Make the most of case management
From Dr Richard Smith
You report that 'the first controlled evaluation of a pilot of Evercare case management had no greater effect on admissions than standard GP care', but you fail to report the severe limitations of the study – even though they were acknowledged by the authors themselves (News, 29 June).
The study was not randomised, the cases and controls were very different, and the study didn't differentiate between planned and unplanned admissions.
Case management might increase planned admissions, particularly in the early stages when patients are discovered to have problems that need hospital care. In addition, the study was severely underpowered.
The important question is less whether case management plus redesign of primary care can reduce unplanned hospital admissions but more what can be done to make it work.
We have identified some 16 components that are needed for success not only to improve patient satisfaction but also to reduce unplanned admissions.
The Evercare pilots could not have had all these components in place but did show considerable improvement in patient and carer satisfaction.
Staff satisfaction also increased.
One essential is involvement of GPs. The programme does not substitute for GPs but rather helps them improve care for frail, elderly patients.
Other essentials include an information system for identifying those most at risk, intense mentoring for community matrons, 24/7 cover, and access to intermediate care services.
If the choice facing a patient is staying at home in perhaps deprived circumstances or admission to an acute hospital, there will be many unplanned admissions: there must be intermediate responses.
These essential components did not exist until recently in many primary care trusts – and still don't in many.
It's because primary care trusts involved in the Evercare pilots have realised the importance of these essentials that their programmes have moved on. It was always expected that there would be developments, not least because there were, for example, no information tools for identifying patient risk when the Evercare pilots began.
Plus, importantly, the evidence from the US is that programmes need to be running for some 18 months before reductions in hospital admissions can be expected.