What did we do?
As part of the NHS England Test Bed Programme, Heywood, Middleton and Rochdale Clinical Commissioning Group (HMR CCG), tested an innovative, multi-component intervention, designed to help identify and support patients at risk of hospital admissions due to specific long-term conditions such as heart failure, type 2 diabetes and Chronic Obstructive Pulmonary Disease (COPD). NIHR CLAHRC Greater Manchester worked with HMR CCG and the partners providing the various elements of the intervention (MSD and Verily), in order to evaluate its implementation and its effect on several health outcomes.
Why was it important?
The number of people living with long term health conditions has increased significantly. Consequently, there is great interest in the development of interventions that can improve care for such conditions and reduce cost whilst improving outcomes and patient experience. The HMR intervention consisted of three MSD elements:
MSDi - a data management tool which supported practices in managing long term conditions in line with national guidelines. This “risk stratification” tool analysed health data, enabling GP practices to identify patients at increased risk of long term health conditions. This element incorporated customized algorithms developed by Verily to facilitate the stratification process.
EVIDENCE into PRACTICE™ - a 12-month facilitated, clinical change management programme which aimed to offer a structured approach to the management of people with long-term conditions and worked with the NHS to ensure that people with diabetes and COPD received optimal care through effective implementation of national and/or local policy and guidelines.
Closercare - a telehealth service where referred patients with COPD or heart failure were provided with digital devices to monitor their own vital health signs at home, enabling health professionals to monitor patients’ health readings remotely.
This was the first time that the combined effects of these components had been investigated. It was this combination that made the intervention innovative. The rationale for the intervention was that this combination applied over at least a 12 month period in one CCG would deliver a greater positive impact on health service utilisation (especially hospital admissions) than each component would individually.
How did we do it?
The evaluation involved two areas of focus:
This explored the acceptability of the intervention to health care professionals and how their behaviour fitted with that intended by the programme leaders. It also identified factors that impeded or facilitated implementation. To do this the project used:
Observations of training sessions and delivery of CloserCare.
Interviews with primary care and MSD staff, CCG Change Team members and other CCG representatives.
This used hospital emergency department data to investigate any difference in health service utilisation pre- and post-implementation within the HMR CCG footprint as well as in comparison with another GM CCG.
Who did we work with?