Impact of a referral management “gateway” on the quality of referral letters; a retrospective time series cross sectional review

Background Referral management centres (RMC) for elective referrals are designed to facilitate the primary to secondary care referral path, by improving quality of referrals and easing pressures on finite secondary care services, without inadvertently compromising patient care. This study aimed to evaluate whether the introduction of a RMC which includes triage and feedback improved the quality of elective outpatient referral letters. Methods Retrospective, time-series, cross-sectional review involving 47 general practices in one primary care trust (PCT) in South-East England. Comparison of a random sample of referral letters at baseline (n = 301) and after seven months of referral management (n = 280). Letters were assessed for inclusion of four core pieces of information which are used locally to monitor referral quality (blood pressure, body mass index, past medical history, medication history) and against research-based quality criteria for referral letters (provision of clinical information and clarity of reason for referral). Results Following introduction of the RMC, the proportion of letters containing each of the core items increased compared to baseline. Statistically significant increases in the recording of ‘past medical history’ (from 71% to 84%, p < 0.001) and ‘medication history’ (78% to 87%, p = 0.006) were observed. Forty four percent of letters met the research-based quality criteria at baseline but there was no significant change in quality of referral letters judged on these criteria across the two time periods. Conclusion Introduction of RMC has improved the inclusion of past medical history and medication history in referral letters, but not other measures of quality. In approximately half of letters there remains room for further improvement

Living at home after emergency hospital admission:prospective cohort study in older adults with and without cognitive spectrum disorder

Background: Cognitive spectrum disorders (CSDs) are common in hospitalised older adults and associated with adverse outcomes. Their association with the maintenance of independent living has not been established. The aim was to establish the role of CSDs on the likelihood of living at home 30 days after discharge or being newly admitted to a care home. Methods: A prospective cohort study with routine data linkage was conducted based on admissions data from the acute medical unit of a district general hospital in Scotland. 5570 people aged ≥ 65 years admitted from a private residence who survived to discharge and received the Older Persons Routine Acute Assessment (OPRAA) during an incident emergency medical admission were included. The outcome measures were living at home, defined as a private residential address, 30 days after discharge and new care home admission at hospital discharge. Outcomes were ascertained through linkage to routine data sources. Results: Of the 5570 individuals admitted from a private residence who survived to discharge, those without a CSD were more likely to be living at home at 30 days than those with a CSD (93.4% versus 81.7%; difference 11.7%, 95%CI 9.7–13.8%). New discharge to a care home affected 236 (4.2%) of the cohort, 181 (76.7%) of whom had a CSD. Logistic regression modelling identified that all four CSD categories were associated with a reduced likelihood of living at home and an increased likelihood of discharge to a care home. Those with delirium superimposed on dementia were the least likely to be living at home (OR 0.25), followed by those with dementia (OR 0.43), then unspecified cognitive impairment (OR 0.55) and finally delirium (OR 0.57). Conclusions: Individuals with a CSD are at significantly increased risk of not returning home after hospitalisation, and those with CSDs account for the majority of new admissions to care homes on discharge. Individuals with delirium superimposed on dementia are the most affected. We need to understand how to configure and deliver healthcare services to enable older people to remain as independent as possible for as long as possible and to ensure transitions of care are managed supportively

Patient and public involvement: how much do we spend and what are the benefits?

BACKGROUND AND OBJECTIVES: Patient and public involvement (PPI) is seen as a way of helping to shape health policy and ensure a patient-focused health-care system. While evidence indicates that PPI can improve health-care decision making, it also consumes monetary and non-monetary resources. Given the financial climate, it is important to start thinking about the costs and benefits of PPI and how to evaluate it in economic terms. DESIGN: We conducted a literature review to assess the potential benefits and costs of involvement and the challenges in carrying out an economic evaluation of PPI. RESULTS: The benefits of PPI include effects on the design of new projects or services, on NHS governance, on research design and implementation and on citizenship and equity. Economic evaluation of PPI activities is limited. The lack of an appropriate analytical framework, data recording and understanding of the potential costs and benefits of PPI, especially from participants' perspectives, represent serious constraints on the full evaluation of PPI. CONCLUSIONS: By recognizing the value of PPI, health-care providers and commissioners can embed it more effectively within their organizations. Better knowledge of costs may prompt organizations to effectively plan, execute, evaluate and target resources. This should increase the likelihood of more meaningful activity, avoid tokenism and enhance organizational efficiency and reputation

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND: Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. METHODS: The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. RESULTS: One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. CONCLUSIONS: Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. TRIAL REGISTRATION: Prospero registration number: 42016037725

A Rapid Review of Educational Preparedness of Advanced Clinical Practitioners

AimThe aim of this study was to synthesize available data on current educational provision related to preparation for the advanced clinical practice role.DesignA mixed methods rapid review of the literature.Data SourcesA search of Ovid Medline and Ovid EMBASE for English language papers published 2006–2018 resulted in 38 publications, which met the criteria for inclusion.Review MethodsUsing Tricco's seven‐stage process, following an identification of relevant papers and data extraction, a data‐based convergent synthesis was used to convert quantitative papers into qualitative data prior to completing a narrative synthesis.ResultsThe four themes identified from data synthesis were consolidation; theory to practice gap; competency and mentoring. A lack of preparedness for new advanced clinical practitioners completing an educational programme was noted with a need identified for a clinically focussed consolidation period to enable practitioners to develop their skills under supervision in the clinical environment.ConclusionAs the needs for different models of health care evolve with the expansion of advanced practice, appropriate education and clinical supervision are important aspects in the delivery of programmes that allow individuals to be competent and confident practitioners providing safe and effective health care.ImpactThere is a paucity of papers on educational preparedness of advanced clinical practitioners. Our findings demonstrate a lack of preparedness and the need for a clinically focussed consolidation period with good role models and mentors following completion of a Master's programme. Employers and higher education institutions need to ensure a protected period of time is available for newly qualified advanced clinical practitioners to allow consolidation of clinical practice

Incentivising a career in older adult nursing: the views of student nurses

Background and aim: Nurse vacancy rates in older adult services are disproportionately high compared to other areas of nursing. This is partly because few student nurses consider it an attractive career option once qualified due to perceptions of low‐status, strenuous nature of the work and impoverished care environments. The study aimed to explore students' perceptions of incentives that could counterbalance the barriers for new graduate nurses joining this speciality. Methods: A qualitative descriptive design using focus group interviews was carried out with six groups of student nurses (n = 27) following completion of their acute care older adult placements in three hospitals. Data were analysed using thematic analysis. Results: The barriers from students' perspectives were constructed as a vicious cycle of staff shortages and inadequate resources that created impoverished environments leading to a dissonance between ideal and delivered care. Over one‐third of students were unlikely to consider a career in older adults nursing, but the remaining students could identify incentives that may tempt them. Four main themes and eight subthemes were identified: gerontological status and leadership (ward leadership; respected others); relational care (legitimising emotional support, care vs. cure goals); quality work environment (pay as recognition, 12‐hr shifts); and education‐career pathways (gerontological knowledge, career progression). Conclusion: Radical new approaches, based on student and nurse engagement, are required to incentivise a career in gerontological nursing. A combination of shorter and longer term strategies that include education‐career pathways, a focus on relation care, and improved work conditions including financial incentives should be trialled. Implications for practice: In terms of practice, addressing high nurse vacancy rates in older adult services that negatively impacts on patient outcomes requires a suite of incentives informed by ‘what matters’ to students and nurses working in the speciality

“Catching your tail and firefighting”: The impact of staffing levels on restraint minimization efforts

Introduction: Safe staffing and coercive practices are of pressing concern for mental health services. These are inter-dependent and the relationship is under-researched. Aim: To explore views on staffing levels in context of attempting to minimise physical restraint practices on mental health wards. Findings emerged from a wider dataset with the broader aim of exploring experiences of a restraint reduction initiative Methods: Thematic analysis of semi-structured interviews with staff (n=130) and service users (n=32). Results: Five themes were identified regarding how staffing levels impact experiences and complicate efforts to minimise physical restraint. We titled the themes – ‘insufficient staff to do the job’; ‘detriment to staff and service users’; ‘a paperwork exercise: the burden of non-clinical tasks’; ‘false economies’; and, ‘you can’t do these interventions’. Discussion: Tendencies detracting from relational aspects of care are not independent of insufficiencies in staffing. The relational, communicative, and organisational developments that would enable reductions in use of restraint are labour intensive and vulnerable to derailment by insufficient and poorly skilled staff. Implications for Practice: Restrictive practices are unlikely to be minimised unless wards are adequately staffed. Inadequate staffing is not independent of restrictive practices and reduces access to alternative interventions for reducing individuals’ distress

The primary care amplification model: taking the best of primary care forward

Background: Primary care internationally is approaching a new paradigm. The change agenda implicit in this threatens to de-stabilise and challenge established general practice and primary care