09/04/23

Challenges in commissioning research on what works in integrated care

Tara Lamont, Scientific AdviserNIHR Evaluation, Trials and Studies Coordinating Centre (NETSCC)www.netscc.ac.uk

 

Impact

Ask the right questions

Answer them the right way

Health Services and Delivery Research

Programme

C£16m (€19.8m)

Focus on quality and effectiveness of

healthcare systems

What research do managers need to

deliver good services?

National Institute for Health

Research (NIHR)

£1bn (€1.2bn)/year applied health

research system for NHS

What do we mean by integration?

What mechanisms work?

Call for new research in 2009 (England/Wales) – Evaluating innovations in integrating health + social care > £2m (€2.4m)

Problems in evaluating integrated models of care

• Complex interplay of context, mechanism and outcome• Difficult to track real patient activity and costs across

settings• Local initiatives which may be difficult to replicate• Small-scale studies often at single sites

Systematic review of international evidence – few high quality,

controlled evaluations of models of integration

[Johri 2003]

How do the new studies tackle these challenges (i)?

• Lewis and team at Nuffield Trust UK• Virtual wards – started as experiment 10 years ago, spreading

widely• Target patients at high risk of emergency admission and monitor

daily by multidisciplinary team (matron, pharmacist, social worker, GP) with coordination by ward clerk and integrated care record

• Sophisticated methods on costing and activity:

- difference-in-difference analysis (comparison of admissions with matched non-intervention groups)

- economic analysis (person-linked data on use of services across health and social care)

• Should answer question: what do virtual wards cost and what effect do they have on costs and use of hospital and other services?

Robust economic analyses

involving 2008 patients over 3

sites

Tracking patients across sectors

using innovative person-level `bottom-up’

costing

New evidence on efficacy and cost-effectiveness of

integration at micro and meso

levels

Useful practical tools for

managers eg calculating

optimal casemix for virtual wards

How do the new studies tackle these challenges (ii)?

• Parker et al at York University, UK• Innovations in integrated services for people with neurological

disorders (as exemplar longterm condition)• 4 organisational case studies selected purposively to test different

forms of structural integration (eg comparison of joint funding agencies versus separate authorities) against micro-level initiatives

• Initiatives compare and contrast models of multidisciplinary team management for brain injury – health led, social care led, joint led

• Multi-methods to understand interplay of context and mechanisms• Working with patients to develop user-derived outcome measures

against which to assess models of care

Case study design

informed by programme

theory

Evidence on how micro-level

integrated care can best be supported at meso- and

macro-levels.

5 top tips for researchersevaluating integrated care

• Describe intervention well (eg workforce – include grademix, skillmix, professions) – could it be replicated elsewhere?

• Think about generaliseability of findings (eg comparator sites, controls, use of national reference data) – will findings be meaningful elsewhere?

• Consider context in study design (eg sampling frame based on variables derived from evidence)

• Consider new methods to capture costs and service complexity (eg person-linked data to track activity across settings) – top class health economics input essential

• Position your study against existing body of knowledge – what is already known and what will your study add?

For more information on these and some other health services research studies, visit http://www.netscc.ac.uk/hsdr/project.php

This presentation presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

 Tara Lamont

Scientific Adviser

NIHR Health Service & Delivery Research Programme

t.lamont@southampton.ac.uk

.