perspective and £3766 from the perspective of the individual. An expenditure of £2851 per person accrued to central government for the additional redistribution of benefit payments to older people. This article highlights the potential contribution of voluntary sector-run help-at-home schemes to an affordable welfare system for ageing societies.

Decision-making and Mental Capacity [NG018]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2018

This guideline covers decision-making in people 16 years and over who may lack capacity now or in the future. It aims to help health and social care practitioners support people to make their own decisions where they have the capacity to do so. It also helps practitioners to keep people who lack capacity at the centre of the decision-making process.

This guideline should be read in conjunction with the Mental Capacity Act 2005. It is not a substitute for the law or relevant Codes of Practice.

It does not cover Deprivation of Liberty Safeguards processes.

Recommendations
This guideline includes recommendations on:

supporting decision-making
advance care planning
assessing mental capacity to make specific decisions at a particular time
best interests decision-making
Who is it for?
Health and social care practitioners working with people who may (now or in the future) lack mental capacity to make specific decisions.
Independent advocates, with statutory and non-statutory roles.
Practitioners working in services (including housing, education, employment, police and criminal justice) who may come into contact with people who lack mental capacity.
People using health and social care services who may (now or in the future) lack mental capacity to make specific decisions, as well as their families, friends, carers and other interested parties.

Related NICE guideline:
Appendix C3: Economic report. DECISION-MAKING AND MENTALCAPACITY Bauer A and Knapp M

Dementia: Assessment, Management and Support for People Living with Dementia and their Carers [NG97]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2018

This guideline covers diagnosing and managing dementia (including Alzheimer’s disease). It aims to improve care by making recommendations on training staff and helping carers to support people living with dementia.

Recommendations
This guideline includes recommendations on:
• involving people living with dementia in decisions about their care
• assessment and diagnosis
• interventions to promote cognition, independence and wellbeing
• pharmacological interventions
• managing non-cognitive symptoms
• supporting carers
• staff training and education

Who is it for?
• Healthcare and social care professionals caring for and supporting people living with dementia
• Commissioners and providers of dementia health and social care services
• Housing associations, private and voluntary organisations contracted by the NHS or social services to provide care for people living with dementia
• People living with dementia, their families and carers

Related NICE guideline:
Appendix J:Health Economics Authors not listed

Economic Evaluation of Social Care Interventions: Lessons Drawn from a Systematic Review of the Methods Used to Evaluate Reablement.
Faria R, Kiss N, Aspinal FJ, et al Health Economics & Outcome Research, Cardiff. 2015

Reablement helps individuals to regain or retain the ability to live independently after an injury and/or exacerbation of an illness. Despite the lack of clear evidence on its effectiveness and cost-effectiveness, or on the optimal model for its implementation, reablement is hailed as one solution to the increased demand for long term care. This study systematically reviews, synthesises and critically appraises the economic evidence on reablement, and makes recommendations to improve future research. A total of 13 studies were included. Data were extracted on: decision, context, study design, intervention, comparators, effectiveness, outcomes, resource use and costs, analytic methods, and study findings. Reablement has been shown to be cost-effective; however the reporting on the decision the study aims to inform and the context could typically be improved and there is uncertainty on the costs and benefits of reablement in the longer term, between different models of service delivery and the impact on carers. All studies used only the data on outcomes and costs that was collected within the study and evaluated cost-effectiveness over the data collection follow-up, but this approach was not justified. These methods results should inform future research. Economic evaluations on reablement should: (i) include all available evidence on the relevant interventions and comparators over the appropriate time horizon, (ii) compare the benefits of the intervention with its opportunity costs and (iii) consider subgroup analysis to identify the groups of individuals most likely to benefit from reablement and therefore better target interventions and resources. More methodological research and guidance is needed on standardised outcome measures on general wellbeing, on informal carer’s burden and on how to trade-off the costs and benefits in different sectors. These recommendations can help improve quality and relevance for decision makers in the future and to guide future economic evaluations and methodological research.

Effectiveness and cost-effectiveness of community singing on mental health-related quality of life of older people: randomised controlled trial
Coulton S, Clift S, Skingley A, et al British Journal of Psychiatry, 207, 250-255. 2015

Abstract
BACKGROUND:
As the population ages, older people account for a greater proportion of the health and social care budget. Whereas some research has been conducted on the use of music therapy for specific clinical populations, little rigorous research has been conducted looking at the value of community singing on the mental health-related quality of life of older people.

AIMS:
To evaluate the effectiveness and cost-effectiveness of community group singing for a population of older people in England.

METHOD:
A pilot pragmatic individual randomised controlled trial comparing group singing with usual activities in those aged 60 years or more.

RESULTS:
A total of 258 participants were recruited across five centres in East Kent. At 6 months post-randomisation, significant differences were observed in terms of mental health-related quality of life measured using the SF12 (mean difference = 2.35; 95% CI = 0.06-4.76) in favour of group singing. In addition, the intervention was found to be marginally more cost-effective than usual activities. At 3 months, significant differences were observed for the mental health components of quality of life (mean difference = 4.77; 2.53-7.01), anxiety (mean difference = -1.78; -2.5 to -1.06) and depression (mean difference = -1.52; -2.13 to -0.92).

CONCLUSIONS:
Community group singing appears to have a significant effect on mental health-related quality of life, anxiety and depression, and it may be a useful intervention to maintain and enhance the mental health of older people.

Effectiveness of Day Services: Summary of Research Evidence
Age UK Age UK, London. 2011

This briefing updates the research evidence on the effectiveness of day services featured in the publication ‘Day services for older people. Quality and effectiveness: a resource for providers and commissioners’ (2008). After outlining the range of services and activities covered by the term ‘day services’, the briefing summarises the key points and outlines the methodology used for the review. The review which involved literature searches on a number of databases, journal archives, websites in July and August 2011. These searches supplement the original literature search which was carried out in December 2007. The findings and summaries of research evidence are then presented, listing each report in turn. Due to the lack of evidence focusing on day services, research is also included on activities to reduce isolation and loneliness. The few studies that specifically evaluated the impact of day services found that older people and their carers benefitted from them. The review also identified the different types of day services that can address older people’s need for social contact, exercise, to engage in and make contributions to society.

Effects of preventive home visits on older people's use and costs of health care services: a systematic review
Liimatta H, Lampela P, Laitinen-Parkkonen P, et al European Geriatric Medicine, 7, 571-580. 2016

Abstract
Introduction
The aim of this study was to systematically review the evidence from randomized controlled trials (RCT) concerning effectiveness of preventive home visit (PHV) programs on older people’s use and costs of health and social services. We also evaluated resultant costs-changes achieved with intervention in older people’s functioning, quality-of-life (QOL) or mortality.

Materials and methods
A systematic review of published RCTs reporting use and/or costs on PHVs on multimorbid older people was performed. The characteristics and methodological quality of studies were assessed.

Results
Of the 3219 articles screened, 19 met the inclusion criteria. The methodological quality of the trials was principally moderate (n = 5) or good (n = 10). Of the studies, 12 evaluated the overall costs of health and social services. None of these studies was able to show significant differences in total costs between intervention and control groups. Six studies suggested that PHVs may decrease nursing home admissions and/or hospital days. Seven studies showed some favorable effect on physical functioning, QOL, or mortality, without increasing the total health care costs.

Conclusions
Of the high number of studies investigating efficacy of PHVs on older people, only a few studies explore economic effects. PHVs do not provide overall savings to health care costs, but some interventions might offer some cost-neutral positive effects on functioning, QOL and/or mortality. More studies are needed to clarify the effective aspects of the programs and cost-effectiveness of the PHVs.

Effects of remote feedback in home-based physical activity interventions for older adults: a systematic review
Geraedts H, Zijlstra A, Bulstra SK, et al Patient Education and Counselling, 91, 14-24. 2013

Abstract
OBJECTIVE:

To evaluate the literature on effectiveness of remote feedback on physical activity and capacity in home-based physical activity interventions for older adults with or without medical conditions. In addition, the effect of remote feedback on adherence was inventoried.
METHODS:

A systematic review. Data sources included PubMed, PsycInfo, Cochrane and EMBASE. A best-evidence synthesis was used for qualitative summarizing of results.
RESULTS:

Twenty-four studies met the inclusion criteria for systematic effectiveness evaluation and 22 for adherence inventory. Three categories of contact were identified: frequent, non-frequent, and direct remote contact during exercising. Evidence for positive enhancement of physical activity or capacity varied from conflicting in frequent contact strategies (16 studies) to strong in non-frequent (5 studies) and direct contact strategies (3 studies). Adherence rates in intervention groups were similar or higher than treatment-as-usual or exercise control groups.
CONCLUSION:

Results imply with varying strength that interventions using frequent, non-frequent or direct remote feedback seem more effective than treatment as usual and equally effective as supervised exercise interventions. Direct remote contact seems a particularly good alternative to supervised onsite exercising.
PRACTICE IMPLICATIONS:

Remote feedback is promising in an older population getting increasingly used to new technology.

Effects of remote feedback in home-based physical activity interventions for older adults: a systematic review
Geraedts H, Zijlstra A, Bulstra SK, et al Patient Education and Counselling, 91, 14-24. 2013

Abstract
OBJECTIVE:
To evaluate the literature on effectiveness of remote feedback on physical activity and capacity in home-based physical activity interventions for older adults with or without medical conditions. In addition, the effect of remote feedback on adherence was inventoried.

METHODS:
A systematic review. Data sources included PubMed, PsycInfo, Cochrane and EMBASE. A best-evidence synthesis was used for qualitative summarizing of results.

RESULTS:
Twenty-four studies met the inclusion criteria for systematic effectiveness evaluation and 22 for adherence inventory. Three categories of contact were identified: frequent, non-frequent, and direct remote contact during exercising. Evidence for positive enhancement of physical activity or capacity varied from conflicting in frequent contact strategies (16 studies) to strong in non-frequent (5 studies) and direct contact strategies (3 studies). Adherence rates in intervention groups were similar or higher than treatment-as-usual or exercise control groups.

CONCLUSION:
Results imply with varying strength that interventions using frequent, non-frequent or direct remote feedback seem more effective than treatment as usual and equally effective as supervised exercise interventions. Direct remote contact seems a particularly good alternative to supervised onsite exercising.

PRACTICE IMPLICATIONS:
Remote feedback is promising in an older population getting increasingly used to new technology.

Evaluation of Extra Care Housing in Wales
Batty E, Foden M, Green S Welsh Government, Cardiff. 2017

This report presents a comprehensive, independent assessment of the current role of extra care.

The findings aim to help inform discussion about the role that extra care should play in delivering the strategic vision on housing for older people in Wales.

The evaluation included a literature review and the collection and analysis of primary and secondary quantitative data.

Case studies were undertaken in six local authority areas, in each area up to 10 key stakeholders were interviewed and in total over 80 extra care residents were engaged in the research.

Evaluation of Redcar and Cleveland Community Agents Project: Outputs and Outcomes Summary Report
Watson P and Shucksmith J Social Care Institute for Excellence, London. 2015

The Community Agents Project, a programme jointly funded through health and adult social care services, is an innovative approach to meeting the social needs of the elderly and vulnerable population. Community agents act as a one-stop shop, signposting people to the appropriate service that meets their needs. This could be an organisation or voluntary group that can help with shopping, arrange transport to the GP surgery or hospital appointments, help to complete forms, offer encouragement to maintain a care plan, organise a befriender, accompany to a local social activity or signposting to other agencies. The project has received a total of 486 referrals across the borough of Redcar & Cleveland for the period September 2014-September 2015, generating positive outcomes in the following areas: maintaining independence; faster discharge from hospital; reducing admissions to hospital; reducing isolation; improved financial status; appropriate use of health and social services; cost saving; and increases in community capacity. The report estimates a social return on investment of £3.29 for every £1 invested in the Community Agents Project

Evaluation of the Cambridgeshire Timebanks
Gemma B Cambridge Centre for Housing and Planning Research, Cambridge. 2014

The research suggested that the timebanks were developing successfully, with increasing numbers of members and exchanges. There was evidence of a range of benefits to the members who are involved and evidence of positive outcomes, including reduced social isolation.
This research evaluated the development of a timebanking project in Cambridgeshire for Cambridgeshire County Council and the CHS Group. Timebanking is a community scheme which enables local people to exchange skills and support in a structured way around the swapping of units of their time. It can help to build social capital in local communities, but may also have the potential to generate cost savings.

Exercise for depression in care home residents: a randomised controlled trial with cost-effectiveness analysis (OPERA)
Underwood M, Lamb SE, Eldridge S, et al Health Technology Assessment, 17, 1-281. 2013

Headline

Study finds no evidence to support the use of a whole-home physical activity and moderate-intensity exercise programme to reduce depression in elderly care home residents.
Abstract
Background:

Many older people living in care homes (long term residential care or nursing homes) are depressed. Exercise is a promising non-drug intervention for preventing and treating depression in this population.
Objective:

To evaluate the impact of a ‘whole-home’ intervention, consisting of training for residential and nursing home staff backed up with a twice-weekly, physiotherapist-led exercise class on depressive symptoms in care home residents.
Design:

A cluster randomised controlled trial with a cost-effectiveness analysis to compare (1) the prevalence of depression in intervention homes with that in control homes in all residents contributing data 12 months after homes were randomised (cross-sectional analysis); (2) the number of depressive symptoms at 6 months between intervention and control homes in residents who were depressed at pre-randomisation baseline assessment (depressed cohort comparison); and (3) the number of depressive symptoms at 12 months between intervention and control homes in all residents who were present at pre-randomisation baseline assessment (cohort comparison).
Setting:

Seventy-eight care homes in Coventry and Warwickshire and north-east London.
Participants:

Care home residents aged ≥ 65 years.
Interventions:

Control intervention: Depression awareness training programme for care home staff. Active intervention: A ‘whole-home’ exercise intervention, consisting of training for care home staff backed up with a twice-weekly, physiotherapist-led exercise group.
Main outcome measures:

Geriatric Depression Scale-15, proxy European Quality of Life-5 Dimensions (EQ-5D), cost-effectiveness from an National Health Service perspective, peripheral fractures and death.
Results:

We recruited a total of 1054 participants. Cross-sectional analysis: We obtained 595 Geriatric Depression Scale-15 scores and 724 proxy EQ-5D scores. For the cohort analyses we obtained 765 baseline Geriatric Depression Scale-15 scores and 776 proxy EQ-5D scores. Of the 781 who we assessed prior to randomisation, 765 provided a Geriatric Depression Scale-15 score. Of these 374 (49%) were depressed and constitute our depressed cohort. Resource-use and quality-adjusted life-year data, based on proxy EQ-5D, were available for 798 residents recruited prior to randomisation. We delivered 3191 group exercise sessions with 31,705 person attendances and an average group size of 10 (5.3 study participants and 4.6 non-study participants). On average, our participants attended around half of the possible sessions. No serious adverse events occurred during the group exercise sessions. In the cross-sectional analysis the odds for being depressed were 0.76 [95% confidence interval (CI) 0.53 to 1.09] lower in the intervention group at 12 months. The point estimates for benefit for both the cohort analysis (0.13, 95% CI −0.33 to 0.60) and depressed cohort (0.22, 95% CI −0.52 to 0.95) favoured the control intervention. There was no evidence of differences in fracture rates or mortality (odds ratio 1.07, 95% CI 0.79 to 1.48) between the two groups. There was no evidence of differences in the other outcomes between the two groups. Economic analysis: The additional National Health Service cost of the OPERA intervention was £374 per participant (95% CI −£655 to £1404); the mean difference in quality-adjusted life-year was −0.0014 (95% CI −0.0728 to 0.0699). The active intervention was thus dominated by the control intervention, which was more effective and less costly.
Conclusion:

The results do not support the use of a whole-home physical activity and moderate-intensity exercise programme to reduce depression in care home residents.
Trial registration:

Current Controlled Trials ISRCTN43769277.
Funding:

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 18. See the Health Technology Assessment programme website for further project information.

Extending the Housing Options for Older People: Focus on Extra Care
Petch A Institute for Research and Innovation in Social Services, Glasgow. 2014

This Insight summarises the evidence on policy and practice issues for housing with care and support for older people, focusing on extra care provision, and the extent to which different models provide an effective alternative to residential and nursing care. The review begins by providing a short overview to the policy context in Scotland. It then looks at the evidence in the following areas: location, support arrangements, quality of life, provision for dementia, building design, end of life and cost. The Insight covers ‘extra care’ that offers self-contained accommodation units, support accessible 24 hours, some collective meal provision and a range of leisure and other facilities on site.

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

Home Care Re-ablement Services: Investigating the Longer-term Impacts (Prospective Longitudinal Study)
Glendinning C, Baxter K, Rabiee P Social Policy Research Unit, York. 2010

Abstract
Re-ablement is a new, short-term intervention in English home care. It helps users to regain confidence and relearn self-care skills and aims to reduce needs for longer-term support.

Research by the Social Policy Research Unit, University of York and the Personal Social Services Research Unit, University of Kent examined the immediate and longer-term impacts of home care re-ablement, the cost-effectiveness of the service, and the content and organisation of re-ablement services. People who received home care re-ablement were compared with a group receiving conventional home care services, both groups were followed for up to one year.

The study found that:
* Re-ablement was associated with a significant decrease in subsequent costs of social care service use
* Re-ablement had positive impacts on users’ health-related quality of life and social care-related quality of life, in comparison with users of conventional home care services
* Using the National Institute for Health and Clinical Excellence cost-effectiveness threshold, re-ablement was cost effective in terms of health and social care costs
* The reduction in social care costs was almost entirely offset by the initial cost of the re-ablement intervention. The average cost of a re-ablement episode was 2,088 pounds with a mean cost of 40 pounds per hour of service user contact time.

Recommendations for the future organisation of these services are made in the report. In autumn 2010, 70 million pounds was allocated to NHS Primary Care Trusts to develop re-ablement services, this will be followed by an additional 150 million pounds in 2011/12, rising to 300 pounds million per annum from 2012 to 2015.

Research areas
ill/disabled adults, social care services issues, older people

Home Care: Delivering Personal Care and Practical Support to Older People Living in their Own Homes [NG21]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers the planning and delivery of person-centred care for older people living in their own homes (known as home care or domiciliary care). It aims to promote older people’s independence and to ensure safe and consistently high quality home care services.

The Care Quality Commission uses NICE guidelines as evidence to inform the inspection process.

Recommendations
The guideline includes recommendations on:

ensuring care is person centred
providing information about care and support options
planning and reviewing home care and support
delivering home care, including recommendations on the length home care visits
joint working between health and social care
ensuring safety and safeguarding people using home care services
recruiting, training and supporting home care workers
Who is it for?
Health and social care practitioners
Home care provider organisations
Home care managers and workers
Older people using or planning to use home care services, and their carers
Commissioners of home care services should ensure any service specifications take into account the recommendations in this guideline.

Related NICE guideline:
APPENDIX C3 – Economics Report Bauer A, King D, Knapp M

Impact and economic assessment of assistive technology in care homes in Norfolk, UK
Al-Oraibi S, Fordham Ric, Lambert R Journal of Assistive Technologies, 6, 192-201. 2012

This study looked at whether new assistive technology (AT) systems in care homes for elderly residents, reduced the number of falls and demands for formal health services. The project collected retrospective data about the incidence of falls before and after AT systems were installed in two care homes in Norfolk, UK. These homes were selected purposefully because a recent assessment identified the need for upgrading their call system. They had different resident profiles regarding the prevalence of dementia. Standard incident report forms were examined for a period starting ten months before the upgrades to ten months after in Care Home 1 and from six months before to six months afterwards in Care Home 2. Overall there were 314 falls reported during the course of the study; the number reduced from 202 to 112 after the introduction of AT. The mean health care costs associated with falls in Care Home 1 were significantly reduced (more than 50%). In Care Home 2 there was no significant difference in the mean cost. The results suggest that installing an AT system in residential care homes can reduce the number of falls and health care cost in homes with a lower proportion of residents with advanced dementia compared to those with more residents with advanced dementia

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.

Improving Housing with Care Choices for Older People: An Evaluation of Extra Care Housing
Netten A, Darton R, Bäumker T, et al Personal Social Services Research Unit and Housing Learning and Improvement Network, London. 2011

This report summarises the results of a
Department of Health (DH) funded evaluation
of 19 extra care housing schemes that opened
between April 2006 and November 2008, and
which received capital funding from the
Department‘s Extra Care Housing Fund. Key
findings on delivering outcomes, costs and costeffectiveness, and improving choice were that:
Delivering person-centred outcomes
• Outcomes were generally very positive, with
most people reporting a good quality of life.
• A year after moving in most residents enjoyed
a good social life, valued the social activities
and events on offer, and had made new friends.
• People had a range of functional abilities
on moving in and were generally less
dependent than people moving into
residential care, particularly with respect
to cognitive impairment.
• One-quarter of residents had died by the
end of the study, and about a third of
those who died were able to end their lives
in the scheme.
• Of those who were still alive at the end of
the study, over 90 per cent remained in
the scheme.
• For most of those followed-up, physical
functional ability appeared to improve or
remain stable over the first 18 months
compared with when they moved in.
Although more residents had a lower level
of functioning at 30 months, more than a
half had still either improved or remained
stable by 30 months. • Cognitive functioning remained stable for the
majority of those followed-up, but at 30
months a larger proportion had improved
than had deteriorated.
Costs and cost-effectiveness
• Accommodation, housing management and
living expenses accounted for approximately
60 per cent of total cost. The costs of social
care and health care showed most variability
across schemes, partly because most detail
was collected about these elements.
• Comparisons with a study of remodelling
appear to support the conclusion that new
building is not inherently more expensive than
remodelling, when like is compared with like.
• Higher costs were associated with higher
levels of physical and cognitive impairment
and with higher levels of well-being.
• Combined care and housing management
arrangements were associated with lower costs.
• When matched with a group of equivalent
people moving into residential care, costs
were the same or lower in extra care housing.
• Better outcomes and similar or lower costs
indicate that extra care housing appears to
be a cost-effective alternative for people with
the same characteristics who currently move
into residential care.
Improving choice
• People had generally made a positive choice
to move into extra care housing, with high
expectations focused on improved social
life, in particular. • Alternative forms of housing such as extra
care housing are seen as providing a means of
encouraging downsizing, but although larger
villages appeal to a wider range of residents,
different expectations among residents can
create tensions and misunderstandings
about the nature of the accommodation and
services being offered.
• While the results support the use of extra care
housing as an alternative to residential care
homes for some individuals, levels of supply
are relatively low.
• Funding of extra care housing is complex and,
particularly in the current financial climate, it is important that incentives that deliver a
cost-effective return on investment in local
care economies are in place if this is to be a
viable option for older people in the future.
• More capital investment and further
development of marketing strategies are
needed if extra care housing is to be made
more available and more appealing to
more able residents. Without continuing
to attract a wide range of residents,
including those with few or no care and
support needs as well as those with higher
levels of need, extra care housing may
become more like residential care and lose
its distinctiveness.

Intermediate Care Including Reablement [NG74]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2017

This guideline covers referral and assessment for intermediate care and how to deliver the service. Intermediate care is a multidisciplinary service that helps people to be as independent as possible. It provides support and rehabilitation to people at risk of hospital admission or who have been in hospital. It aims to ensure people transfer from hospital to the community in a timely way and to prevent unnecessary admissions to hospitals and residential care.
Recommendations

This guideline includes recommendations on:

core principles of intermediate care, including reablement
supporting infrastructure
assessment of need for intermediate care
referral into intermediate care and entering the service
delivering intermediate care
transition from intermediate care
training and development

Who is it for?

Health and social care practitioners who deliver intermediate care and reablement in the community and in bed-based settings
Other practitioners who work in voluntary and community services, including home care, general practice and housing
Health and social care practitioners in acute inpatient settings
Commissioners and providers
Adults using intermediate care and reablement services, and their families and carers

Related NICE guideline:
Appendix C3: Economic report Intermediate care Bauer A and Fernandez JL

Investing to Save: Assessing the Cost-effectiveness of Telecare. Summary Report
Clifford P, et al Face Recording and Measurement Systems, Nottingham. 2012

This summary report describes the findings of a project evaluating the potential cost savings arising from the use of telecare. Another aim was to develop a methodology that will support routine evaluation and comparison of the cost-effectiveness of local telecare implementations. Evaluation was made of the suitability of telecare for 50 clients for whom Overview Assessments had been completed by FACE Recording & Measuring Systems Ltd. Where telecare appeared suitable, the social care costs of meeting the client’s needs before and after provision of telecare were estimated. Estimates were also made of the total savings achievable by the deployment of telecare. Out of the 50 cases, 33 were identified as potentially benefitting from telecare. The average weekly cost of telecare was £6.25, compared to £167 for the average weekly care package for the sample pre-telecare. The results confirmed previous studies showing that very substantial savings are achievable through the widespread targeted use of telecare. Potential savings lie in the range of £3m to £7.8m for a typical council, or 7.4-19.4% of total older people’s social care budget.

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.

LinkAge Bristol
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2012

An independent evaluation of LinkAge by the University of the West of England concluded that: LinkAge meets the agendas established by the Marmot Review–Fair Society Healthy Lives. Its outreach work draws people in that may feel isolated in their community. Through activities LinkAge helps people feel more socially connected, improves wellbeing and happiness (on the ONS Happiness Index) and increases physical activity.

In 2012 a Social Return on Investment Calculation was completed on the Whitehall and St. George LinkAge hub and found that for every £1 invested there was a SROI of at least £1.20. LinkAge believes this represents a substantial underestimate as, since 2012, the organisation has increased its public profile, expanded its referral network and is now drawing in more lonely
and isolated individuals – supporting them with befriending and through the ACE project.

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.

Making the Case for Investing in Actions to Prevent and/or Tackle Loneliness: A Systematic Review. A Briefing Paper
McDaid D, Bauer A, Park A Personal Social Services Research Unit, London. 2017

Summarises findings from a systematic review on the available economic evidence on the cost effectiveness of loneliness interventions for older people. The review found mixed evidence for the cost effectiveness of befriending interventions and the benefits of participation in social activities, ranging from cost saving to cost ineffective interventions. Recent evidence identified suggests that signposting and navigation services have the potential to be cost effective, with a saving of up to £3 of health costs for every £1 invested. The paper also makes suggestions for strengthening the evidence based on the cost effectiveness of interventions to address loneliness.

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

Older People with Social Care Needs and Multiple Long-term Conditions [NG22]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers planning and delivering social care and support for older people who have multiple long-term conditions. It promotes an integrated and person-centred approach to delivering effective health and social care services.

Recommendations
The guideline includes recommendations on:

identifying and assessing social care needs
care planning, including the role of the named care coordinator
supporting carers
integrating health and social care planning
delivering care
preventing social isolation
training health and social care practitioners

Who is it for?
Health and social care practitioners
Providers of care and support in health and social care services
Older people with social care needs and multiple long-term conditions (including both physical and mental health conditions), and their carers.
Commissioners should ensure any service specifications take into account the recommendations in this guideline.

Related NICE guideline:
Appendix C3: Cost-consequence and cost-utility analysis of an outpatient geriatric multidisciplinary assessment and case management intervention: the ‘GRACE’ model of care Trachtenberg M and Fernandez JL

Older People: Independence and Mental Wellbeing [NG32]
The National Institute for Health and Care Excellence (NICE) National Institute for Health and Care Excellence, London. 2015

This guideline covers interventions to maintain and improve the mental wellbeing and independence of people aged 65 or older and how to identify those most at risk of a decline.

Recommendations
The guideline includes recommendations on:

principles of good practice
group-based activities
one-to-one activities
volunteering
identifying people most at risk of a decline
Who is it for?
Local authorities working in partnership with organisations in the public, private, voluntary and community sectors that come into contact with older people
The NHS and other service providers with a remit for older people
It may also be of interest to older people, their families and carers
Commissioners of services for older people should ensure any service specifications take into account the recommendations in this guideline.

Related NICE guideline:
Independence and mental wellbeing (including social and emotional wellbeing) for older people Economic analysis Mallender J, Pritchard C, Tierney R, et al

Preventing Loneliness and Social Isolation: Interventions and Outcomes. SCIE Research Briefing 39
Windle K, Francis J, Coomber C Social Care Institute for Excellence, London. 2011

This is one in a series of research briefings about preventive care and support for adults.

Prevention is broadly defined to include a wide range of services that:

promote independence
prevent or delay the deterioration of wellbeing resulting from ageing, illness or disability
delay the need for more costly and intensive services.

Preventive services represent a continuum of support ranging from the most intensive, ‘tertiary services’ such as intermediate care or reablement, down to ‘secondary’ or early intervention, and finally, ‘primary prevention’ aimed at promoting wellbeing. Primary prevention is generally designed for people with few social care needs or symptoms of illness. The focus therefore is on maintaining independence and good health and promoting wellbeing. The range of these ‘wellbeing’ interventions includes activities to reduce social isolation, practical help with tasks like shopping or gardening, universal healthy living advice, intergenerational activities and transport, and other ways of helping people get out and about.

Just as the range of wellbeing services is extensive, so too is the available literature examining how well they work. For this research briefing, the focus has been narrowed to the effectiveness and cost-effectiveness of services aimed at preventing social isolation and loneliness. Our review question was: ‘To what extent does investment in services that prevent social isolation improve people’s wellbeing and reduce the need for ongoing care and support?’

While ‘social isolation’ and ‘loneliness’ are often used interchangeably, one paper examined the distinct meanings that people attach to each concept. ‘Loneliness’ was reported as being a subjective, negative feeling associated with loss (e.g. loss of a partner or children relocating), while ‘social isolation’ was described as imposed isolation from normal social networks caused by loss of mobility or deteriorating health. This briefing focuses on services aimed at reducing the effects of both loneliness and social isolation. Although the terms might have slightly different meanings, the experience of both is generally negative and the resulting impacts are undesirable at the individual, community and societal levels.
Key messages

Older people are particularly vulnerable to social isolation or loneliness owing to loss of friends and family, mobility or income.
Social isolation and loneliness impact upon individuals’ quality of life and wellbeing, adversely affecting health and increasing their use of health and social care services.
The interventions to tackle social isolation or loneliness include: befriending, mentoring, Community Navigators, social group schemes.
People who use befriending or Community Navigator services reported that they were less lonely and socially isolated following the intervention.
The outcomes from mentoring services are less clear; one study reported improvements in mental and physical health, another that no difference was found.
Where longitudinal studies recorded survival rates, older people who were part of a social group intervention had a greater chance of survival than those who had not received such a service.
Users report high satisfaction with services, benefiting from such interventions by increasing their social interaction and community involvement, taking up or going back to hobbies and participating in wider community activities.
Users argued for flexibility and adaptation of services. One-to-one services could be more flexible, while enjoyment of group activities would be greater if these could be tailored to users’ preferences.
When planning services to reduce social isolation or loneliness, strong partnership arrangements need to be in place between organisations to ensure developed services can be sustained.
We need to invest in proven projects. Community Navigator interventions have been shown to be effective in identifying those individuals who are socially isolated. Befriending services can be effective in reducing depression and cost-effective.
Research needs to be carried out on interventions that include different genders, populations and localities.
There is an urgent need for more longitudinal, randomised controlled trials that incorporate standardised quality-of-life and cost measures.

Reablement, reactivation, rehabilitation and restorative interventions with older adults in receipt of home care: a systematic review
Sims-Gould J, Tong CE, Wallis-Meyer L, et al Journal of the American Medical Directors Association, 18, 653-663. 2017

Abstract
OBJECTIVE:
To systematically review the impact of reablement, reactivation, rehabilitation, and restorative (4R) programs for older adults in receipt of home care services.

DESIGN:
Systematic review.

DATA SOURCES:
We searched the following electronic bibliographic databases: MEDLINE, EMBASE, PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health), SPORTDiscus and The Cochrane Library and reference lists.

STUDY SELECTION:
Randomized controlled trials that describe original data on the impact of home-based rehabilitative care and were written in English.

DATA EXTRACTION AND SYNTHESIS:
Fifteen studies were identified. Study details were recorded using a predefined data abstraction form. Methodological quality was assessed by 2 independent reviewers. If there were discrepancies, a third author resolved these.

MAIN OUTCOMES AND MEASURES:
Given the tailored and personalized approach of the 4R interventions, a range of primary outcomes were assessed, including functional abilities, strength, gait speed, social support, loneliness, and the execution of activities of daily living (ADL) and instrumental ADL (IADL). 4R interventions are intended to reduce the long-term use of home care services. As such, health care resource utilization will be assessed as a secondary outcome.

RESULTS:
There are 2 distinct clusters of interventions located in this systematic review (defined by hospitalizations): (1) “hospital to home” programs, in which participants are discharged from hospital wards with a 4R home care, and (2) those that focus on clients receiving home care without a hospital stay immediately preceding. Reflecting the highly tailored and personalized nature of 4R interventions, the studies included in this review assessed a wide range of outcomes, including survival, place of residence, health care service usage, functional abilities, strength, walking impairments, balance, falls efficacy and rates of falls, pain, quality of life, loneliness, mental state, and depression. The most commonly reported and statistically significant outcomes were those pertaining to the service usage and functional abilities of participants.

CONCLUSIONS:
From cost savings to improvements in clinical outcomes, 4R interventions show some promise in the home care context. However, there are several key issues across studies, including questions surrounding the generalizability of the results, in particular with respect to the ineligibility criteria for most interventions; the lack of information provided on the interventions; and lack of information on staff training.

Research briefing 36: Reablement: a cost-effective route to better outcomes
Francis J, Fisher M, Rutter D Research Briefing, Social Care Institute for Excellence Research, London. 2011

This is one in a series of research briefings about preventive care and support for adults. Prevention is broadly defined to include a wide range of services that:

promote independence
prevent or delay the deterioration of wellbeing resulting from ageing, illness or disability
delay the need for more costly and intensive services.

Preventive services represent a continuum of support ranging from ‘primary prevention’ aimed at promoting wellbeing, through to ‘secondary’ or early intervention, and on to ‘tertiary services’ such as intermediate care provided by health and social care professionals. Tertiary services are aimed at minimising disability or deterioration from established health conditions or complex social care needs.1 The emphasis is on maximising people’s functioning and independence through approaches such as rehabilitation, intermediate care and reablement. This research briefing focuses on reablement.

Reducing Delayed Transfer of Care through Housing Interventions: Evidence of Impact. Case Study
Adams S Care and Repair England, London. 2016

A case study and independent evaluation of a housing intervention designed to help older patients to return home from hospital more rapidly and safety. The initiative is delivered by West of England Care & Repair (WE C&R), who organise clutter clearance/deep cleaning; urgent home repairs, emergency heating repairs and essential housing adaptations for older people in hospital. The evaluation examined all case records, interviewed 15 hospital staff and undertook an in depth analysis of a sample of 4 cases. Analysis of the case records estimated a saving in hospital bed days of £13,526. The cost of housing interventions was £948, resulting in a cost benefit ratio of 14:1. Additional savings in hospital staff time amounted to a further £897. A short case study illustrates how the service was able to help one woman return home from hospital. It concludes that the small scale evaluation is indicative of the potential savings that a practical and effective home from hospital housing intervention service can generate for the health service

Review of the international evidence on support for unpaid carers
Brimblecombe N, Fernandez JL, Knapp M, et al Journal of Long-Term Care, September, 25-40. 2018

Abstract Globally and locally, ongoing demographic, socio-cultural and economic changes have implications for unpaid carers. For those who provide unpaid care, particularly at higher intensities, there is substantial evidence of negative effects on employment, health and wellbeing, with associated individual and soci-etal costs. For these reasons, there is increasing policy emphasis on supporting unpaid care in the UK, mirrored, and in some cases exceeded, internationally. This paper aims to provide an overview of the interna-tional evidence on effective support for unpaid carers. This evidence synthesis finds an extensive literature on a wide range of potentially effective interventions to support unpaid carers under the broad categories of indirect support (services for the care-recipient), direct support (such as psychological therapies), work condi-tions, and combinations of these. However, there are significant gaps in the evidence base with regards to interventions, outcomes and types of caring situation studied, with a dearth of evidence on cost-effectiveness and few evaluations of key recent policy initiatives. Evidence is strongest and most consistent for formal care services for people with care needs (so-called ‘replacement’ or ‘substitution’ care); flexible working conditions; psychological therapy, training and educa-tion interventions; and support groups. In many cases it may be that a combination of interventions is most effective. These findings have implications for social care policy and practice which aims to support carers, particularly in the context of the changing landscape of global macro-level processes and recent policy, legislative and funding changes for local authority and voluntary sector providers of support and services for carers in the UK.Keywords: unpaid care, support for unpaid carers, social care services, work conditions, cash benefits, review.

Room to Improve: The Role of Home Adaptations in Improving Later Life
Centre for Ageing Better Centre for Ageing Better, London. 2017

This report summarises the findings from an evidence review on how home adaptations can improve later lives and provides recommendations to improve access to, and delivery of, home adaptation and repair services. It shows that both minor and major home adaptations are an effective intervention to improve outcomes for people in later life, including improved performance of everyday activities, improved mental health and preventing falls and injuries. It also identifies good evidence that greatest outcomes are achieved when individuals and families are involved in the decision-making process, and when adaptations focus on individual goals. Based on the findings, the report makes recommendations for commissioners and service provides. These include for Local Sustainability and Transformation partnerships to put in place preventative strategies to support people at risk in their home environment; for local authorities to make use of the Disabled Facilities Grant to fund both major and minor adaptations; and for local authorities to ensure people have access to information and advice on how home adaptations could benefit them, in line with the Care Act 2014.

Rotherham Social Prescribing Scheme
Social Care Institute for Excellence Social Care Institute for Excellence, London. 2017

An evaluation conducted by the Centre for Regional Economic and Social Research (CRESR) at Sheffield Hallam University of the pilot phase of the service found that the service had positive social and economic impacts. The service uses a specially developed health and wellbeing tool to measure social outcomes for people referred to the service. Its 8 measures cover different aspects of self-management and wellbeing, such as lifestyle and managing symptoms, to work and volunteering, to friends and family, and people are asked to use a 5 point scale to rate their progress. 17 qualitative interviews were also held with participants and their carers, who were referred to 5 of the 31 service providers.

During the pilot phase of the project, of the 280 participants who had their wellbeing measures followed up after 3-4 months, 83 per cent of people experienced positive change in at least one social outcome area. The biggest changes were seen for patients who scored the least at baseline (work, volunteering etc., and feeling positive); and a majority of low scoring participants (two points or less at baseline) made progress- among them 54% improved their score in work & volunteering area, while 61% improved their score in the feeling positive area. Among the case studies (those interviewed), the positive outcomes described using four broad themes of increased well-being, reduced social isolation and loneliness, increased independence, and access to wider welfare benefits.

There were also significant benefits to the NHS, with inpatient admissions reduced by 21 per cent; Accident and Emergency attendances reduced by as much as 20 per cent; and outpatient appointments reduced by as much as 21 per cent, These increases were calculated looking at patient-level Hospital Episode Statistics provided by the Commissioning Support Unit (CSU), of a cohort of 108 participants who had 12-months of post-referral data available, after being referred between September and December 2012.

Small But Significant: The Impact and Cost Benefits of Handyperson Services
Adams S Care and Repair England, London. 2018

An evaluation of the impacts and cost benefits of handyperson services carrying out small repairs and minor adaptations in the home for older people. It looks at how handyperson service fit into the current policy landscape summarises current evidence on their impact and cost effectiveness. It then provides an in depth evaluation of the of Preston Care and Repair handyperson service, with analysis of outputs, outcomes and examines the cost benefits in relation to falls prevention. The evaluation involved data analysis of jobs completed, a survey of users of the service and interviews with staff and service users. It reports that during the 9 month evaluation period 1,399 jobs were carried out in the homes of 697 older people, which exceeded outcome targets. Of people using the service, 46 percent were over 80 years and 72 percent were older people living alone. Older people also valued the service. Ninety-six percent of those surveyed said that the Preston Care and Repair handyperson service made them less worried about their home and 100 percent said that they would recommend the service to others. Analysis of the falls prevention impact on a small number of higher risk cases, found that for every £1 spent on the handyperson service the saving to health and care was £4.28. Other health and social care related outcomes included a risk reduction for hospital admission risk reduction and faster discharge to home, improved wellbeing, safer independent living, and reduced isolation. The report illustrates the impacts of handyperson services cover health, housing and social care aims and objectives. They also offer a cost effective solution with significant cost benefits and a high rate of return on investment, both financial and social

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.

Social Value of Local Area Coordination. Learning Outcomes from Thurrock Council and Derby City Council SROI Analyses
Kingfishers (Project Management) Ltd Kingfishers (Project Management) Ltd, Manchester. 2016

The aim of Local Area Coordination is to support residents in the local community to ‘get a life, not a service’, empowering individuals to find community based solutions instead of relying on traditional services.Thurrock Council and Derby City Council both implemented Local Area Coordination as part of a driver for wider change to deliver community based person focussed services. The service has proved successful in both of the unitary authorities and has since expanded to nine wards in Thurrock and ten wards in Derby over the past few years.A forecast Social Return on Investment Analysis was commissioned by each Council independently to better understand and start to quantify the impact of the service together with demonstrating how Local Area Coordination is effecting real change in the community. The analyses completed for Thurrock and Derby demonstrate that Local Area Coordination is delivering significant benefit to the local community and other stakeholders with up to £4 forecast for every £1 invested. Furthermore, the service has the potential to influence wider cultural change and a shift to community based services longer term; decreasing the reliance on traditional services.Although the specific calculations are not directly comparable due to the differing quantities, recording methods and assumptions made in each, the overall recommendations and approaches of each Council to delivering Local Area Coordination – both at a strategic and operational level – can inform learning to further enhance the service in both authorities. This report summarises the two analyses and recommendations from both to share best practice and optimise the social value delivered in Thurrock and Derby, ultimately to the benefit of the individuals receiving the service.The key outcomes are comparable between Thurrock and Derby demonstrating how Local Area Coordination across two differing authorities is having a similar impact. This highlights how the principles of Local Area Coordination can effectively be applied across areas. The understanding and upholding of the principles driven by strong leadership is critical to enabling this and is being achieved in both Thurrock and Derby.

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.

The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency
Sahota O, Pulikottil-Jacob R, Marshall F, et al Age and Ageing, 46, 26-32. 2017

Objective: to compare the clinical and cost-effectiveness of a Community In-reach Rehabilitation and Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service. Design: pragmatic randomised controlled trial with an integral health economic study. Settings: large UK teaching hospital, with community follow-up. Subjects: frail older people aged 70 years and older admitted to hospital as an acute medical emergency. Measurements: Primary outcome: hospital length of stay; secondary outcomes: readmission, day 91-super spell bed days, functional ability, co-morbidity and health-related quality of life; cost-effectiveness analysis. Results: a total of 250 participants were randomised. There was no significant difference in length of stay between the CIRACT and THB-Rehab service (median 8 versus 9 days; geometric mean 7.8 versus 8.7 days, mean ratio 0.90, 95% confidence interval (CI) 0.74–1.10). Of the participants who were discharged from hospital, 17% and 13% were readmitted within 28 days from the CIRACT and THB-Rehab services, respectively (risk difference 3.8%, 95% CI −5.8% to 13.4%). There were no other significant differences in any of the other secondary outcomes between the two groups. The mean costs (including NHS and personal social service) of the CIRACT and THB-Rehab service were £3,744 and £3,603, respectively (mean cost difference £144; 95% CI −1,645 to 1,934). Conclusion: the CIRACT service does not reduce major hospital length of stay nor reduce short-term readmission rates, compared to the standard THB-Rehab service; however, a modest (<2.3 days) effect cannot be excluded. Further studies are necessary powered with larger sample sizes and cluster randomisation.

The Cost-benefit to the NHS Arising from Preventative Housing Interventions
Garrett H, Roys M, Burris S, et al IHS BRE Press, Bracknell. 2016

BRE (Building Research Establishment) is an independent, research-based consultancy, testing and training organisation, operating in the built environment and associated industries.

In 2014 a ‘Bletchley Day’ workshop was organised by Care & Repair England. BRE was tasked with considering ways to demonstrate the investment value of home adaptations and modifications.

BRE researched some of the cost-benefits to the NHS of undertaking preventative home interventions for households with a long-term sickness or disability, where the risks of accidents in their home are worse than the national average. This identified the need for preventative work in around 3 million households who have a long-term sickness and disability. This work would make their homes safer and warmer and so would reduce the likelihood of NHS treatment and the need for a Disabled Facilities Grant (DFG) adaptation required as a result of injury.

On 29 April 2016, BRE published The cost-benefit to the NHS arising from preventative housing interventions (FB82) by Helen Garrett, Mike Roys, Selina Burris and Simon Nicol.

The Economic Case for a Befriending and Practical At-Home Support Scheme for Older People in Shropshire, England
Bauer A, Knapp M, Perkins M, et al LSE PSSRU and NIHR SSCR Research Findings, Personal Social Services Research Unit, London. 2014

Abstract
Our aim for this particular case study was to examine the economic case for a help-at-home scheme focused on supporting older people to live more independently in their homes. For this purpose we sought to evaluate the costs of the scheme and the outcomes it achieved, including those linked to cost savings. While the focus was on assessing whether the scheme was able to achieve potential cost savings from a public sector perspective, and in particular an adult social care perspective, we also evaluated additional social benefits, including those to the individual older people (including in their role as carers for their spouse in some cases) and volunteers. We also wanted to explore the capacity of the project to engage with a process of economic analysis and to present our economic evidence in the wider context of qualitative data about, for example, service user satisfaction.

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.

The PiTSTOP study: a feasibility cluster randomized trial of delirium prevention in care homes for older people.
Siddiqi N, Cheater F, Collinson M, et al Age and Ageing, 45, 652-661. 2016

Abstract
BACKGROUND AND OBJECTIVES:

delirium is a distressing but potentially preventable condition common in older people in long-term care. It is associated with increased morbidity, mortality, functional decline, hospitalization and significant healthcare costs. Multicomponent interventions, addressing delirium risk factors, have been shown to reduce delirium by one-third in hospitals. It is not known whether this approach is also effective in long-term care. In previous work, we designed a bespoke delirium prevention intervention, called ‘Stop Delirium!’ In preparation for a definitive trial of Stop Delirium, we sought to address key aspects of trial design for the particular circumstances of care homes.
DESIGN:

a cluster randomized feasibility study with an embedded process evaluation.
SETTING AND PARTICIPANTS:

residents of 14 care homes for older people in one metropolitan district in the UK.
INTERVENTION:

Stop Delirium!: a 16-month-enhanced educational package to support care home staff to address key delirium risk factors. Control homes received usual care.
MEASUREMENTS:

we collected data to determine the following: recruitment and attrition; delirium rates and variability between homes; feasibility of measuring delirium, resource use, quality of life, hospital admissions and falls; and intervention implementation and adherence.
RESULTS:

two-thirds (215) of eligible care home residents were recruited. One-month delirium prevalence was 4.0% in intervention and 7.1% in control homes. Proposed outcome measurements were feasible, although our approach appeared to underestimate delirium. Health economic evaluation was feasible using routinely collected data.
CONCLUSION:

a definitive trial of delirium prevention in long-term care is needed but will require some further design modifications and pilot work.

The Social Value of Sheltered Housing: Briefing Paper
Wood C Demos, London. 2017

In February 2017, Demos carried out research to explore and quantify thesocial value of sheltered housing, as a form of housing for older people distinct from other housing with care or generic retirement housing options. This was to help Anchor,Hanover and Housing andCare 21consider the implications of the proposals put forward by the Government, that by 2019, the core rent and service charges for a variety of forms of supported housing will be funded through Housing Benefit or Universal Credit up to the Local Housing Allowance (LHA) rate. The Work and Pensions Committee and the Communities and Local Government Committee launched a joint inquiry into these proposals in December 20161. This paper provides a review of the existing evidence regarding the impact of sheltered housing, and then draws on this to make some initial estimates as to the cost savings it can achieve in a range of fields.

Warm Homes for Health: Exploring the Costs and Outcomes of Improving Population Health through Better Housing
Tudor Edwards R, Nathan Bray N, Burns P, et al Centre for Health Econmics and Medicine Evaluation, Bangor. 2016

This briefing by the University of Bangor reports on a research project undertaken with Gentoo in Sunderland to understand the impact that warmth-related housing improvements have on the health, well-being and quality of life of families living in social housing.

In addition, it sought to find out the costs and outcomes associated with new warmth-related housing improvements, compared to existing, unmodified social housing.

Of note, it found that after installation of housing improvements:

across the cohort the number of GP visits in six months reduced by 10%
hospital visits reduced by 67%
accident and emergency department attendance reduced by 45%
inpatient stays reduced by 4%
More than £50,000 worth of NHS cost savings were observed due to reduced health service use

The researchers estimate, ‘if the 4.8million ‘unhealthy’ UK homes were to receive similar housing improvements the NHS could potentially save £1billion a year in health service use costs.’

When practical help is valued so much by older people, why do professionals fail to recognise its value?
Brannelly T and Matthews B Journal of Integrated Care, 18, 33-40. 2010

This article draws on the evaluation of a handyperson service which augments health and social services to enable older frail people to remain living at home. It considers current trends and policy, and asks why practical help is under‐valued by professionals caring for older people.