'Weighing up risks': a model of care home staff decision-making about potential resident hospital transfers

Models of Care for Older People: A Scoping Review

BACKGROUND

International recognition of the increasing importance of care for older people has seen growing interest in models of care for older people. Yet there is limited information about the scope and breadth of models of care for older people. This article clarifies what is known about models of care for older people by summarizing relevant publications, describing the models depicted in these publications, and synthesizing the outcomes and impact presented in the publications.

METHOD

A scoping review was conducted that involved searching multiple databases to identify relevant publications, published in English, which presented a model of care for older people-specifically, non-Indigenous people aged ≥ 65 years and/or Indigenous people aged ≥ 50 years; and included evidence, broadly defined, about the utility or otherwise of the model. Commentaries, narrative letters, editorials, and reviews were excluded.

RESULTS

From 21,767 publications, 276 were deemed relevant. From these, four key findings are apparent. First, models of care for older people are understood in disparate ways and are typically devoid of clear stepwise guidance. Second, most of the publications reported on a multidisciplinary approach. Third, they generally failed to involve carers. Fourth, very few publications reported on studies conducted in a rural area, and none involved Indigenous people.

CONCLUSION

Given the heterogeneity and breadth of models of care for older people, further research is needed to establish: a definition of a model of care for older people; reporting standards; the factors that help or hinder their effectiveness; how to ensure carer involvement; and how to adapt models of care for older people for priority populations.

Care home quality and 'inappropriate' emergency healthcare use-failing to engage with complexity

Care home residents are more likely to experience unplanned, emergency healthcare than those living elsewhere in the community. This can be potentially burdensome for both individual residents and healthcare systems. Academic and policy attention has focussed on quantifying this resource use, exploring potential causes and reducing unplanned emergency healthcare. Considerable attention has been placed on emergency healthcare that may be 'inappropriate' or 'avoidable'. In this commentary, we problematise such concepts. We suggest that the absence of an agreed definition can lead to wide variation in estimations which fail to acknowledge the complexity of care home residents' needs and their right to timely healthcare support. We draw attention to the impact of popular discourse in this area as potentially stigmatising to care home organisations, staff and residents. We argue that emergency healthcare use data alone is insufficient to measure and evaluate the quality of care provided by care homes. We propose a move away from over-simplistic distinctions, between emergency healthcare that is or is not 'appropriate', to develop more nuanced conceptualisations that account for the complexity involved in providing healthcare support to people living in care homes. People living in care homes have significant healthcare needs. It is necessary that models of care supporting homes are resourced to respond and support care home professionals. Rather than focusing solely on quantifying emergency healthcare use, acknowledging and embracing complexity will help to refocus our efforts and redesign our services around both individual and population needs, rather than around existing systems.

Addressing unnecessary and avoidable transfers from residential aged care to emergency departments and hospitals

Purpose The purpose of this article is to examine and discuss the literature regarding emergency department (ED) transfers from residential aged care with a focus on reducing potentially avoidable transfers to enhance care experiences, safety, and outcomes. Design Researchers experienced in evidence synthesis and policy research in the aged care space reviewed the literature about residential aged care transfers to EDs, including factors underlying transfers and interventions to reduce transfers. Findings Transfers to EDs from aged care are common. They can be harmful, distressing, costly, and have a variety of negative impacts on residents, staff, and the aged care and health system. High rates of potentially avoidable or unwarranted transfers suggests the presence of systemic issues, including the lack of sufficient staffing levels and skills mix with the requisite knowledge, training, resources, and support. Reforms are required to improve staffing levels and skills mix, enhance access to on-site and in-reach clinical expertise, provide access to quality improvement initiatives, and engage consumers to ensure shared decision-making. Further research is also required to help determine the best approach to reducing unnecessary hospital transfers from aged care considering the specific scopes of practice of aged care workers. Conclusion While some transfers from residential aged care to EDs are necessary, many do not represent safe, dignified care for older people. Unwarranted transfers are burdensome and risky and should be minimised through the provision of a range of reforms including sufficient staffing, resources, and support, that allow for the delivery of care in place where appropriate.

Using Palliative Care Needs Rounds in the UK for care home staff and residents: an implementation science study

Background

Care home residents often lack access to end-of-life care from specialist palliative care providers. Palliative Care Needs Rounds, developed and tested in Australia, is a novel approach to addressing this.

Objective

To co-design and implement a scalable UK model of Needs Rounds.

Design

A pragmatic implementation study using the integrated Promoting Action on Research Implementation in Health Services framework.

Setting

Implementation was conducted in six case study sites (England, n = 4, and Scotland, n = 2) encompassing specialist palliative care service working with three to six care homes each.

Participants

Phase 1: interviews (n = 28 care home staff, specialist palliative care staff, relatives, primary care, acute care and allied health practitioners) and four workshops (n = 43 care home staff, clinicians and managers from specialist palliative care teams and patient and public involvement and engagement representatives). Phase 2: interviews (n = 58 care home and specialist palliative care staff); family questionnaire (n = 13 relatives); staff questionnaire (n = 171 care home staff); quality of death/dying questionnaire (n = 81); patient and public involvement and engagement evaluation interviews (n = 11); fidelity assessment (n = 14 Needs Rounds recordings).

Interventions

(1) Monthly hour-long discussions of residents' physical, psychosocial and spiritual needs, alongside case-based learning, (2) clinical work and (3) relative/multidisciplinary team meetings.

Main outcome measures

A programme theory describing what works for whom under what circumstances with UK Needs Rounds. Secondary outcomes focus on health service use and cost effectiveness, quality of death and dying, care home staff confidence and capability, and the use of patient and public involvement and engagement.

Data sources

Semistructured interviews and workshops with key stakeholders from the six sites; capability of adopting a palliative approach, quality of death and dying index, and Canadian Health Care Evaluation Project Lite questionnaires; recordings of Needs Rounds; care home data on resident demographics/health service use; assessments and interventions triggered by Needs Rounds; semistructured interviews with academic and patient and public involvement and engagement members.

Results

The programme theory: while care home staff experience workforce challenges such as high turnover, variable skills and confidence, Needs Rounds can provide care home and specialist palliative care staff the opportunity to collaborate during a protected time, to plan for residents' last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while harnessing services' complementary expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication. This can improve resident care, enabling residents to be cared for and die in their preferred place, and may benefit relatives by increasing their confidence in care quality.

Limitations

COVID-19 restricted intervention and data collection. Due to an insufficient sample size, it was not possible to conduct a cost-benefit analysis of Needs Rounds or calculate the treatment effect or family perceptions of care.

Conclusions

Our work suggests that Needs Rounds can improve the quality of life and death for care home residents, by enhancing staff skills and confidence, including symptom management, communications with general practitioners and relatives, and strengthen relationships between care home and specialist palliative care staff.

Future work

Conduct analysis of costs-benefits and treatment effects. Engagement with commissioners and policy-makers could examine integration of Needs Rounds into care homes and primary care across the UK to ensure equitable access to specialist care.

Study registration

This study is registered as ISRCTN15863801.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128799) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 19. See the NIHR Funding and Awards website for further award information.

Anticipatory prescribing of injectable controlled drugs (ICDs) in care homes: a qualitative observational study of staff role, uncertain dying and hospital transfer at the end-of-life

BACKGROUND

The anticipatory prescribing of injectable controlled drugs (ICDs) by general practitioners (GPs) to care home residents is common practice and is believed to reduce emergency hospital transfers at the end-of-life. However, evidence about the process of ICD prescribing and how it affects residents' hospital transfer is limited. The study examined how care home nurses and senior carers (senior staff) describe their role in ICDs prescribing and identify that role to affect residents' hospital transfers at the end-of-life.

METHODS

1,440 h of participant observation in five care homes in England between May 2019 and March 2020. Semi-structured interviews with a range of staff. Interviews (n = 25) and fieldnotes (2,761 handwritten A5 pages) were analysed thematically.

RESULTS

Senior staff request GPs to prescribe ICDs ahead of residents' expected death and review prescribed ICDs for as long as residents survive. Senior staff use this mechanism to ascertain the clinical appropriateness of withholding potentially life-extending emergency care (which usually led to hospital transfer) and demonstrate safe care provision to GPs certifying the medical cause of death. This enables senior staff to facilitate a care home death for residents experiencing uncertain dying trajectories.

CONCLUSION

Senior staff use GPs' prescriptions and reviews of ICDs to pre-empt hospital transfers at the end-of-life. Policy should indicate a clear timeframe for ICD review to make hospital transfer avoidance less reliant on trust between senior staff and GPs. The timeframe should match the period before death allowing GPs to certify death without triggering a Coroner's referral.

Economic and cost considerations of delivering and using mobile X-ray services in residential aged care facilities: A qualitative study

OBJECTIVE

To describe the economic and cost considerations of mobile X-ray services (MXS) in residential aged care facilities (RACFs), according to stakeholders (involved in residents' healthcare), residents living in RACFs and informal carers (ICs) of residents.

METHODS

Semistructured interviews were conducted with 20 residents and 27 ICs recruited from six RACFs across metropolitan Adelaide (South Australia, Australia), and 22 stakeholders, on their perspectives of using MXS in RACFs. Data relating to economic and cost considerations were extracted and analysed using thematic analysis.

RESULTS

Residents' mean age was 85 years, 60% were women and 40% had experienced an MXS in the last 12 months. Most ICs were daughters (70%) and wives (11%) and 30% had a family member who had experienced an MXS in the last 12 months. Stakeholders included RACF staff, GPs, a hospital avoidance program clinician, paramedics, emergency department clinicians, MXS radiographers and manager, and a radiologist. Four themes were presented: (1) business considerations, where private providers found it necessary to charge residents a co-payment to deliver MXS; (2) cost and payment process as a potential barrier to using MXS, with varied willingness and ability to pay for an MXS co-payment, and equity concerns; (3) overcoming cost and payment barriers, with staff and consumers sometimes using strategies to overcome cost barriers; and (4) perceived cost benefits of MXS to the healthcare system, residents and ICs.

CONCLUSIONS

Mobile X-ray services providers charge residents an upfront co-payment for business viability, which can be a barrier to some residents wishing to access MXS.

Recognising and responding to acute deterioration in care home residents: a scoping review

BACKGROUND

Acute deterioration describes a rapid change in physical and/or mental health resulting from an acute illness - e.g., heart attack or infection. Older people in care homes are some of the frailest and vulnerable in society. They have complex health needs, experience multiple long-term conditions (MLTC) and have weakened immune systems due to the ageing process. They are more susceptible to acute deterioration and delayed recognition and response, is linked to poorer health outcomes, adverse events and death. Over the past five years, the need to manage acute deterioration in care homes and prevent hospital admissions has led to development and implementation of improvement projects, including the use of hospital derived practices and tools to identify and manage this condition. This is potentially problematic as care homes are different from hospitals-options to escalate care vary throughout the UK. Further, hospital tools have not been validated for use in care homes and have shown to be less sensitive in older adults living with frailty.

OBJECTIVES

To collate the available evidence on how care home workers recognise and respond to acute deterioration in residents using published primary research, non-indexed and grey literature, policies, guidelines and protocols.

METHODS

A systematic scoping review was conducted following Joanna Briggs Institute (JBI) scoping review methodology. Searches were conducted using: CINAHL (EBSCOhost), EMCARE (OVID), MEDLINE (OVID) and HMIC (OVID). Snowball searches of included studies' reference lists were conducted. Studies that featured care homes with or without nursing and provided 24/7 care to residents were included.

RESULTS

Three hundred and ninety-nine studies were identified. After reviewing all studies against inclusion criteria, n = 11 were included in the review. All studies used qualitative methods and were conducted in Australia, UK, South Korea, USA and Singapore. Four themes were generated from the review: identifying residents with acute deterioration; managing acute deterioration, care home policies and procedures, and factors affecting recognition and response to acute deterioration.

FINDINGS

Recognition and response to acute deterioration in residents is determined by multiple factors and is context sensitive. There are several interrelated factors within and external to the care home that contribute to how acute deterioration is recognised and managed.

CONCLUSIONS AND IMPLICATIONS

The available literature on how care home workers recognise and respond to acute deterioration is limited and often subtends other areas of interest. Recognising and responding to acute deterioration in care home residents is reliant on a complex and open system encompassing multiple interrelated components. The phenomenon of acute deterioration remains underexplored and further research is required to examine contextual factors that accompany identification and management of this condition in care home residents.

Factors influencing conveyance of older adults with minor head injury by paramedics to the emergency department: a multiple methods study

BACKGROUND

Head injury (HI) in older adults due to low-energy falls result in a substantial number of emergency department (ED) attendances. However, mortality associated with minor HI is very low. Reducing conveyance to hospital is important for older adults and is a priority for the National Health Service (NHS). Therefore, paramedics are required to make accurate decisions regarding conveyance to the ED. This study used routine data and semi-structured interviews to explore the factors that influence paramedic decision-making when considering whether to convey an adult aged 65 years and over with a minor HI to the ED.

METHODS

Semi-structured telephone interviews were completed with ten UK paramedics from a single EMS (ambulance) provider organisation. Interviews explored the factors influencing the paramedics' conveyance decision-making in adults aged 65 years and over with a minor HI. Data were initially analysed inductively to develop a thematic framework. A retrospective analysis of ambulance service data was also completed to determine the scope and scale of the issue in Southwest England. An in-depth audit of 100 conveyed patient records was used to determine the proportion of patients conveyed to the ED who met National Institute for Health and Care Excellence (NICE) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines.

RESULTS

In 2019 South Western Ambulance Service NHS Foundation Trust (SWASFT) attended 15,650 emergency calls to patients aged 65 and over with minor HI, with 70.5% conveyed to ED. 81% of conveyed patients met NICE and JRCALC guideline criteria for conveyance, with the remainder conveyed due to wound care or other medical concerns. The framework developed from the interviews comprised four themes: resources; patient factors; consequences; paramedic factors. Important factors included: the patient's social situation; guidelines; clinical support availability; the history and presentation of the patient; risk.

CONCLUSION

This study examined paramedic conveyance decisions for older people with minor HI. It identified multiple influencing factors, highlighting the complex nature of these decisions, and may serve as a basis for developing an intervention to safely decrease ED conveyance in this patient group.