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Background: The emergence of Integrated Care Systems (ICSs) across England poses an additional challenge and responsibility for local commissioners to accelerate the implementation of integrated care programmes and improve the overall efficiency across the system. To do this, ICS healthcare commissioners could learn from the experience of the former local commissioning structures and identify areas of improvement in the commissioning process. This study describes the investment decision process in integrated care amid the transition toward ICSs, highlights challenges, and provides recommendations to inform ICSs in their healthcare commissioning role.Methods: Twenty-six semi-structured interviews were conducted with local commissioners and other relevant stakeholders in South East England in 2021. Interviews were supplemented with literature.Results: England’s local healthcare commissioning has made the transition towards a new organisational architecture, with some integrated care programmes running, and a dual top-down and bottom-up prioritisation process in place. The commissioning and consequent development of integrated care programmes have been hindered by various barriers, including difficulties in accessing and using information, operational challenges, and resource constraints. Investment decisions have mainly been driven by national directives and budget considerations, with a mixture of subjective and objective approaches. A systematic and data-driven framework could replace this ad-hoc prioritisation of integrated care and contribute to a more rational and transparent commissioning process.Conclusion: The emerging ICSs seem to open an opportunity for local commissioners to strengthen the commissioning process of integrated care with evidence-based priority-setting approaches similar to the well-established health technology assessment framework at the national level.

Introduction: In an era of fiscal constraint, economic evaluations are increasingly playing a role in resource allocation decisions to invest in integrated care IC approaches. Posing significant ethical concerns are healthcare investments informed by misleading or biased evidence due to poor methodological quality. We conducted a systematic review to assess the quality of economic evaluations in IC interventions, and identified the challenges associated with the evaluations. Theory/Methods: English publications that reported the concepts of “integrated care” and “economic evaluations”, were searched from the period 2000 to August 2017 in the following databases: PubMed, EMBASE, CINAHL, Web of Science and Scopus. The methodological rigor of the studies was assessed independently by two reviewers using a 30 item-check list adapted from the Consolidated Health Economic Evaluation Reporting Standards CHEERS. Descriptive statements about the challenges experienced when evaluating IC interventions, as reported by authors, were also thematically analysed. Results: We included 40 studies in this review, however, approximately half were considered full economic evaluations; often as part of randomized control trials. Four studies that stated that their research objectives were to examine the cost-effectiveness of the IC interventions, did not perform an incremental cost-effectiveness ratio or a net benefit regression analysis. Of the cohort studies that performed cost comparisons, only one study controlled for potential confounding differences between the intervention and standard care. Valuation of the effects of the IC intervention in the full economic evaluations was often measured using quality-adjusted-life years. In some scenarios where this was challenging to ascertain; particularly in large cohort studies, natural units were used, such as estimated depression-free days. There was variability in the perspectives used, with a minority of the evaluations considering the societal impacts, such as cost shifting between sectors or the economic burden on caregivers. The long-term costs and effects of the interventions were limited in the analyses due to the short observation periods range of 3 months to 5 years. However, some studies attempted to address this through modelling estimated lifetime costs and health outcomes associated with the intervention. Discussions: The complex nature of IC can challenge the application of traditional economic evaluation, making it important to identify these methodological gaps and learn from best-practices. However, other factors may explain the heterogeneous quality of the studies. These may include; the need for further guidance on the methods, the substantial human and financial resources required for data collection and conducting the evaluations, and a lack of economic evaluation culture. Conclusions: This review intended to highlight some of the gaps and opportunities for applying the fundamentals of economic evaluation to IC interventions. Benchmarking economic evaluations against guidelines such as the CHEERS checklist can be a potential catalyst for more consistent and higher quality evidence for decision makers. Limitations: A limitation is the subjective interpretations of the quality of the studies by the reviewers, which could influence how they were rated based on the criteria. However, a major strength is that two-blinded reviewers assessed the studies and based the quality scoring on a consensus.

Introduction : In the Netherlands, bundled payments were introduced gradually after 2010 to stimulate the integration of primary care services for different chronic conditions including diabetes, vascular risk management, COPD, depression, asthma, as well as for the elderly. The expectation for this reform was that integrated care could control healthcare expenditure by improving efficiency in primary care and promoting prevention. However, little is known whether this expectation is fulfilled. The aim of this study was to investigate the association between integrated care and healthcare costs in the Netherlands. Methods : Claims data from 2008 to 2017 from all Dutch health insurers was used. Enrolment of individuals in an integrated care programme was identified based on payment codes for integrated care services. Individuals entered integerated care at different points during this period. The control cohort consisted of individuals who were not enrolled in any integrated care programme and who were matched with individuals in the intervention cohort based on gender, age, socio-economic status, and type and number of chronic conditions. Cost were available on spending from basic health insurance in multiple categories e.g. GP, medication, and medical-specialist per person per half year from 2008 to 2015. Descriptive statistics and a preliminary analysis with an ordinary least squares were conducted. Preliminary Results : The intervention group consists of 2.8 million and the control group of 1 million persons. In 2008, both were of similar age median 70 and gender female 51%, and had similair costs €1600, semi-annual. More people in the intervention group used medical care, for example, for medication 87% vs. 77% and secondary care 64% vs. 53%. The largest integrated care programme in 2015 was for diabetes 675,000 people. From the people who started integrated care in 2008 over 55% stayed in the full 8 years. Patients with more than one chronic condition had higher costs €3640 vs €1236. For indivduals who had been enrolled in integrated care at the time, mean total costs remained virtually stable between the first half-year of 2008 and the first half-year of 2015 from €2558 to €2543. For those who had not been enrolled in integrated care at the time, the costs increased €1538 to €1964. Preliminary regression analysis showed that people in integrated care had increased costs of around €180 and that this amount did not reduce over time. Discussion : Preliminary results indicate that integrated care programmes were associated with higher costs. Further analysis based on type of costs needs to indicate whether cost differences were likely to be due to severity of disease for integrated care patients or due to integrated care itself. Sensitivity analysis will be performed to assess robustness of the results. Future analysis will focus on the effect of different types of financing for these programmes and whether integrated care has a different effect on people with multi-morbidity.

Background: Multi-morbidity is an increasing threat to population health and healthcare systems. A high proportion of people living in care homes have dementia, mental illness and/or physical frailty. Thus, this population has high and complex care needs, which require substantial healthcare expenditure. Intervention: An Integrated Care Home Support Service (CHSS) in Oxfordshire, England, combined two evidence based approaches to deliver a stepped care and treatment to meet both physical and mental health needs, called the BRIghTER DAWN programme. These evidenced based approaches trained staff to deliver Dementia Assessment of Wellbeing and Needs (DAWN) and/or a personalised intervention focusing on Building Relationships and Individually Tailored Evaluation and Responses (BRIghTER). Methods: Different data sources and methods were combined in this observational study to perform an economic evaluation of the CHSS. Individual patient data (IPD) on two-year community care utilisation and time alive since admission to a care home were used to calculate community care costs and Life Years (LYs) per patient. Mahalanobis one-to-one propensity score matching (PSM) was used to match 443 residents who received DAWN and/or BrighTER with residents from a control cohort of 5,339 residents with respect to community care costs at baseline, date admitted to a care home, date of birth, mental health cluster codes, gender, and care home. Multiple imputation by predictive mean matching was used to impute missing observations in community care cost at baseline. To reduce remaining confounding, 5,000 bootstrapped samples were generated from the paired dataset and for each one, Generalised Linear Models were specified to estimate incremental community care costs and incremental Lys adjusting for confounders. Difference-in-differences analysis supplemented with inverse probability weighting for propensity score matching was performed to estimate incremental non-elective hospital costs based. A decision model was built to combine the incremental costs and effects from the two different analyses to estimate costs per LY gained and to perform probabilistic sensitivity analysis. Uncertainty was displayed in cost-effectiveness acceptability curves. Results: The CHSS resulted to £575 higher costs and 0.04 more Lys than usual care resulting to an ICER of £13,886, which is considered to be cost-effective under conventional NICE thresholds (i.e. £20,000-£30,000). Looking at the interventions separately, DAWN was even more cost-effective (ICER=£2,081), while DAWN was less cost-effective (ICER=14,837) but still under NICE’s threshold. The probability of the interventions to be cost-effective at £20.000 ceiling ration was more than 80%. Discussion: This study demonstrated a series of methods to be used by health economists when dealing with Murphy’s law in the economic evaluation of complex interventions. Conclusion: The Integrated Care Home Support Service implemented in Oxfordshire was very likely to be cost-effective. Lessons learned: Evidence-based, integrated, and in-reach care home services improve health outcomes at reasonable costs. These value-for-money interventions can improve efficiency in elderly care and meet the complex needs of an rapidly increasing part of the population. Limitations: The impact of the CHSS on quality of life is not included in the economic evaluation. Suggestions for future research: Investigate whether the cost-effectiveness results are sustainable in time and replicable in other settings.

Introduction: A high proportion of people living in care homes have dementia, mental illness and/or physical frailty. An Integrated Care Home Support Service (CHSS) combined two evidence based approaches to deliver a stepped care and treatment to meet both physical and mental health needs, called the BRIghTER DAWN programme. These evidenced based approaches trained staff to deliver Dementia Assessment of Wellbeing and Needs (DAWN) and/or a personalised intervention focusing on Building Relationships and Individually Tailored Evaluation and Responses (BRIghTER). This presentation will outline some preliminary findings which formed part of a large implementation study over an 18 month period. Methods: Staff in the CHSS responded to care home concerns about residents needs for support with pain management and behaviour which staff found challenging and was distressing to residents. Measures, including staff ratings of residents’ symptoms, Neuropsychiatric Inventory and Abbey Pain Scale scores were collected from care home residents receiving the BRIghTER DAWN programme as part of care delivery in order to identify their needs and the effectiveness of the stepped care interventions provided. Results: A total of 507 episodes of care were completed across 81 care homes within one county of 102 care homes. The results identify the way in which care homes engaged with the service and the effectiveness of the stepped care approach in this setting. Key well-being needs were identified by the programme and how these were associated with effective clinical interventions. Discussion: The results of this evaluation demonstrates good uptake of an integrated service and successful ways of detecting pain and mental health needs within a care home population. It illustrates how service pathways can be integrated to provide early detection and intervention. Conclusion: A stepped care model of psycho-social interventions can be successfully implemented by an integrated physical and mental health team in reaching into care homes. The findings highlight the effectiveness of this approach in the treatment of pain and challenging behaviour in this context. Lessons learned: The wellbeing and mental health needs of residents in care homes can successfully be addressed in a stepped care model. With the appropriate training, integrated teams can successfully develop shared protocols and practice to provide early identification and treatment of needs. Limitations: This study was conducted in the context of the UK and whilst the clinical interventions themselves may be replicable widely the service model may not easily generalise to other service settings. Suggestions for future research: Future research would benefit from conducting a follow up to evaluate the maintenance of clinical outcomes for residents as well as to consider possible changes to the support needs of care homes.

Introduction: Decision-makers are interested in the cost-effectiveness of population health interventions but there is often lack of (robust) evidence from empirical economic evaluations. Thus, data synthesis and decision-modelling are frequently used by health economists to inform evidence-based decision-making. However, most literature reviews of evaluation studies are not designed to support an economic evaluation. Aim: We sought to develop a methodological approach to assess the cost-effectiveness of population health interventions alongside literature reviews. Methods: Several research methods and data sources were used to perform an economic analysis alongside a COCHRANE literature review of randomised controlled trials that compared inpatient comprehensive geriatric assessment (CGA) to usual care for older people urgently admitted to hospital. The review followed standard methodological procedures expected by Cochrane and EPOC. In addition, individual patient data (IPD) was requested from trialists and a survey of trialists was conducted to obtain details of the delivery of CGA. Mean hospital length of stay was derived from meta-analysis of seventeen studies and the relative costs were valued using English unit cost prices 2013/2014. Quality Adjusted Life Years (QALYs), were calculated by converting the Barthel Index from 3 trials, using IPD, to EQ-5D scores based on mapping studies. Life years (LYs) were estimated using the IPD from four trials by calculating the time-to-death from recruitment, and expressed as a fraction of a year. We created a variable 'life years living at home' (LYLAHs) after discharge from hospital, as a measure of independence and well-being in an older population, based on IPD from two trials. A decision model combined information from the meta-analyses and IPD and estimated an incremental cost-effectiveness ratio (ICER) of inpatient CGA expressed as a cost per QALY gained, cost per LY gained and cost per LYLAH gained from a health service perspective. Uncertainty was addressed by performing probabilistic and univariate sensitivity analysis. Results: The review of twenty nine trials recruiting 13,766 participants across nine countries found that patients who received CGA were more likely to be alive and in their own homes at follow-up. This is similar to the results from the economic evaluation that showed that CGA was more effective with respect to all three health outcome measurements (0.012 more QALYs, 0.037 more LYs, and 0.019 LYLAHs per patient). The health care costs per patient in the CGA group were £234 (95% CI -£144 to £605) higher than in usual care group. The ICER in terms of QALYs was £19,802, which is close to the £20,000 threshold that NICE suggests as a ceiling value for a QALY; the cost for a LY gained was £6,305 and for a LYLAH gained was £12,568. The probability of CGA to be cost-effective at a £20,000 ceiling ratio for a QALY, LY and LYLAH was 0.50, 0.89, and 0.47 respectively. Conclusions: The methodological approach used in this study provides decision-makers with economic evidence about CGA and could be used to evaluate any other health intervention. CGA is likely to be cost-effective at the NICE cut-off value of £20,000 for a QALY but the uncertainty is high. Limitations: The analysis did not include costs after patient discharge. Future research: Further work is required to establish the optimum way of combining review-based results with model-based economic evaluations.

There are 35 million people with dementia worldwide, many of whom live in care homes. For example, in the UK one third of people with dementia live in care home facilites, and a large proportion of these individuals have moderate or severe dementia and have highly complex care needs resulting from a combination of cognitive, functional and communication impairments, neuropsychiatric symptoms and medical comorbidity. The aim of the redesigned care home in-reach service in Oxfordshire is to improve the quality of care and health outcomes for people with dementia and enable family and paid carers to feel better supported to deliver their caring role. The model of care combines new ways of working which incorporates a biopsychosocial approach which has been effective in large scale research trials (Fossey, 2006;. Ballard, 2009) and to evaluate the effectiveness of the implementation in a routine NHS setting in the UK. The redesigned service integrates an established Care Home Support Service (physical health/ falls prevention team) with a mental health service which can work with all 102 care homes in the county in a responsive and preventative manner. The evaluation of this service uses the RE-AIM framework (Glasgow 1999) to determine the impact on - Reach of the service for indiivudals and services in the county - Effectiveness in terms of : o Health and well-being for people with dementia who receive the service using routine service outcome data for individuals . o County- wide Service use data – diagnosis rates for dementia, referrals to other services,admissions and length of stay o Family/carer satisfaction - Implementation , Adoption and maintenance factors o By thematic analysis of focus groups of staffs’ perception of benefits and difficulties of new model o Service quality data - Economic impact of this model of care This presentation will outline to key elements of the service redesign and initial findings arising from this 12 month study.