Thousands of vulnerable older people are being "missed" by the NHS and social services until they end up in hospital, trials of a US-led programme have suggested.
Early results from nine primary care trusts suggest large numbers of patients admitted to wards as emergencies have never appeared on the radar as being potentially at risk. Many are then sent home without support or care.
The health minister, John Hutton, said: "We certainly need to improve dramatically our performance on chronic diseases management and care."
But he welcomed signs that the trials were already averting preventable hospital admissions by getting patients fast-track care and planned treatment as well as shortening hospital stays for those who needed them. Patients were also said to be having a better quality of life.
An interim report by the Minneapolis-based organisers of the Evercare programme fails to give any hard figures on cuts in hospital admissions, but the Department of Health is convinced lessons are being learned.
Evercare, part of the United Health Group, has reduced admissions for similar vulnerable patients in the US by 50%.
A small US management team is overseeing the trials as well as bringing staff over on short trips to mentor and help train NHS "advanced primary nurses" into adopting more pro-active roles in spotting at-risk patients and improving liaison between GPs and hospital consultants.
In the trial patients were considered to be at high risk if they had had two unplanned hospital admissions in 13 months. Some had been in hospital 10 times in a year. Many had more than one chronic illness, took several drugs (placing them at increased risk of side-effects), and lived alone.
The trials have revealed that 3% of the over-65s in areas covered by the trials accounted for 35% of hospital admissions for that age group. Yet only a quarter of these vulnerable patients were being seen by district nurses and only 35% were on the local social services books. Three-quarters were still living in their own home.
The interim report said many unplanned admissions could have been avoided with good preventative care. Many patients had conditions such as urinary tract infections that should not normally become so severe as to require hospital treatment.
Mr Hutton said the government was determined to improve care for the 17.5 million people with conditions such as congestive lung disease, arthritis, diabetes or mental illness.
The Evercare experiment will cost about £5m, including £400,000 towards pilot areas, which also include Bristol, Wandsworth and Bexley in London, south Gloucestershire, Walsall, Airedale, Yorkshire and Halton in Cheshire.
"It seems modest expenditure for very significant health gain," said Ian Winstanley, the director of patient services at Luton PCT. "Many people over the age of 65 are more vulnerable to hospital admission and we must look at new ways of reducing this risk."
Help the Aged welcomed the report: "Two thirds of hospital patients are over the age of 65. Preventing the often avoidable decline into ill-health and dependency must be a priority."
