Improving the effectiveness and efficiency of Health and social care services for vulnerable Older Brazilians (IHOB).

Just as in the UK, Brazil has a large public healthcare system which aims to provide good care to all. And just as in the UK, it is facing mounting financial pressure, partly due to the health needs of a rapidly ageing population. This project aims to support policy and practice, with a view to improving the efficiency of service provision and optimising the health of older Brazilians.

We will focus on reducing numbers of unnecessary admissions of older people to hospitals, as well as to residential care homes, and excessively long stays there. These take resources away from services that could better meet the needs of older Brazilians. Also, unnecessary hospital stays expose older people to new health risks, such as hospital acquired infections, and are at odds with the stated preference of most older people to remain living in their own homes.

The study will develop a clear strategy for identifying whether an admission could have been averted, or a length of stay feasibly reduced. We will do this by looking at studies and experiences in other countries such as the UK and talking to policymakers and practitioners in Brazil. We will then analyse data from a new national survey called ELSI to see which older people are most likely to experience these problems and what situations trigger unneeded admissions/lengthy stays.

Brazil is geographically diverse and there are limits to what can be learned from statistical data. With this in mind, we will develop more detailed case studies of 2 cities in different regions: Belo Horizonte and Fortaleza. We will ask policymakers and practitioners about how things are done locally -this will cover many issues, including how people are referred from family doctors to hospital and how they are discharged from hospital. We will also work closely with people in social care, as this strongly affects health service use. In each city we will select about 20 older people from participants in the ELSI survey and talk to them and their families about their experiences.

Together, this information should provide a clear picture of the problem. We will also focus on solutions. We will look at experiences of other countries, especially the UK which has implemented a number of related policies and projects. We will review an interesting pilot project in Belo Horizonte (one reason we chose this location). The project offers temporary homecare services for frail people, in order to help family members learn how to provide this care themselves and with a view to preventing future need for more intensive and expensive service provision. We will carefully assess this project, considering how well it has worked (in the eyes of practitioners, as well as older people and families) and if it has effected unneeded admissions/long stays. We will also use local data on hospital admissions for different health conditions. Working closely with local officials, we will suggest modifications to the project, as needed.

In all pilot projects a big challenge is assessing if they can be extended to new locations. Belo Horizonte is a relatively affluent city with good services, but what about poorer cities? Why this in mind, we will assess the feasibility of extending the pilot project (or a modified version, if required) to Fortaleza. Working with policymakers and practitioners, we will develop a local version of the project and apply it to about 20 families over 6 months. If it looks promising, we plan to ask for more funds, separately from this study, for a larger pilot which we can assess more thoroughly.

We will work closely with policymakers and practitioner throughout the study. Towards the end, we will provide a high-level national report summarising the evidence and what we have learned, as well as more specific "toolkits" for people working in local Brazilian health districts. We hope this will also inform efforts in the UK and other countries to face these important challenges.

This study will support policy and practice to reduce unneeded admissions of older people to hospitals and care homes, and reduce unnecessarily long stays. We will develop and apply a new concept, "avoidable displacement from home" (ADH), and apply it in the Brazilian context.

Drawing on a systematic review and interviews with policymakers and practitioners, we will identify criteria for defining ADHs (admissions to hospitals/care homes that could have been realistically averted or shortened) which are applicable in Brazil.

Using survey data, supplemented by in-depth, multi-method case studies in Belo Horizonte (BH) and Fortaleza (FZ), we will assess the prevalence of ADH nationally and in specific settings. Likewise, we will identify key predictors of ADH, with a particular focus on more vulnerable older people and their families.

We will identify potential interventions to reduce rates of ADH in different parts of Brazil. This will draw on the systematic review, an evaluation of an intervention in BH and the implementation of a validation/feasibility study in FZ. The BH intervention provides frail older people with a week of intensive home care, serving both as respite for family carers and to build family carer capacity. We will apply a mixed method evaluation of process and outcome, drawing on interviews with key informants, practitioners and users and data linking diagnostic related groups and admissions. We will develop a version of this intervention (contingent on BH evaluation results) in FZ, with a view to full pilot and evaluation in a further funded study.

We will produce a national report and develop an ADH toolkit for Brazilian policymakers and practitioners including definitional criteria for ADHs, predictors of ADH and evidence-based strategies to reduce ADH. We will engage intensively with policy networks in the UK and globally, assessing the wider conceptual and operational relevance of ADH.

National impact:
Policy-makers have expressed a strong interest in improving the effectiveness of health and social care provision for older people. This includes exploiting new resources such as ELSI-Brasil, learning from interventions piloted in local settings and drawing from international experience. This project directly meets all these needs. We will publish an evidence-based plan to enhance health and social care provision for vulnerable older people and practitioner toolkit: both on reducing unneeded admissions and providing integrated community services.

Local impact:
Our analysis of admissions predictors will enable policymakers to target current interventions on most high risk groups. Our evidence will support enhancements to protocols and practice. The evaluation of PMC will lead to either the extension, modification or termination of this project. PMC may be identified as a model of good practice for other Brazilian states. The Fortaleza feasibility study will not directly inform policy until it has been evaluated more robustly. It will, however, generate greater awareness of related issues among local professionals and policymakers.

Engagement strategies in Brazil:
During inception, at least 2 national policymakers (one with a focus on health and one on social care) and 2 each from Minas Gerais and Ceará will be recruited to the user group. The user group will include NGOs and local organisations representing older people, and will feed into all aspects of the project. They will attend all project planning meetings and the national workshop. Members of the group will be asked to perform the role of "change agents" within their networks of influence. We will support this activity by providing them with study findings in suitable formats. The national workshop will launch a major policy paper and we will publish at least 3 papers in Brazilian academic journals.

International:
The ELSI analysis and case studies will inform similar studies in other middle-income countries. Surveys on the health of older people are increasingly available in these countries. Policy-makers are interested in drawing on these surveys to support policies to limit unneeded hospital and care home admissions. Analysis of the PMC project in Belo Horizonte and insights from the feasibility study will be of interest to policy-makers, who are seeing to identify examples of good practice in this area. The UK PI has strong international networks in related areas, including a senior secondment to WHO's Department of Ageing and Life Course, was a core author of WHO's 2015 Ageing and Health flagship report and has ongoing collaborations with WHO. He is a senior health policy adviser for HelpAge International and has an ongoing ESRC funded project on health interventions for older people in South Africa and Ghana.

Global engagement strategies:
Specific activities will depend on research insights and opportunities generated during the study, but include:

submit an abstract proposal to the Fifth Global Symposium on Health Systems Research to be held in Liverpool, UK in October 2018. This will lead onto a proposal for a related Thematic Working Group on Health Systems for Older People to Health Systems Global (http://www.healthsystemsglobal.org/twg/).

publish and disseminate a global policy brief and international journal article based on the systematic literature review of interventions to reduce unneeded hospital and social care admissions of older people, with a particular focus on LMICs.

publish and disseminate a global policy brief and international journal article based on Brazilian secondary data analysis of health service use by older people and triggers for hospitalisation. This will be used to inform similar analysis and policy debate in other LMICs.

share intervention materials and findings, including as part of a new WHO Ageing and Life Course inventory of best practice in LMICs.