Models of Social Care for Older Adults in an Integrated Care System (MOSAICS).

The aim of this study, funded by the NIHR School for Social Care Research was to identify new models of integrated social care delivery for older people emerging within the Greater Manchester integrated arrangements ('Devo Manc'). There were three objectives.
•To identify and explore emergent service models attempting to integrate health and social care and their components.
•To describe potential costs and outcomes.
•To capture changes to service arrangements and associated workforce and training implications.

The devolution agenda as part of the ‘Manchester experiment’ has so far reported on the structure of resource integration and governance arrangements but has not explicated precisely what is happening on the ground in terms of changed service configurations and their possible impacts. The case study descriptions in this study (of who does what, where, for whom) are intended to enhance the social care evidence base by describing, in precise terms, how these newly integrated arrangements, between health and social care, are being operationalised. The study provides new data on the progress of individual local authorities and their achievements against a standard of integrated care practice; in terms of the fact that most investment is still required in relation to performance management and results focussed learning.

A mixed methods comparative case study approach was used comprising: documentary analysis; senior manager/practitioner interviews; examination of costs along proposed care pathways with cost-effectiveness modelling; measurement of the extent of integrated care, using an existing Development Model for Integrated Care tool; simulations with practitioners; and review of workforce implications.

Six case study sites were studied as exemplars of new working practices as part of the Greater Manchester agenda to integrate health and social care.

These sites offered changes in practice relating to complex care of older people; they focused on social care and integrated home care (n=2), old age mental health (n=2), and primary care (n=2).

Sites varied in the dimensions of integrated practice they achieved. Half of the sites (3/6) reached a consolidation and transformation phase, where integrated care is the regular way of working.

Through practitioner interviews and group exercises, we generated costs of both assessments and service delivery for each site. We compared these with costs from a previous study on a similar population of older people with complex needs before integration. Similarly, we derived outcomes, in terms of Quality Adjusted Life Years (QALYs), before and after integrated practices, from the literature.

All six sites achieved cost savings through their assessments, compared with before integration. However, service delivery costs, overall, were higher particularly for health care inputs.

Despite higher total costs for each site, compared with before integration, user well-being measured by the QALY was also higher for all sites. This necessitated incremental analysis to judge whether sites could be judged cost-effective. Analysis revealed that only one site, where social care interfaced with primary care, had a high probability of being cost-effective, against a commonly accepted cost threshold.