This High Impact Change Model aims to support local care, health, and wellbeing partners to work together to prevent, delay or divert the need for acute hospital or long-term bed-based care.
The tool recognises that, while sometimes hospital is the most appropriate place for someone to be, most people want to be at home and independent for as long possible, and that this is generally the best place for them to recover.
A preventable admission is one where there was scope for earlier, or different, action to prevent an individual’s health or social circumstances deteriorating to the extent where hospital or long-term bed-based residential or nursing care is required. The shorthand collective term ‘avoidable admissions’ is also often used to refer to admissions which could be considered preventable.
This tool identifies actions and interventions which will enable systems to understand their populations, identify those most at-risk of a preventable admission and take action to engage individuals and target support to improve their health and wellbeing.
How to use this document
System leaders and staff from across local government, the NHS, the voluntary, community and social enterprise sector, and service user and carers groups all have a part to play in working together to improve health and wellbeing and deliver person-centred care in the most appropriate setting.
By working together, partners can pool and build on their collective local knowledge and expertise to identify and take a strengths- and asset-based approach to understanding and addressing preventable admissions in their area.
Local partners should take from this resource what is most relevant and appropriate for their context, acknowledging that not all the interventions outlined here will be appropriate for all individuals and in all circumstances.
The Care and Health Improvement Programme’s Integration support offer can support local systems with these conversations.
Overview of the model
The model focuses on two goals and five high impact changes that help realise one or both goals.
The two goals are:
- Goal 1: Prevent crisis: Actions to prevent crises developing or advancing into preventable admissions
- Goal 2: Stop crisis becoming an admission: Actions to divert or prevent an attendance at A&E becoming an admittance to hospital or long-term bed-based care
The five high impact changes and the goal or goals they relate to:
- Change 1: Population health management approach to identifying those most at risk (Goal 1)
- Change 2: Target and tailor interventions and support for those most at risk (Goal 1)
- Change 3: Practise effective multi-disciplinary working (Goals 1 and 2)
- Change 4: Educate and empower individuals to manage their health and wellbeing (Goals 1 and 2)
- Change 5: Provide a coordinated and rapid response to crises in the community (Goal 2)
Each high impact change describes good practice through:
- top tips and actions
- examples of emerging and good practice from local systems around the country
- links to national guidance, guides and other publications
All changes are underpinned by:
- Eight overarching principles
There is a platform of eight overarching principles that underpin this model and its implementation:
1. Commitment and focus to support people to remain in their homes or usual place of residence, when they are having a health or social care crisis, preventing admission to hospital or long-term care where possible AND then supporting them to maintain or regain skills, confidence and independence.
2. Transferring power and knowledge to individuals and communities so they can take ownership of their health and wellbeing.
3. “Right care, right time, right place.”
4. The workforce understands the community it serves and places the individual at the centre.
5. Inclusive, person-centred, strength-based partnerships with communities and individuals provide the foundation for reducing preventable admissions.
6. Do it at scale: support planning, infrastructure, delivery, and person-centred practice with, and across, individuals, neighbourhood, place, and system levels.
7. Health and wider inequalities, as well as their compounding effects, must be considered and addressed in every high impact change.
8. Focus on what works using research, emerging and established evidence and lessons learned.
- I and We statements from Think Local Act Personal's Making It Real framework
Providing personalised care and support is central to providing the right care in the right place and reducing preventable admissions.
This model borrows from Think Local Act Personal’s Making it Real framework, which is a set of I and We statements that describes what good care and support looks like from a person’s perspective and encourages organisations to work together to achieve good outcomes for people.
The framework is based on the following principles and values of personalisation and community-based support:
- People are citizens first and foremost.
- A sense of belonging, positive relationships and contributing to community life are important to people’s health and wellbeing.
- Conversations with people are based on what matters most to them.
- Support is built around people’s strengths, their own networks of support, and resources (assets) that can be mobilised from the local community.
- People are at the centre. Support is available to enable people to have as much choice and control over their care and support as they wish.
- Co-production is key. People are involved as equal partners in designing their own care and support.
- People are treated equally and fairly, and the diversity of individuals and their communities should be recognised and viewed as a strength.
- Feedback from people on their experience and outcomes is routinely sought and used.
The Making it Real framework includes a full list of I and We statements to describe good care and support.
Risk factors in the model
There are many different labels that are used to categorise people at risk of a preventable admission and the statistics can hide the richness, challenges, and complexity in their lives. The COVID-19 pandemic has both increased awareness of, and exacerbated, the risks that health and wider inequalities, including deprivation, can pose to health and wellbeing, and how these risks can overlap and compound their impact. Being frail, for example, does not preclude anyone from also having any number of long-term health conditions, mental ill-health, or from experiencing the impact of inequalities.
This model promotes emerging and good practice and includes a wide range of interventions which relate to some, or all, of these different risks. The model, however, cannot capture all examples or interventions relating to every different factor that increases risk of admission. Rather, it seeks to signpost to resources for further reading. We encourage the reader also to consider the spirit of the changes described and how these can apply to different cohorts at risk of preventable admissions.
Collaborate with local partners to bring together data and insight to form an integrated view of those at high risk of preventable admissions
Address the most pressing clinical and social barriers, identified by data and insight, that put people at risk of a preventable admission through dedicated services
Foster trusted and joint assessments, shared decision-making and positive risk-taking to deliver pro-active person-centred care. Working together with individuals, and their family and/or carers can build confidence and facilitate a holistic approach to meeting needs
Facilitate sustainable interventions and support that enable individuals, and their carers, to confidently manage their own health and wellbeing, and maintain their independence at home or their usual place of residence.
Establish a range of integrated services that provide a coordinated and personalised response in the community