Context to the High Impact Change Model: Reducing Preventable Admissions

Who is at most risk of a preventable admission?

The people most at risk of a preventable admission are those who experience ill-health or a social crisis that could be managed at, or close to, home if the right support, care, safeguards, and treatments are available at the right time. 

Research commissioned by the LGA found in 2016 (Efficiency opportunities through health and social care integration: delivering more sustainable health and care): "In over a quarter (26 per cent) of cases reviewed where people had been admitted to an acute hospital, there had been missed opportunities to make interventions that would have avoided the need for admission."

High rates of emergency hospital admissions of people with conditions that are considered to be amenable to prompt, person-centred care in the community, suggest the need for more co-ordinated care. The Nuffield Trust has shown (Quality Watch, August 2020): "In 2019/20, nine in every 1,000 people in England were admitted to hospital in an emergency with an ambulatory care sensitive condition and 25 in every 1,000 people were admitted with an urgent care sensitive condition. This is surprisingly high given that these are potentially preventable causes of emergency admission."

As outlined in the introduction, there are many risk factors to which this model can be applied. The key is to apply them in the context of the local population's needs.

Why use this model to reduce preventable admissions now?

  • Intervening proactively with lower-intensity support can help to delay or reduce someone’s need for more care in the future and help them retain their independence, health and wellbeing for longer.
  • The incidence of preventable admissions is a strong indicator of both the local social, demographic and economic environment and the degree of system cohesion in supporting person-centred and coordinated care, support, treatment and safeguards.
  • Unplanned admissions, whether to hospital or a care home, can be distressing experiences for individuals and their families, and expensive in terms of resource use for the health and care system. They can create uncertainty for those responsible for planning and delivering services.
  • Significant savings are possible by reducing avoidable admissions to bed-based care (Shifting the balance of care: great expectations, Nuffield Trust 2017) Research routinely demonstrates that people are over-prescribed care, which is above their care needs, reducing their independence and tying up resources in the provision of unnecessary care.
  • Those with ambulatory care sensitive conditions account for a significant proportion of avoidable admissions that could have been prevented with timely detection and intervention in the community (Reducing avoidable emergency admissions, analysis of the impact of ambulatory care sensitive conditions in England).
  • Identifying those people who have a greater level of frailty can help avoid these events happening; such identifying those who have a higher risk of falls, self-neglect, carer breakdown, infections leading to delirium, hospital admissions or admission to long-term bed-based care.  
  • Those who experience health, social and/or economic inequalities have an increased risk of preventable admissions and the compounding effects of overlapping inequalities.
  • The COVID-19 pandemic has required partners to develop a joint response which has in turn highlighted the importance of reducing preventable admissions and the role of community-based services in achieving this.

Policy context

This High Impact Change Model to Reduce Preventable Admissions is informed by:

  • The Care Act’s vision that “the care and support system works to actively promote wellbeing and independence, and does not just wait to respond when people reach a crisis point”.
  • The LGA and partners vision Shifting the Centre of Gravity which shows how a model of person-centred, place-based integrated care and support can successfully improve people’s health and wellbeing, including reducing the need for unplanned hospital admissions and long-term residential care.
  • How the Better Care Fund supports many areas to join health and care services through implementing integrated local models of health and care that aim to enable people to manage better their own health and wellbeing, and live in their communities for as long as possible.
  • The Home First ethos and the Hospital Discharge Service: Policy and Operating Model which encourages wraparound care at home to aid recovery and sustain independence at home for longer .
  • The NHS Long Term Plan and the NHS 2021/22 priorities and planning guidance which include, for example, population health management, anticipatory care, urgent community response and recovery of elective activity
  • Requests to focus on this area, which were made during the 2019 review of the ‘High Impact Change Model: Managing Transfers of Care between Hospital and Home’.
  • Learning from the COVID-19 pandemic, includes:
    • systems have immense ability to overcome barriers and shift resources for timely response
    • that there is an appetite and impatience for faster and sustainable change
    • an adverse impact on those who were already experiencing inequalities 
    • the importance of having an adaptable and sufficient workforce with parity between health and social care
    • because of its impact, such as on mental health or for those with long COVID for example, it is generating a need for certain services.

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Reducing preventable admissions to hospital and long-term care – A High Impact Change Model

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.

Change 1: Population health management approach to identifying those most at risk

Collaborate with local partners to bring together data and insight to form an integrated view of those at high risk of preventable admissions

Change 2: Target and tailor interventions and support for those most at risk

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

Change 3: Practise effective multi-disciplinary working

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

Change 4: Educate and empower individuals to manage their health and wellbeing

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.

Change 5: Provide a coordinated and rapid response to crises in the community

Establish a range of integrated services that provide a coordinated and personalised response in the community


This self-assessment includes questions to guide conversations between local care, health and wellbeing partners, and work with local people, to assess where they are on their journey to realising the twin goals of preventing crises and stopping crises becoming admission.