Identifying models of care to improve outcomes for older people with urgent care needs: a mixed methods approach to develop a system dynamics model

Conroy S, Brailsford S, Burton C, England T, Lalseta J, Martin G, Mason S, Maynou-Pujolras L, Phelps K, Preston L, Regen E, Riley P, Street A, van Oppen J
Record ID 32018005222
Authors' objectives: We aimed to understand urgent and emergency care pathways for older people and develop a decision support tool using a mixed methods study design. Work package 1 identified best practice through a review of reviews, patient, carer and professional interviews. Work package 2 involved qualitative case studies of selected urgent and emergency care pathways in the Yorkshire and Humber region. Work package 3 analysed linked databases describing urgent and emergency care pathways identifying patient, provider and pathway factors that explain differences in outcomes and costs. Work package 4 developed a system dynamics tool to compare emergency interventions. This study addressed emergency care for people aged 75 years or older, from the point of an ambulance being called through to admission, and/or transfer out from hospital, focusing on emergency department (ED) interventions. We aimed to identify promising care models and guidance derived from best practice and produce guidance on implementation that address the needs of older people accessing urgent and emergency care (UEC) services. Work package (WP) 1 – identifying best practice WP 1.1 – review of reviews of UEC interventions for older people, their outcomes and costs and any implementation factors identified Research question (RQ) 1.1.1 – what is the evidence base for UEC interventions for older people, the outcomes of these interventions and the costs associated with these interventions? RQ 1.1.2 – what factors have been described in the evidence base to date that influence implementation of UEC interventions for older people? WP 1.2 – patient and carer preferences RQ 1.2.1 – what elements of care are most important to older people and their carers with UEC needs? RQ 1.2.2 – how could UEC interventions be configured to best meet the needs of older people? WP 1.3 – staff perspectives RQ 1.3.1 – what other interventions, not yet reported in the literature, offer promising models for improving outcomes for older people in the UEC pathway?
Authors' results and conclusions: A total of 18 reviews summarising 128 primary studies found that integrated social and medical care, screening and assessment, follow-up and monitoring of service outcomes were important. Forty patient/carer participants described emergency department attendances; most reported a reluctance to attend. Participants emphasised the importance of being treated with dignity, timely and accurate information provision and involvement in decision-making. Receiving care in a calm environment with attention to personal comfort and basic physical needs were key. Patient goals included diagnosis and resolution, well-planned discharge home and retaining physical function. Participants perceived many of these goals of care were not attained. A total of 21 professional participants were interviewed and 23 participated in focus groups, largely confirming the review evidence. Implementation challenges identified included the urgent and emergency care environment, organisational approaches to service development, staff skills and resources. Work package 2 involved 45 interviews and 30 hours of observation in four contrasting emergency departments. Key themes relating to implementation included: intervention-related staff: frailty mindset and behaviours resources: workforce, space, and physical environment operational influences: referral criteria, frailty assessment, operating hours, transport. context-related links with community, social and primary care organisation and management support COVID-19 pandemic. approaches to implementation service/quality improvement networks engaging staff and building relationships education about frailty evidence. The linked databases in work package 3 comprised 359,945 older people and 1,035,045 observations. The most powerful predictors of four-hour wait and transfer to hospital were age, previous attendance, out-of-hours attendance and call handler designation of urgency. Drawing upon the previous work packages and working closely with a wide range of patient and professional stakeholders, we developed an system dynamics tool that modelled five evidence-based urgent and emergency care interventions and their impact on the whole system in terms of reducing admissions, readmissions, and hospital related mortality. We have reaffirmed the poor outcomes frequently experienced by many older people living with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to help including clinicians, service managers and commissioners improve emergency care for older people. WP1 – identifying best practice WP 1.1 review of reviews In total, 806 articles were retrieved; 18 eligible reviews were identified, published between 2005 and 2019. These reviewed 128 unique primary studies (published 1994–2018); 25 were included in more than one review. Most reviews defined 65 years as their age threshold for ‘older people’, although some included papers with populations aged 60 years and older, few stratified by condition or severity. Reviews of ED interventions were organised into four evidence clusters: discharge-focused interventions staff-focused interventions population focused interventions intervention component focused reviews. Discharge interventions vary in their components but tend to employ improved linkages between the ED and the community, either through direct linkage or referral interventions. Comprehensive geriatric assessment (CGA) was frequently used. There was limited evidence for its effectiveness – two meta-analyses found no benefit from this intervention, and narrative synthesis reported an increase in ED readmissions in the short term among patients who had received these interventions. Staff-focused interventions described conflicting evidence around the benefits of nurse-led interventions for older people in the ED. Some reported reduced service use and reduced functional decline, but others increased service use. The meta-analysis found no effect from nurse-led interventions. There was evidence of lowered admission rates following geriatrician-led CGA interventions. There was limited evidence for population-focused interventions, such as the identification and management of older people with cognitive impairment in the ED. There was considerable agreement for the components of successful interventions. Effective interventions: integrate social and medical care involvement include screening and assessment initiate care in the ED and bridge this with follow-up monitor and evidence successful practices. Call handler designation was the most powerful predictor of a four-hour wait and of transfer to hospital. We confirmed that frailty risk was a strong, independent predictor of LoS and in-hospital death, but not 30-day readmission. Changes at the levels of clinical practice and service design are required to deliver person-centred care for older people living with frailty in the ED environment. Holistic interventions initiated in the ED and continued elsewhere can improve outcomes. The evidence-based, clinically validated decision support tool for use by clinicians, service managers and commissioners is available at FutureNHS, which is open to anyone working in or for health and care ( For future service changes, call handler designation of urgency could be relatively easily embedded in EDs, which alongside frailty risk, could identify those at the highest risk of adverse events upon arrival at ED. It might be that frailty expertise in combination with emergency medicine expertise could be usefully deployed to support these individuals. In summary, we have reaffirmed the poor outcomes frequently experienced by older people with urgent care needs. We have identified interventions that could improve patient and service outcomes, as well as implementation tools and strategies to transform emergency care for older people.
Authors' methods: Across the reviews there was incomplete reporting of interventions. People living with severe frailty and from ethnic minorities were under-represented in the patient/carer interviews. The linked databases did not include patient reported outcomes. The system dynamics model was limited to evidence-based interventions, which could not be modelled conjointly. WP1 – identifying best practice WP 1.1 review of reviews of UEC interventions for older people, their outcomes and costs and any implementation factors identified. WP 1.2 interviews of older people and their carers with recent experience of UEC, using the findings to ensure that the patient’s voice is at the centre of this study. WP 1.3 clinician interviews and focus groups about emerging interventions and key elements of high-quality care.
Project Status: Completed
Year Published: 2023
URL for additional information: English
English language abstract: An English language summary is available
Publication Type: Full HTA
Country: England, United Kingdom
MeSH Terms
  • Emergency Medical Services
  • Aged
  • Aged, 80 and over
  • Health Services for the Aged
  • Delivery of Health Care, Integrated
Organisation Name: NIHR Health Services and Delivery Research programme
Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK
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