PITCH: 'Patient journeys into hospital'. An in-depth exploration of primary care's role in the emergency admission of older people with multimorbidity'

Problem

A 47% rise in the number emergency admissions into hospital within the last 15 years has cost the NHS up to £12bn per year. Many involve older people with multimorbidity, and it has been claimed that a fifth of emergency admissions could be avoided. The problem is complex, with demographic changes, patient expectations and provision of care all involved.

Using a qualitative approach and mapping of the patients' journeys to hospital, this study aims to understand emergency admissions from a primary care and patient perspective, in order to help prevent those that are avoidable.

Approach

4-6 practices have been recruited and asked to compile a list of patients over 65 years with multimorbidity who have been admitted as an emergency by a GP during working hours in the previous four weeks.

An initial review of case records for eligible patients will rate each admission as 'unavoidable' or 'potentially avoidable', using a previously tested method.

2- 6 patients (or Consultees for those who lack capacity) with a 'potentially avoidable' admission will be chosen from each practice for interview, along with a carer if applicable and the admitting GP. Interviews will focus on their decision-making process surrounding the admission and will review care provided in the previous twelve months. Practice managers will also be invited to interview. All topic guides will be informed by the Theory of Planned Behaviour and review of the literature.

Using a process mapping approach, a detailed review of the case record of interviewed patient will highlight the care received by the patient and any interactions with primary care or other services in the twelve months prior to admission. The maps will be discussed, referred to and updated through the interviews.

Short periods of observation in practices will be undertaken. This may include attendance at meetings discussing recent admissions.

Findings

Ethics approval has been granted. Nine practices of 137 invited expressed an interest. We have chosen four to participate so far based on patient (% age >64, IMD and ethnicity) and practice variables (admission rates for chronic disease and list size). Three have consented to participate and one has had an initial visit to discuss the study. One has started the initial database search and has so far found two patients that are eligible.

Consequences

Our results will aim to inform the development of an intervention that could be used in general practices and by policy makers in primary care to reduce avoidable unplanned admissions for patients with multimorbidity.

This intervention could provide a framework for practices to work within, therefore giving guidance around when to admit a patient and knowledge about alternatives to admission.