Promoting health and well-being for older people: professionals’

perspectives

Melanie Handley Centre for Research in Primary and Community Care University of Hertfordshire

Project team Dr Kate Walters, UCL (Chief Investigator) Kalpa Kharicha, UCL (Project Manager) Prof Steve Iliffe, UCL (Primary Care) Prof Jill Manthorpe, King’s College London (Social Care) Prof Claire Goodman, University of Hertfordshire (Community Nursing/Health Services Research) Melanie Handley, University of Hertfordshire (Research Assistant) Prof Mima Cattan, University of Northumbria (Gerontology/Public Health) Prof Steve Morris, UCL (Health Economics)

Presentation

• Background to WISH study

• Overview of the WISH study

• Findings from interviews with service providers

• Key Messages

Background

Great Expectations: Proactive care: experience up to 1990 Health promotion trials for older people in US, UK &

Denmark up to 1990 showed: • A rise in morale • Increased referrals to all agencies • Reduced duration of in-patient stay (sometimes) • Increased in-patient rates (mostly respite care) • Reduction in mortality in some trials • No improvement in functional ability • GP workload increased unless alternative services

were organised Stuck AE et al (1993)

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In practice…more recent studies of proactive care:

• MRC UK trial: little impact on quality of life or health outcomes Fletcher AE et al (2004)

• ProAge study: no change in health risk behaviours

Harari D et al (2008)

• Expectations that case management would reduce hospital admission rates for frail older people not met

Gravelle H et al (2007)

• Integrated care pilots & POPPS had equivocal results Steventon A et al (2011), Ling, T et al (2012), Roland M et al (2012)

• Limited evidence of effectiveness of targeted, home-based, nurse-led interventions

Tappenden P et al (2012)

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Known unknowns

• Unclear what are the effective ingredients of these proactive interventions

• Unclear whether they will work in the NHS

• No real sense of the cost-benefit of proactive care

Policy context in England

Shared cross-government commitment to create a new culture of co-operation and co-ordination between care sectors………. • The National Collaborative for Integrated Care (May 2013)

The WISH Study Overview

WISH Study Overview Study design • Feasibility study, 2 diverse localities

• 5 General practices in London Borough of Ealing and Hertfordshire

• Invited older people (65+ years) to take part in ‘health and well-being questionnaire’ (MRAO) with a feedback report and practice follow-up

Participation

• 527/1550 (34%) of older patients agreed to take part

• Of these 454/527 (86%) completed postal questionnaires at baseline

• Follow-up: 90% completed follow-up at 3 months, 77% at 6 months

• Questionnaires were completed fully

Stakeholder Characteristics

Healthcare Professionals 10

Local Authority 10

Voluntary Sector 8

Other 4

Total 32

Findings for services: feasibility, acceptability, utility

Integration into routine clinical care

• Practices developed systems for dealing with new needs

• Follow-up was led by practice nurse (4) or salaried GP (1)

• 19.4% of people on average were actively followed up by their practice nurse or GP

• This was feasible where there was someone with time to review and act on reports.

Integration into routine clinical care

Qualitative data suggests: • The reports yielded some new and useful

information

• The process was feasible to implement

• Some changes to care have resulted

Integration into routine clinical care

Example • High levels of pain and incontinence reported

• Healthcare professionals did not expect these problems would be so prevalent in older people who, in general, did not have complex needs

Pain (reported by 70% of respondents)

• “That was really shocking. So many elderly people suffer pain in silence… I know from our sort of engagement with the Intermediate Care Centre locally that it is a big issue finding something that’s effective, but doesn’t actually cause more problems.” {Healthcare Professional 5}

Incontinence (reported by 25% of respondents)

• “I don’t often discuss continence with people, so that was interesting because it’s obviously something that worries quite a lot of people but they don’t necessarily always want to present with it or talk about it” {Healthcare Professional 4}

• “I suspect that sometimes things have to get very bad before they actually come and ask for help… if we’re not being proactive in asking those questions, then we’re often not going to know” {Healthcare Professional 5}

Non-health related matters • Support for health matters was straight forward But… • Identifying agencies to help with social problems was

more problematic

• Healthcare professionals admitted limited knowledge of local provision for social problems

• “I remember thinking, gosh, this is opening up a whole new area that a lot of GPs and staff perhaps wouldn’t necessarily tackle at all, or know how to.” (Voluntary Sector Manager 1)

• “I don’t feel I’m that knowledgeable about local organisations.” (Healthcare Professional 7)

• “I wouldn’t have had a clue. I’d have probably gone and asked our secretary about Social Services; I wouldn’t know.” “I’ve got that [signposting service details] thing up there now! So I’ve used that quite a bit since actually with certain people.” (Healthcare Professional 8)

Aggregated Data • Much interest in findings of local profiles “I was just sort of thinking, oh, there’s so much in

here, and the potential is so powerful” (Voluntary Sector Manager 4)

“I think this could be used then in strategies or bids

that we are putting in.” (Local Authority Manager 3)

• However it was much harder to make service

recommendations, especially for front line professionals unfamiliar with commissioning

“My feeling is that sometimes there can be a lot of discussions

and then constructively nothing may be happening” (Local Authority Representative 1)

Service utilisation & costs

• Practice nurse consultations were higher at 3 months, but by 6 months were lower than baseline.

• GP consultations were unchanged. • No significant difference in use of any non-NHS

services • No significant change in NHS costs at 6 months

compared to baseline ▫ Median £144/patient for last 3 months at baseline,

£139/patient for last 3 months at 6 months.

Service utilisation & costs

Intervention costs: • £125 per practice set up costs, then £4.68 per older

person invited (with 30% response). ▫ Includes costs postal questionnaire, report

generation & checking, review of reports and follow-up by nurse or GP in 20%.

▫ Excludes local adaption of software (approx. 1 week administrator time).

Key messages

In summary • DH wants more pro-active health promotion for older people • ‘Population scanning’ using a comprehensive postal

questionnaire is one approach, that can be automated so a tailored report is generated

• Using this approach, with active follow-up of new complex needs appeared feasible for General Practices

• Professionals were able to discuss needs of the local population • Data generated from the MRAO could be used assist Health

and Wellbeing boards to identify unmet needs and promote healthy ageing

Acknowledgments and disclaimer

• Thanks to participants and practices and members of the study’s Working Groups and Advisory Group

• Disclaimer: The views expressed are those of the authors and not necessarily those of the funder. For further information contact Melanie Handley, m.j.handley@herts.ac.uk

References Chief Scientist Office Scottish Government (2011) Promoting health & well-being in later life: interventions in primary care and community settings. www.SCPHRP.ac.uk Stuck AE, et al (1993) Effects of a comprehensive geriatric assessment on survival, residence and function; a meta-analysis of controlled trials Lancet;342:1032-6 Fletcher AE, et al (2004) Population-based multidimensional assessment of older people in UK general practice: a cluster-randomised factorial trial. Lancet 2004; 364: 1667-77 Harari D et al (2008) Promotion of health in older people: a randomised controlled trial of health risk appraisal in British general practice. Age & Ageing 2008; 37: 565-571 Gravelle et al (2007) Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data. BMJ 2007; 334:31. Tappenden P, et al. The clinical effectiveness and cost-effectiveness of home-based, nurse-led health promotion for older people: a systematic review. Health Technol Assess 2012;16(20). National Collaboration for Integrated Care and Support (May 2013) Integrated Care and Support: Our Shared Commitment. www.gov.uk/government/publications/integrated-care Steventon, A., Bardsley, M., Billings, J., Georghiou, T., Lewis, G., (2011) An evaluation of the impact of community-based interventions. Nuffield Trust London Ling, T., et al (2012) Barriers and facilitators to integrating care: experiences from the English Integrated Care Pilots. International journal of integrated care 12. Roland M, et al. (2012) Case management for at-risk elderly patients in the English integrated care pilots: observational study of staff and patient experience and secondary care utilisation. Int J Integr Care. 2012 Jul-Sep;12.