The Evercare programme has been developed in the USA to improve the quality of life for vulnerable older people. The programme involves developing new ways of working for healthcare professionals and is now being piloted by 9 Primary Care Trusts. The focus is on helping older people to maintain their independence, improve their wellbeing and avoid the need to go into hospitals. This report provides an interim review of the pilots. It suggests that the programme and its underlying principles have the potential to improve care in England.

Key findings include:

Executive Summary of Report in Full.

Evercare is an internationally unique health care improvement programme originally developed for the U.S. government that has successfully improved quality whilst reducing costs of care for 60,000 vulnerable older people. In the United States, Evercare reduced hospitalisations by 50 percent amongst its patients in care facilities whilst achieving high family satisfaction and the same mortality outcomes as compared to a control group.

In autumn 2002, the Department of Health in England invited Ovation’s Evercare programme to contribute its tools, techniques, and expertise to help Primary Care Trusts (PCTs) enhance the speed and certainty of achieving the NHS Plan. An eight-week assessment in 10 PCTs was completed in February 2003. Following this, nine PCTs elected to implement the Evercare model of care management to improve the health of frail older people whilst reducing their need for hospitalisations.

This interim report provides a midterm review of the 17-month implementation phase of the Evercare project. The implementation phase began in April 2003 and runs through August 2004. We are greatly encouraged by the results achieved to date, which can to attributed to the receptivity and enthusiasm of people within the NHS toward making a transformational change in services for older people.

We are honoured to have this opportunity to work with the NHS, and are greatly impressed by the management and clinical staff within the NHS.

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Delivering the NHS Plan by Improving Care Management for Older People

Care of the elderly and chronically ill is of prime importance because or the opportunity to improve older persons’ quality of life and often fragmented journey through the care system. Gaps in care delivery can quickly translate into quality-of-care concerns and reduced health care access. The Evercare programme was specifically designed to meet the complex needs of this population and its core principles are congruent with the NSF for Older People.

At the very foundation of the Evercare programme are core principles in geriatric and chronic care management. These principles guide Evercare's interventions in medical care and coordination of services. The principles are:

1. Apply an individualized, whole-person approach to care of older persons with all interventions focused on promoting maximal function, independence, comfort, and quality of life.

2. Use primary care as the central organizing force for health care across the continuum.

3. Provide care in the least invasive manner, in the least intensive setting.

4. Avoid adverse effects of medications and polypharmacy.

5. Use data to strengthen decision-making.

• Looking at the entire system from a patient’s point of view and correcting the most serious gaps or duplications in the care pathway.

• Assuring care is delivered in the least intensive setting consistent with patient needs in order to use NHS resources to benefit the broadest group of NHS patients.

• Reallocating existing resources to new purposes rather than assigning new resources.

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Evercare Project Achievements and Lessons Learned

Through three groups of interventions, which are described below, the Evercare model is serving as both a catalyst for transformational change locally and a process for syndicating best practices across PCTs. The Evercare project team (the PCTs assisted by the U.S. Evercare programme) made important achievements and discoveries during the first 10 months of project implementation. These are discussed below:

1. Data interventions identified a previously "hidden" population of older people at high risk of suboptimal outcomes.

   What we found: the data needed for intervention are available, but not in ready form, so resources must be devoted to preparing it for new analytic uses.

   What we accomplished: applied methods and tools to synthesize data into strategic information empowering care management interventions.

   • The identified high-risk population (those with two or more hospitalisations in the past year) represented 3% of people over 65 years of age, but was responsible for 35% of unplanned hospital admissions for all people over 65 years of age in participating PCTs.

   • Many high-risk patients were not actively being managed by the system. Only 24% were on active district nursing caseloads, and only 35% were known to Social Services.

   • Contrary to expectations, this high-risk population primarily lived in the community: 75% lived in their private homes, 6% were in residential care homes, and 10% were in nursing care homes.

   Benefits to the NHS: established feasibility of applying extant operational data to new analytic uses to identify high-risk populations that are in need of more proactive care management.

   Implications: investment in enhancing the data and analytic infrastructure would support improved care management in the NHS.

2. Role re-engineering interventions are preparing a workforce skilled in addressing the complex needs of a vulnerable population.

   What we found: the system’s specialisation strength has been a barrier to achieving integrated care coordination. Through focused on-the-job training and mentoring by GPs and consultants, qualified nurses can take on an expanded primary care role that shifts away from the specialist role to one of "generalists with special interests."

   What we accomplished: extended the GP role through collaborative partnership with a new Advance Practice Nurse (APN) role that developed five core nursing competencies for proactive care management of older people. These five competencies are: clinician, care orchestrator, communicator, coach, and champion.

   • In a November evaluation, 26 (90%) of the 29 nurses recruited to serve as APNs were deemed to have made satisfactory progress in assimilating advanced clinical care and coordination skills for older people.

   • APNs have established many successful mentoring and collaborative practice relationships with GPs and geriatric consultants, which emphasize proactive care coordination to anticipate and prevent acute events.

   • As of 15 January 2004, the 29 APNs were managing a total of 1,222 high-risk patients (average caseload of 47 based on 26 WTE) in 72 practices involving 197 GPs.

   • Collaboration is underway with local universities to develop curriculum in support of skills needed by new APNs, creating a vehicle for programme sustainability.

   Benefits to the NHS: the new APN role fulfils the NHS vision for enhanced primary care nursing, increases the GP’s span of control, and thereby makes better use of scarce resources. In addition, the intervention has accelerated plans for reengineering the nursing workforce more broadly.

   Implications: transforming nurses’ role to "proactive generalists" rather than "reactive specialists" creates a ripple effect that calls forth positive responses from the care management team in understanding the value and practice of care collaboration.

Process re-engineering interventions are improving the capability of the system to respond to the special needs of high-risk older people.

• Eight tools were successfully introduced to assist APNs (and care teams) with better patient assessment, anticipatory care management, advanced life planning, and identification of medication safety problems.

• Many APNs are reaching across organisational boundaries to follow patients into the hospital and nursing care home to help plan for discharge and care management as appropriate.

• Many hospitals have established a process to notify GPs and APNs when high-risk patients are admitted; this timely exchange of information helps to facilitate discharge planning.

• Supported by project management tools, cross-functional teams established within (and amongst some) PCTs demonstrated substantial interdepartmental coordination to sustain momentum and achieve results.

The report describes, in additional detail, how each of these interventions has been implemented, the barriers that were encountered, the successes achieved, and ongoing goals for each activity during the remainder of the project.

Formal evaluation will be conducted during the last six months of the project. This will include surveys of participating patients and their family or carer, a survey of APNs, interviews and focus groups with GPs and PCT staff, and analyses of service utilization and adverse medication effects before and after Evercare implementation.

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Summation and Implications

The universal principles that are the foundation of Evercare are mirrored in the philosophy and vision of the new NHS. The pilot programme has demonstrated that Evercare’s tools, approaches, and processes could be modified for application in the UK to speed the certainty of results and bridge the gap between policy and operational reality.

During the first 10 months of the 17-month pilot implementation in nine PCTs, Evercare has served as a catalyst to introduce critical new initiatives into the NHS in fulfilment of the NHS Plan, including:

• using information and tools for proactive care management of a previously unidentified high-risk population,
• accelerating nursing workforce re-engineering consistent with the NHS vision for promoting proactive generalists with special interests,
• improving collaborative patient care and information flow across organisational boundaries, and
• establishing goal-driven, cross-functional teams capable of achieving transformational change within the PCTs.

Positive results from these interventions have been documented by the APNs, including:

• averting preventable hospital admissions,
• shortening hospital stays,
• improving patient functional status and quality of life,
• making medication changes to avoid adverse reactions,
• enhancing care orchestration to reduce fragmentation among services, and
• honouring patient preferences.

Formal evaluation of the outcomes of these data, and workforce and process changes will be completed during the last six months of the project.

Whilst the Evercare project is initially focused on older people, our experience to date suggests that these strategies can be extended to address the needs of the population more widely. The organisational and workforce skills and techniques that are becoming embedded by a focused management of this critical population can serve as a catalyst for the development of broader sustainable improvement programmes for syndication across the NHS.

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