SHarED: Supporting people who are ‘high impact users’ of emergency departments
In England, patients who attend emergency departments (A&E) five or more times a year represent 2 per cent of attendees but account for 11 per cent of attendances. These patients are known as ‘high impact users’.
High impact users have often experienced extremely challenging situations in their lives. This can include experiences of violence, exploitation, alcohol and drug abuse, homelessness, chaotic life conditions, chronic pain, complex medical conditions, and, particularly, mental health conditions.
These patients often:
- have a complex medical history
- access other health and social care services
- are admitted to hospital
- have long-term health conditions
Personalised care plans for high impact users could improve how these people access healthcare. These plans could help more of these patients use other services such as GP care, and reduce their use of emergency care and admission to hospital. Managing these patients better could improve their lives and save the NHS money.
The West of England Academic Health Science Network (AHSN) programme ‘Supporting high impact users in emergency departments’ (SHarED) supported six emergency departments in the region to introduce personalised care plans for high impact users, with input from healthcare professionals from a range of disciplines.
The SHarED programme was based on an approach developed at the Bristol Royal Infirmary. SHarED aimed to reduce emergency department attendances by high impact users by 20 per cent in a year.
Project aims
We added to the West of England AHSN’s evaluation of the SHarED programme by:
- Analysing whether patients enrolled in SHarED changed their use of emergency department attendance compared to other high impact users
- Interviewing healthcare professionals who support high impact users about their experience of SHarED
- Estimating how much the SHarED approach cost to provide
- Providing support to the West of England AHSN and emergency department staff to improve analysis of the impact on emergency department attendance by high impact users
What we found and what this means
SHarED successfully promoted better and more integrated care for high impact users. It also gave practical support to emergency department staff working in very difficult environments.
SHarED helped emergency departments improve how they managed high impact users. Staff learned from the Bristol Royal Infirmary model and established networks between staff working in different emergency departments. From non-existent or unstructured services for these patients, SHarED enabled more structured services to develop.
The main way to manage these patients was personal support plans, which:
- Enabled staff to engage with some patients about their behaviour and needs
- Gave staff recommendations on how to interact with and care for patients
- Promoted collaboration between different specialist teams across the health and care system for more integrated care
The staff involved in the programme felt SHarED was very positive for both emergency department staff and high impact users. They believed care was more appropriate, consistent and person-centred. They also felt patients would experience less stigma if staff were more empowered to help them.
A total of 148 high impact users enrolled in SHarED, but emergency department attendance and hospital admission follow-up data varied from three months (148 patients) to 12 months (33 patients). Data was available for 86% (127/148) of patients for six months before and after being enrolled in SHarED. For these cases, attendance reduced by 33% from 2.1 to 1.4 attendances per month on average. Similarly, hospital admissions reduced by 67% from 0.6 to 0.2 admissions per month on average.
SHarED enabled training on the management of high impact users to be given to 55% of staff (372/671) across the emergency departments.
What next?
The SHarED programme has helped improve care for high impact users and the working conditions of staff. Integrated Care Boards should consider funding teams focused on these patients. Rollout of the SHarED model could help establish better services and reduce emergency department attendance and hospital admissions for these patients.
Lead collaborators
- Clare Evans, West of England Academic Health Science Network
ARC West Staff
Carlos Sillero Rejon
Research Associate, Health Economics
Gareth Myring
Research Associate, Health EconomicsPartners on this project
University of Bristol
The University of Bristol is internationally renowned and one of the very best in the UK, due to its outstanding teaching and research, its superb facilities and highly talented students and staff. Its students thrive in a rich academic environment which is informed by world-leading research. It hosts the Elizabeth Blackwell Institute for Health Research.
West of England Academic Health Science Network
The West of England Academic Health Science Network is a diverse network of partners working collaboratively to put innovation at the heart of healthcare, to improve patient outcomes and contribute to wealth creation. It aims to do this by translating research into practice, and developing and implementing integrated health care services.