Optimal healthcare delivery to care homes in the UK: a realist evaluation of what supports effective working to improve healthcare outcomes

Integrated Long-Term Care 'Neighbourhoods' to Support Older Populations: Evolving Strategies in Japan and England

Western countries are currently facing the public health challenge of a rapidly aging population and the associated challenge of providing long-term care services to meet its needs with a reduced working age population. As people age, they will increasingly require both health and social care services to maintain their quality of life and these will need to be integrated to provide cost-effective long-term care. The World Health Organization recommended in 2020 that all countries should have integrated long-term care strategies to better support their older populations. Japan, with the most rapidly ageing society in the world, started to address this challenge in the 1990s. In 2017, it introduced a national policy for integrated long-term health and social care services at a local geographical level for older people. England has recently embarked on its first plan aiming for the integration of services for older people. In this article, we compare these approaches to the integration of long-term care systems, including the strengths of each. The paper also considers the effects of historical, cultural and organizational factors and the emerging role of technology. Finally, we identify critical lessons that can inform strategy development in other countries, and highlight the need to provide more international comparisons.

Realist approach to community-based participatory research on a community health break-down in Japan: mechanism reasoning, knowledge and a trust partnership

BACKGROUND

Our 10-year programme of community health regeneration and community-based participatory research (CBPR) was initially unknown. However, we succeeded in creating a collaboration between residents, medical staff, and administrative staff. We adopted a realist approach as an evaluation method.

METHODS

The realist approach evaluates a programme using a Context-Mechanism-Outcome configuration (CMOc), which is a relatively new methodology. First, the programme manager summarised the entire programme, conducted questionnaires and interviews with seven core members, and summarised each into a CMOc. The programme was evaluated with particular focus on mechanistic reasoning.

RESULTS

The number of doctors and nurses increased and residents became more active. The success factors were the acquisition of participants' knowledge and trust partnerships. In addition, it was important that the timing of the activity was good and that the participants were highly conscious.

CONCLUSIONS

The 10-year CBPR was examined using a realist evaluation method. Knowledge acquisition and trust partnerships are important for reasoning mechanism.

Patterns of visiting nurse services for older adults in Japanese residential facilities: A latent class analysis

AIM

To examine the patterns of the visiting nurse services provided to older adults in a type of residential facility in Japan and to identify associated factors.

METHODS

This secondary analysis used past survey data from visiting nurse service agencies providing services to older adults in residential facilities with few nurses, known as non-specified facilities in Japan. Approximately 515 cases were used to determine the patterns of visiting nurse services using latent class analysis. Multinomial logistic regression analysis examined the relationships between identified classes, residents' characteristics, facilities, and services provided by visiting nurses.

RESULTS

Three service patterns were identified as follows: Class 1, observational and follow-up care (37.1%); Class 2, chronic disease care (35.7%); and Class 3, end-of-life care (27.2%). Class 1 comprised fewer nursing services than the other classes and primarily involved the observation of medical conditions, whereas Classes 2 and 3 involved higher care-need levels and provided diverse nursing care support. Specifically, Class 3 was associated with the inclusion of family (odds ratio: 2.42) and a visiting nurse at the attached facility (odds ratio: 4.88).

CONCLUSIONS

The three identified classes describe the older residents' healthcare needs. Additionally, the factors associated with the end-of-life care class suggest that older residents with these factors may have difficulty accessing end-of-life care by visiting nurses. Geriatr Gerontol Int 2023; ••: ••-••.

Provision of palliative and end-of-life care in UK care homes during the COVID-19 pandemic: A mixed methods observational study with implications for policy

Introduction

Little consideration has been given to how the provision of palliative and end-of-life care in care homes was affected by COVID-19. The aims of this study were to: (i) investigate the response of UK care homes in meeting the rapidly increasing need for palliative and end-of-life care during the COVID-19 pandemic and (ii) propose policy recommendations for strengthening the provision of palliative and end-of-life care within care homes.

Materials and methods

A mixed methods observational study was conducted, which incorporated (i) an online cross-sectional survey of UK care homes and (ii) qualitative interviews with care home practitioners. Participants for the survey were recruited between April and September 2021. Survey participants indicating availability to participate in an interview were recruited using a purposive sampling approach between June and October 2021. Data were integrated through analytic triangulation in which we sought areas of convergence, divergence, and complementarity.

Results

There were 107 responses to the survey and 27 interviews. We found that (i) relationship-centered care is crucial to high-quality palliative and end-of-life care within care homes, but this was disrupted during the pandemic. (ii) Care homes' ability to maintain high-quality relationship-centered care required key "pillars" being in place: integration with external healthcare systems, digital inclusion, and a supported workforce. Inequities within the care home sector meant that in some services these pillars were compromised, and relationship-centered care suffered. (iii) The provision of relationship-centered care was undermined by care home staff feeling that their efforts and expertise in delivering palliative and end-of-life care often went unrecognized/undervalued.

Conclusion

Relationship-centered care is a key component of high-quality palliative and end-of-life care in care homes, but this was disrupted during the COVID-19 pandemic. We identify key policy priorities to equip care homes with the resources, capacity, and expertise needed to deliver palliative and end-of-life care: (i) integration within health and social care systems, (ii) digital inclusivity, (iii) workforce development, (iv) support for care home managers, and (v) addressing (dis)parities of esteem. These policy recommendations inform, extend, and align with policies and initiatives within the UK and internationally.

General practitioners' role in improving health care in care homes: a realist review

BACKGROUND

Despite recent focus on improving health care in care homes, it is unclear what role general practitioners (GPs) should play. To provide evidence for future practice we set out to explore how GPs have been involved in such improvements.

METHODS

Realist review incorporated theory-driven literature searches and stakeholder interviews, supplemented by focussed searches on GP-led medication reviews and end-of-life care. Medline, Embase, CINAHL, PsycInfo, Web of Science, and the Cochrane library were searched. Grey literature was identified through internet searches and professional networks. Studies were included based upon relevance. Data were coded to develop and test contexts, mechanisms, and outcomes for improvements involving GPs.

RESULTS

Evidence was synthesized from 30 articles. Programme theories described: (i) "negotiated working with GPs," where other professionals led improvement and GPs provided expertise; and (ii) "GP involvement in national/regional improvement programmes." The expertise of GPs was vital to many improvement programmes, with their medical expertise or role as coordinators of primary care proving pivotal. GPs had limited training in quality improvement (QI) and care home improvement work had to be negotiated in the context of wider primary care commitments.

CONCLUSIONS

GPs are central to QI in health care in care homes. Their contributions relate to their specialist expertise and recognition as leaders of primary care but are challenged by available time and resources to develop this role.

Frailty nurse and GP-led models of care in care homes: the role of contextual factors impacting Enhanced health in care homes framework implementation

BACKGROUND

The Enhanced Health for Care homes (EHCH) framework is an innovative response to provide more proactive, preventative approaches to care for residents living in care homes. It involves co-producing a shared vision with primary care. As part of EHCH a UK clinical commissioning group supported GP's in two localities to implement their preferred delivery approach involving a new Frailty Nurse-led (FN-led) model in care homes alongside an existing General Practitioner-led (GP-led) model. This paper focuses on implementation of the new FN-led model.

METHODS

A qualitative study design was adopted. Forty-eight qualitative semi-structured interviews were undertaken across six care home sites in a Northern locality: three implementing the FN-led and three engaged in an existing GP-led model. Participants included residents, family members, care home managers, care staff, and health professionals working within the EHCH framework.

RESULTS

Two overarching themes were generated from data analysis: Unanticipated implementation issues and Unintended consequences. Unsuccessful attempts to recruit Frailty Nurses (FN) with enhanced clinical skills working at the desired level (UK NHS Band 7) led to an unanticipated evolution in the implementation process of the FN-led model towards 'training posts'. This prompted misaligned role expectations subsequently provoking unexpected temporary outcomes regarding role-based trust. The existing, well understood nature of the GP-led model may have further exacerbated these unintended consequences.

CONCLUSION

Within the broader remit of embedding EHCH frameworks, the implementation of new FN roles needed to evolve due to unforeseen recruitment issues. Wider contextual factors are not in the control of those developing new initiatives and cannot always be foreseen, highlighting how wider factors can force evolution of planned implementation processes with unintended consequences. However, the unintended consequences in this study highlight the need for careful consideration of information dissemination (content and timing) to key stakeholders, and the influence of existing ways of working.

Developing a care home data platform in Scotland: a mixed methods study of data routinely collected in care homes

BACKGROUND

care homes collect extensive data about their residents, and their care, in multiple ways, for multiple purposes. We aimed to (i) identify what data are routinely collected and (ii) collate care home managers' views and experiences of collecting, using and sharing data.

METHODS

we examined data collected in six care homes across Lothian, Scotland. We extracted the meta-data, cross-referenced definitions and assessed the degree of harmonisation between care homes and with data sets currently in use in Scotland and internationally. We interviewed care home managers about their views and experiences of collecting, using and sharing data.

RESULTS

we identified 15 core data items used routinely, with significant heterogeneity in tools and assessments used, and very limited harmonisation. Two overarching themes were identified of importance to the development of a care home data platform: (i) the rationale for collecting data, including to (a) support person-centred care, (b) share information, (c) manage workforce and budget and (d) provide evidence to statutory bodies and (ii) the reality of collecting data, including data accuracy, and understanding data in context.

DISCUSSION

considerable information is collected by care home staff, in varied formats, with heterogeneity of scope and definition, for range of reasons. We discuss the issues that should be considered to ensure that individual resident-level form the strong foundations for any data platform for care homes, which must also include, robust infrastructure and clear interoperability, with appropriate governance. It must be co-produced by academics, policy makers and sector representatives, with residents, their families and care staff.

A realist evaluation of a multifactorial falls prevention programme in care homes

BACKGROUND

falls in care homes are common, costly and hard to prevent.Multifactorial falls programmes demonstrate clinical and cost-effectiveness, but the heterogeneity of the care home sector is a barrier to their implementation. A fuller appreciation of the relationship between care home context and falls programme delivery will guide development and support implementation.

METHODS

this is a multi-method process evaluation informed by a realist approach.Data include fidelity observations, stakeholder interviews, focus groups, documentary review and falls-rate data. Thematic analysis of qualitative data and descriptive statistics are synthesised to generate care home case studies.

RESULTS

data were collected in six care homes where a falls programme was trialled. Forty-four interviews and 11 focus groups complemented observations and document review.The impact of the programme varied. Five factors were identified: (i) prior practice and (ii) training may inhibit new ways of working; (iii) some staff may be reluctant to take responsibility for falls; (iv) some may feel that residents living with dementia cannot be prevented from falling; and, (v) changes to management may disturb local innovation.In some care homes, training and improved awareness generated a reduction in falls without formal assessments being carried out.

CONCLUSIONS

different aspects of the falls programme sparked different mechanisms in different settings, with differing impact upon falls.The evaluation has shown that elements of a multifactorial falls programme can work independently of each other and that it is the local context (and local challenges faced), which should shape how a falls programme is implemented.

Models of Care and Relationships with Care Homes: Cross-Sectional Survey of English General Practices

The Enhanced Health in Care Homes framework for England sets out standards for how primary care should work with care homes. How care home staff and General Practitioners work together and the quality of their working relationships are core to resident healthcare. This study explored the current models of care and relationships between General Practitioners' practices and care homes. Sixty-seven respondents from 35 practices were recruited in the East of England and completed a semi-structured online survey. Responses were analysed using descriptive statistics. Free text responses were interpreted thematically. The number of care homes that practices supported ranged from 0-15. Most reported having designated General Practitioners working with care homes and a good working relationship. Despite the national rollout of the Enhanced Health in Care Homes framework, two-thirds reported no recent changes in how they worked with care homes. There is a shift towards practices working with fewer care homes and fewer accounts of fractured working relationships, suggesting that residents' access to primary care is improving. The continuing variability suggests further work is needed to ensure it is driven by context, not inequitable provision. Future work needs to address how policy changes are changing work practices and residents' health outcomes.

A qualitative exploration of the clinical presentation, trajectory, management and recovery of COVID-19 in older people: Learning from frontline staff experiences

COVID-19 had a devastating impact on older people living in care homes. This study explored the clinical trajectory and management of COVID-19, as well as recovery of older people following infection during the early stages of the pandemic (May to August 2020). A two-phase exploratory qualitative study was used. Frontline staff with experience of caring for older people with COVID-19 were recruited to Phase 1, and senior care home operational and quality managers were recruited to Phase 2. During Phase 1 remote semi-structured interviews (n = 35) were carried out with staff working in care homes, hospital and community settings in England. During Phase 2, a remote consultation event was carried out with senior care home operational and quality managers (n = 11) to share Phase 1 findings and check resonance, relevance and gaps. Data were analysed using Framework Analysis. Older people with COVID-19 presented with wide ranging symptoms, and an unpredictable illness trajectory. The wide range of COVID-19 symptoms required timely testing and supportive interventions. Staff used different interventions to manage symptoms and reported uncertainties of how individuals would respond. In care home settings, health and social care staff needed to work together when administering interventions such as subcutaneous fluids or oxygen therapy. Alongside symptom management, supportive care focused on nutrition and hydration, social interaction, and maintaining physical activity to meet both physical and emotional needs. The effects of prolonged periods of social isolation and inactivity on the health and well-being of older people means rehabilitation is essential to enhance physical and emotional recovery, and to minimise impacts on cognition and function. The pandemic highlighted important areas for care of this population.

The interface between primary care and care homes: General Practitioner experiences of working in care homes for older people

Supporting residents in care homes for older people is an important, though little studied, aspect of the General Practitioner (GP) role. This study explored GPs' experiences of working to support older people living in care homes, and the challenges and facilitators to providing effective care in this unique practice environment. A qualitative online survey was shared with GPs in England via Twitter and through Named Doctor for Safeguarding networks. This was available from October 2019-March 2020 and was completed by 58 GPs. Responses were analysed using inductive Thematic Analysis. Participants highlighted the complexity of care home residents' health, with multiple long-term conditions frequently reported. Furthermore, dementia and communication difficulties meant the GPs were often reliant on communication with others (staff and families). GPs had to navigate multiple relationships within care homes, including with residents, staff/managers, families and other healthcare practitioners, all of whom could have competing perspectives and priorities. Gaining access to information about resident health could be challenging, and was affected by staff continuity/discontinuity; lack of Wi-Fi access was also common. Care home organisation of and support for the visit was important. We conclude that care home work requires GP skills to meet resident healthcare needs, as well as to navigate multiple relationships. GPs are often reliant on others; this has important implications, both risking marginalising the resident voice, and in respect of recognising and reporting abuse.

Impact of the Enhanced Universal Support Offer to Care Homes during COVID-19 in the UK: Evaluation using appreciative inquiry

There are over 2,300 care homes in the North East and Yorkshire Region, with rising rates of COVID-19 infection in April 2020. The Enhanced Universal Support Offer (EUSO) planned to improve support to care homes, working collaboratively with local integrated community services. Implementation was organised at 'place', through clinical commissioning and it was focused on leadership, prevention, additional clinical support, and workforce planning. The aim of the evaluation research was to understand the impact of the EUSO. The evaluation was co-produced by a group of senior leaders with additional academic involvement. An appreciative inquiry approach informed the interviews and focus groups with representative stakeholders. A thematic analysis using NVivo enabled a validation process and the data were charted into a systems framework. Data analysis resulted in five high level themes: Communication, Working Relationships, Systemic Perceptions, COVID-19 Implementation, and Organisational Support. Best practices were associated with joint working between health, local authority and care homes including medication optimisation and technology use. Care homes valued access to a named General Practitioner and community nursing working as a part of a wider multidisciplinary team. Conversely an overly reactive response to care homes combined with 'command and control' limited the benefits that were achieved. The EUSO was delivered at pace and resulted in an increased appreciation of the policy and principles of care home residents and workforce. The evaluation reflected a need to appreciate the care homes' knowledge and experience of resident wellbeing, and more fully involve them in the design of the support.

Ageing well with diabetes: A workshop to co-design research recommendations for improving the diabetes care of older people

AIMS

To identify key research questions where answers could improve care for older people living with diabetes (PLWD), and provide detailed recommendations for researchers and research funders on how best to address them.

METHODS

A series of online research workshops were conducted, bringing together a range of PLWD and an acknowledged group of academic and clinical experts in their diabetes care to identify areas for future research. Throughout the pre-workshop phase, during each workshop, and in manuscript preparation and editing, PLWD played an active and dynamic role in discussions as part of both an iterative and narrative process.

RESULTS

The following key questions in this field were identified, and research recommendations for each were developed: How can we improve our understanding of the characteristics of older people living with diabetes (PLWD) and their outcomes, and can this deliver better person-centred care? How are services to care for older PLWD currently delivered, both for their diabetes and other conditions? How can we optimise and streamline the process and ensure everyone gets the best care, tailored to their individual needs? What tools might be used to evaluate the level of understanding of diabetes in the older population amongst non-specialist Healthcare Professionals (HCPs)? How can virtual experts or centres most effectively provide access to specialist multi-disciplinary team (MDT) expertise for older PLWD and the HCPs caring for them? Is a combination of exercise and a nutrition-dense, high protein diet effective in the prevention of the adverse effects of type 2 diabetes and deterioration in frailty, and how might this be delivered in a way which is acceptable to people with type 2 diabetes? How might we best use continuous glucose monitoring (CGM) in older people and, for those who require support, how should the data be shared? How can older PLWD be better empowered to manage their diabetes in their own home, particularly when living with additional long-term conditions? What are the benefits of models of peer support for older PLWD, both when living independently and when in care?

CONCLUSIONS

This paper outlines recommendations supported by PLWD through which new research could improve their diabetes care and calls on the research community and funders to address them in future research programmes and strategies.

A multidomain decision support tool to prevent falls in older people: the FinCH cluster RCT

BACKGROUND

Falls in care home residents are common, unpleasant, costly and difficult to prevent.

OBJECTIVES

The objectives were to evaluate the clinical effectiveness and cost-effectiveness of the Guide to Action for falls prevention in Care Homes (GtACH) programme.

DESIGN

A multicentre, cluster, parallel, 1 : 1 randomised controlled trial with embedded process evaluation and economic evaluation. Care homes were randomised on a 1 : 1 basis to the GtACH programme or usual care using a secure web-based randomisation service. Research assistants, participating residents and staff informants were blind to allocation at recruitment; research assistants were blind to allocation at follow-up. NHS Digital data were extracted blindly.

SETTING

Older people's care homes from 10 UK sites.

PARTICIPANTS

Older care home residents.

INTERVENTION

The GtACH programme, which includes care home staff training, systematic use of a multidomain decision support tool and implementation of falls prevention actions, compared to usual falls prevention care.

OUTCOMES

The primary trial outcome was the rate of falls per participating resident occurring during the 90-day period between 91 and 180 days post randomisation. The primary outcome for the cost-effectiveness analysis was the cost per fall averted, and the primary outcome for the cost-utility analysis was the incremental cost per quality adjusted life-year. Secondary outcomes included the rate of falls over days 0-90 and 181-360 post randomisation, activity levels, dependency and fractures. The number of falls per resident was compared between arms using a negative binomial regression model (generalised estimating equation).

RESULTS

A total of 84 care homes were randomised: 39 to the GtACH arm and 45 to the control arm. A total of 1657 residents consented and provided baseline measures (mean age 85 years, 32% men). GtACH programme training was delivered to 1051 staff (71% of eligible staff) over 146 group sessions. Primary outcome data were available for 630 GtACH participants and 712 control participants. The primary outcome result showed an unadjusted incidence rate ratio of 0.57 (95% CI 0.45 to 0.71; p < 0.01) in favour of the GtACH programme. Falls rates were lower in the GtACH arm in the period 0-90 days. There were no other differences between arms in the secondary outcomes. Care home staff valued the training, systematic strategies and specialist peer support, but the incorporation of the GtACH programme documentation into routine care home practice was limited. No adverse events were recorded. The incremental cost was £20,889.42 per Dementia Specific Quality of Life-based quality-adjusted life-year and £4543.69 per quality-adjusted life-year based on the EuroQol-5 dimensions, five-level version. The mean number of falls was 1.889 (standard deviation 3.662) in the GtACH arm and 2.747 (standard deviation 7.414) in the control arm. Therefore, 0.858 falls were averted. The base-case incremental cost per fall averted was £190.62.

CONCLUSION

The GtACH programme significantly reduced the falls rate in the study care homes without restricting residents' activity levels or increasing their dependency, and was cost-effective at current thresholds in the NHS.

FUTURE WORK

Future work should include a broad implementation programme, focusing on scale and sustainability of the GtACH programme.

LIMITATIONS

A key limitation was the fact that care home staff were not blinded, although risk was small because of the UK statutory requirement to record falls in care homes.

TRIAL REGISTRATION

This trial is registered as ISRCTN34353836.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 9. See the NIHR Journals Library website for further project information.

Making progress: but a way to go-the age and ageing care-home collection

Care homes enable people with advanced physical and cognitive impairment to live well with 24-h support from staff. They are a feature of care systems in most countries. They have proved pivotal to the coronavirus disease 2019 (COVID-19) response. We searched Age and Ageing for care-home articles published since 2015. From these we collated 42 into the Age and Ageing care-home collection. This collection draws together important papers that show how Age and Ageing is helping to shape and grow care-home research. The  collection outlines the technical issues that researchers face by grouping together important feasibility trials conducted in the sector. It looks at the challenges of measuring quality of life and working with routine data in care homes. It brings together observational studies considering loneliness, functional dependency, stroke outcomes, prescribing and acute deterioration. Health services research in care homes is represented by two studies that demonstrate realist evaluation as a way to make sense of service innovations. Papers are included that consider: non-pharmacological strategies for residents with dementia, end-of-life care, sexuality and intimacy and the care-home workforce. Given the importance of the COVID-19 pandemic in care homes, all of the care home COVID-19 papers published in Age and Ageing to date are included. Finally, a group of papers that present innovative approaches to research in care homes, each of which give voice to residents and/or staff, are collated and presented as a way of moving towards a more resident and care home centred research agenda.

A qualitative comparison of care home staff and palliative care specialists' experiences of providing end of life care to people living and dying with dementia in care homes in two countries: A focus group study

BACKGROUND

Palliative care for people with dementia dying in care homes is an important aspect of long-term care. Whilst there is consensus about the principles of palliative care, less is known about how care home staff negotiate and influence decisions around end of life and how organisational context shapes that process.

AIM

To explore the views and experiences of care home staff and palliative care specialists on end of life care in care homes and understand how care home settings affected palliative care provision in England and Australia.

DESIGN/PARTICIPANTS

Eight focus groups in Australia and England with care home staff and palliative care specialists (n = 49). Reflexive thematic analysis was undertaken.

FINDINGS

Australian participants reported collaboration between care home staff, visiting professions and family members though case conferences. English participants discussed resident-focussed involvement from specialists that was less formally organised. Negotiating roles and responsibilities in end of life care; the importance of relationships to overcome deficiencies in formal processes; and the legitimacy and authority of advance care planning at times of crisis were recurring themes. The organisation and embedding of end of life care in processes and practices of care homes differed; this closely linked to care home procedures in Australia but was less apparent in England.

CONCLUSION

In both countries, partnership working was recognised and valued as key to effective palliative care. Work that enables care home staff to identify challenges with visiting professionals, such as agreeing priorities for care and negotiating their shared responsibilities, may lead to context-sensitive, sustainable solutions.

A Rapid Realist Review of Quality Care Process Metrics Implementation in Nursing and Midwifery Practice

Quality measurement initiatives promote quality improvement in healthcare but can be challenging to implement effectively. This paper presents a Rapid Realist Review (RRR) of published literature on Quality Care-Process Metrics (QCP-M) implementation in nursing and midwifery practice. An RRR informed by RAMESES II standards was conducted as an efficient means to synthesize evidence using an expert panel. The review involved research question development, quality appraisal, data extraction, and evidence synthesis. Six program theories summarised below identify the key characteristics that promote positive outcomes in QCP-M implementation. Program Theory 1: Focuses on the evidence base and accessibility of the QCP-M and their ease of use by nurses and midwives working in busy and complex care environments. Program Theory 2: Examines the influence of external factors on QCP-M implementation. Program Theory 3: Relates to existing cultures and systems within clinical sites. Program Theory 4: Relates to nurses’ and midwives’ knowledge and beliefs. Program Theory 5: Builds on the staff theme of Programme Theory four, extending the culture of organizational learning, and highlights the meaningful engagement of nurses and midwives in the implementation process as a key characteristic of success. Program Theory 6: Relates to patient needs. The results provide nursing and midwifery policymakers and professionals with evidence-based program theory that can be translated into action-orientated strategies to help guide successful QCP-M implementation.

Implementing lateral flow devices in long-term care facilities: experiences from the Liverpool COVID-19 community testing pilot in care homes- a qualitative study

Introduction

Antigen-based lateral flow devices (LFDs) offer the potential of widespread rapid testing. The scientific literature has primarily focused on mathematical modelling of their use and test performance characteristics. For these tests to be implemented successfully, an understanding of the real-world contextual factors that allow them to be integrated into the workplace is vital. To address this gap in knowledge, we aimed to explore staff’s experiences of integrating LFDs into routine practice for visitors and staff testing with a view to understand implementation facilitators and barriers.

Methods

Semi-structured interviews and thematic analysis.

Results

We identified two main themes and five subthemes. The main themes included: visitor-related testing factors and staff-related testing factors. Subthemes included: restoring a sense of normality, visitor-related testing challenges, staff-related testing challenges, and pre-pilot antecedent factors.

Conclusion

Our study demonstrates that the real-world implementation of LFDs to test visitors and staff faces significant challenges as a result of several contextual factors negatively affecting the work practice and environment. More comprehensive studies are needed to identify and inform effective implementation strategies to ensure that LFDs can be adopted in an agile way that better supports an already exhausted and morally depleted workforce.

GPs’ involvement to improve care quality in care homes in the UK: a realist review

Background

Organising health-care services for residents living in care homes is an important area of development in the UK and elsewhere. Medical care is provided by general practitioners in the UK, and the unique arrangement of the NHS means that general practitioners are also gatekeepers to other health services. Despite recent focus on improving health care for residents, there is a lack of knowledge about the role of general practitioners.

Objectives

First, to review reports of research and quality improvement (or similar change management) in care homes to explore how general practitioners have been involved. Second, to develop programme theories explaining the role of general practitioners in improvement initiatives and outcomes.

Design

A realist review was selected to address the complexity of integration of general practice and care homes.

Setting

Care homes for older people in the UK, including residential and nursing homes.

Participants

The focus of the literature review was the general practitioner, along with care home staff and other members of multidisciplinary teams. Alongside the literature, we interviewed general practitioners and held consultations with a Context Expert Group, including a care home representative.

Interventions

The primary search did not specify interventions, but captured the range of interventions reported. Secondary searches focused on medication review and end-of-life care because these interventions have described general practitioner involvement.

Outcomes

We sought to capture processes or indicators of good-quality care.

Data sources

Sources were academic databases [including MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Cumulative Index to Nursing and Allied Health Literature, PsycInfo® (American Psychological Association, Washington, DC, USA), Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA) and Cochrane Collaboration] and grey literature using Google Scholar (Google Inc., Mountain View, CA, USA).

Methods

Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines were followed, comprising literature scoping, interviews with general practitioners, iterative searches of academic databases and grey literature, and synthesis and development of overarching programme theories.

Results

Scoping indicated the distinctiveness of the health and care system in UK and, because quality improvement is context dependent, we decided to focus on UK studies because of potential problems in synthesising across diverse systems. Searches identified 73 articles, of which 43 were excluded. To summarise analysis, programme theory 1 was ‘negotiated working with general practitioners’ where other members of the multidisciplinary team led initiatives and general practitioners provided support with the parts of improvement where their skills as primary care doctors were specifically required. Negotiation enabled matching of the diverse ways of working of general practitioners with diverse care home organisations. We found evidence that this could result in improvements in prescribing and end-of-life care for residents. Programme theory 2 included national or regional programmes that included clearly specified roles for general practitioners. This provided clarity of expectation, but the role that general practitioners actually played in delivery was not clear.

Limitations

One reviewer screened all search results, but two reviewers conducted selection and data extraction steps.

Conclusions

If local quality improvement initiatives were flexible, then they could be used to negotiate to build a trusting relationship with general practitioners, with evidence from specific examples, and this could improve prescribing and end-of-life care for residents. Larger improvement programmes aimed to define working patterns and build suitable capacity in care homes, but there was little evidence about the extent of local general practitioner involvement.

Future work

Future work should describe the specific role, capacity and expertise of general practitioners, as well as the diversity of relationships between general practitioners and care homes.

Study registration

This study is registered as PROSPERO CRD42019137090.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 20. See the NIHR Journals Library website for further project information.

Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: A systematic review without meta-analysis

AIM

To synthesize evidence on the ability of specialist care home support services to prevent hospital admission of older care home residents, including at end of life.

DESIGN

Systematic review, without meta-analysis, with vote counting based on direction of effect.

DATA SOURCES

Fourteen electronic databases were searched from January 2010 to January 2019. Reference lists of identified reviews, study protocols and included documents were scrutinized for further studies.

REVIEW METHODS

Papers on the provision of specialist care home support that addressed older, long-term care home residents' physical health needs and provided comparative data on hospital admissions were included. Two reviewers undertook study selection and quality appraisal independently. Vote counting by direction of effect and binomial tests determined service effectiveness.

RESULTS

Electronic searches identified 79 relevant references. Combined with 19 citations from an earlier review, this gave 98 individual references relating to 92 studies. Most were from the UK (22), USA (22) and Australia (19). Twenty studies were randomized controlled trials and six clinical controlled trials. The review suggested interventions addressing residents' general health needs (p < .001), assessment and management services (p < .0001) and non-training initiatives involving medical staff (p < .0001) can reduce hospital admissions, while there was also promising evidence for services targeting residents at imminent risk of hospital entry or post-hospital discharge and training-only initiatives. End-of-life care services may enable residents to remain in the home at end of life (p < .001), but the high number of weak-rated studies undermined confidence in this result.

CONCLUSION

This review suggests specialist care home support services can reduce hospital admissions. More robust studies of services for residents at end of life are urgently needed.

IMPACT

The review addressed the policy imperative to reduce the avoidable hospital admission of older care home residents and provides important evidence to inform service design. The findings are of relevance to commissioners, providers and residents.

Experiences of a National Early Warning Score (NEWS) intervention in care homes during the COVID-19 pandemic: a qualitative interview study

BACKGROUND

The COVID-19 pandemic has taken a heavy toll on the care home sector, with residents accounting for up to half of all deaths in Europe. The response to acute illness in care homes plays a particularly important role in the care of residents during a pandemic. Digital recording of a National Early Warning Score (NEWS), which involves the measurement of physical observations, started in care homes in one area of England in 2016. Implementation of a NEWS intervention (including equipment, training and support) was accelerated early in the pandemic, despite limited evidence for its use in the care home setting.

OBJECTIVES

To understand how a NEWS intervention has been used in care homes in one area of North-East England during the COVID-19 pandemic, and how it has influenced resident care, from the perspective of stakeholders involved in care delivery and commissioning.

METHODS

A qualitative interview study with care home (n=10) and National Health Service (n=7) staff. Data were analysed using thematic analysis.

RESULTS

Use of the NEWS intervention in care homes in this area accelerated during the COVID-19 pandemic. Stakeholders felt that NEWS, and its associated education and support package, improved the response of care homes and healthcare professionals to deterioration in residents' health during the pandemic. Healthcare professionals valued the ability to remotely monitor resident observations, which facilitated triage and treatment decisions. Care home staff felt empowered by NEWS, providing a common clinical language to communicate concerns with external services, acting as an adjunct to staff intuition of resident deterioration.

CONCLUSIONS

The NEWS intervention formed an important part of the care home response to COVID-19 in the study area. Positive staff perceptions now need to be supplemented with data on the impact on resident health and well-being, workload, and service utilisation, during the pandemic and beyond.

How quality improvement collaboratives work to improve healthcare in care homes: a realist evaluation

BACKGROUND

Quality improvement collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood.

METHODS

A realist evaluation to develop and test a programme theory of how QICs work to improve healthcare in care homes. A multiple case study design considered implementation across 4 sites and 29 care homes. Observations, interviews and focus groups captured contexts and mechanisms operating within QICs. Data analysis classified emerging themes using context-mechanism-outcome configurations to explain how NHS and care home staff work together to design and implement improvement.

RESULTS

QICs will be able to implement and iterate improvements in care homes where they have a broad and easily understandable remit; recruit staff with established partnership working between the NHS and care homes; use strategies to build relationships and minimise hierarchy; protect and pay for staff time; enable staff to implement improvements aligned with existing work; help members develop plans in manageable chunks through QI coaching; encourage QIC members to recruit multidisciplinary support through existing networks; facilitate meetings in care homes and use shared learning events to build multidisciplinary interventions stepwise. Teams did not use measurement for change, citing difficulties integrating this into pre-existing and QI-related workload.

CONCLUSIONS

These findings outline what needs to be in place for health and social care staff to work together to effect change. Further research needs to consider ways to work alongside staff to incorporate measurement for change into QI.

Raising the profile of care home nursing through collaborative working

AIM

To explore the innovative educational practices of two care home teams based in the United Kingdom (UK). Both homes aimed to provide education and developmental opportunities so that they could further deliver effective nursing care to residents. Through such practices, the care homes sought to enhance nursing career development and improve workforce retention. Meeting the long-term care needs of older people remains a challenge and the nursing workforce need to be adequately supported to deliver effective care. Employers have an important role in supporting the educational and developmental needs of nursing staff so that they can fulfil their challenging roles.

CONCLUSION

Using several approaches to nursing education and development, the care homes described in this Discussion Paper were able to show positive impact. Considering the care home workforce shortage and employability churn, it is hoped these ideas can offer inspiration to others in the sector.

Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study

BACKGROUND

From late February 2020, English care homes rapidly adapted their practices in response to the COVID-19 pandemic. In addition to accommodating new guidelines and policies, staff had to adjust to rapid reconfiguration of services external to the home that they would normally depend upon for support. This study examined the complex interdependencies of support as staff responded to COVID-19. The aim was to inform more effective responses to the ongoing pandemic, and to improve understanding of how to work with care home staff and organisations after the pandemic has passed.

METHODS

Ten managers of registered care homes in the East Midlands of England were interviewed by videoconference or phone about their experiences of the crisis from a structured organisational perspective. Analysis used an adapted organisational framework analysis approach with a focus on social ties and interdependencies between organisations and individuals.

RESULTS

Three key groups of interdependencies were identified: care processes and practice; resources; and governance. Care home staff had to deliver care in innovative ways, making high stakes decisions in circumstances defined by: fluid ties to organisations outside the care home; multiple, sometimes conflicting, sources of expertise and information; and a sense of deprioritisation by authorities. Organisational responses to the pandemic by central government resulted in resource constraints and additional work, and sometimes impaired the ability of staff and managers to make decisions. Local communities, including businesses, third-sector organisations and individuals, were key in helping care homes overcome challenges. Care homes, rather than competing, were found to work together to provide mutual support. Resilience in the system was a consequence of dedicated and resourceful staff using existing local networks, or forging new ones, to overcome barriers to care.

CONCLUSIONS

This study identified how interdependency between care home organisations, the surrounding community, and key statutory and non-statutory organisations beyond their locality, shaped decision making and care delivery during the pandemic. Recognising these interdependencies, and the expertise shown by care home managers and staff as they navigate them, is key to providing effective healthcare in care homes as the pandemic progresses, and as the sector recovers afterwards.

A complex intervention to reduce avoidable hospital admissions in nursing homes: a research programme including the BHiRCH-NH pilot cluster RCT

Background

An unplanned hospital admission of a nursing home resident distresses the person, their family and nursing home staff, and is costly to the NHS. Improving health care in care homes, including early detection of residents’ health changes, may reduce hospital admissions. Previously, we identified four conditions associated with avoidable hospital admissions. We noted promising ‘within-home’ complex interventions including care pathways, knowledge and skills enhancement, and implementation support.

Objectives

Develop a complex intervention with implementation support [the Better Health in Residents in Care Homes with Nursing (BHiRCH-NH)] to improve early detection, assessment and treatment for the four conditions. Determine its impact on hospital admissions, test study procedures and acceptability of the intervention and implementation support, and indicate if a definitive trial was warranted.

Design

A Carer Reference Panel advised on the intervention, implementation support and study documentation, and engaged in data analysis and interpretation. In workstream 1, we developed a complex intervention to reduce rates of hospitalisation from nursing homes using mixed methods, including a rapid research review, semistructured interviews and consensus workshops. The complex intervention comprised care pathways, approaches to enhance staff knowledge and skills, implementation support and clarity regarding the role of family carers. In workstream 2, we tested the complex intervention and implementation support via two work packages. In work package 1, we conducted a feasibility study of the intervention, implementation support and study procedures in two nursing homes and refined the complex intervention to comprise the Stop and Watch Early Warning Tool (S&W), condition-specific care pathways and a structured framework for nurses to communicate with primary care. The final implementation support included identifying two Practice Development Champions (PDCs) in each intervention home, and supporting them with a training workshop, practice development support group, monthly coaching calls, handbooks and web-based resources. In work package 2, we undertook a cluster randomised controlled trial to pilot test the complex intervention for acceptability and a preliminary estimate of effect.

Setting

Fourteen nursing homes allocated to intervention and implementation support (n = 7) or treatment as usual (n = 7).

Participants

We recruited sufficient numbers of nursing homes (n = 14), staff (n = 148), family carers (n = 95) and residents (n = 245). Two nursing homes withdrew prior to the intervention starting.

Intervention

This ran from February to July 2018.

Data sources

Individual-level data on nursing home residents, their family carers and staff; system-level data using nursing home records; and process-level data comprising how the intervention was implemented. Data were collected on recruitment rates, consent and the numbers of family carers who wished to be involved in the residents’ care. Completeness of outcome measures and data collection and the return rate of questionnaires were assessed.

Results

The pilot trial showed no effects on hospitalisations or secondary outcomes. No home implemented the intervention tools as expected. Most staff endorsed the importance of early detection, assessment and treatment. Many reported that they ‘were already doing it’, using an early-warning tool; a detailed nursing assessment; or the situation, background, assessment, recommendation communication protocol. Three homes never used the S&W and four never used care pathways. Only 16 S&W forms and eight care pathways were completed. Care records revealed little use of the intervention principles. PDCs from five of six intervention homes attended the training workshop, following which they had variable engagement with implementation support. Progression criteria regarding recruitment and data collection were met: 70% of homes were retained, the proportion of missing data was < 20% and 80% of individual-level data were collected. Necessary rates of data collection, documentation completion and return over the 6-month study period were achieved. However, intervention tools were not fully adopted, suggesting they would not be sustainable outside the trial. Few hospitalisations for the four conditions suggest it an unsuitable primary outcome measure. Key cost components were estimated.

Limitations

The study homes may already have had effective approaches to early detection, assessment and treatment for acute health changes; consistent with government policy emphasising the need for enhanced health care in homes. Alternatively, the implementation support may not have been sufficiently potent.

Conclusion

A definitive trial is feasible, but the intervention is unlikely to be effective. Participant recruitment, retention, data collection and engagement with family carers can guide subsequent studies, including service evaluation and quality improvement methodologies.

Future work

Intervention research should be conducted in homes which need to enhance early detection, assessment and treatment. Interventions to reduce avoidable hospital admissions may be beneficial in residential care homes, as they are not required to employ nurses.

Trial registration

Current Controlled Trials ISRCTN74109734 and ISRCTN86811077.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 2. See the NIHR Journals Library website for further project information.

Pilot cluster randomised trial of an evidence-based intervention to reduce avoidable hospital admissions in nursing home residents (Better Health in Residents of Care Homes with Nursing-BHiRCH-NH Study)

OBJECTIVES

To pilot a complex intervention to support healthcare and improve early detection and treatment for common health conditions experienced by nursing home (NH) residents.

DESIGN

Pilot cluster randomised controlled trial.

SETTING

14 NHs (7 intervention, 7 control) in London and West Yorkshire.

PARTICIPANTS

NH residents, their family carers and staff.

INTERVENTION

Complex intervention to support healthcare and improve early detection and treatment of urinary tract and respiratory infections, chronic heart failure and dehydration, comprising: (1) 'Stop and Watch (S&W)' early warning tool for changes in physical health, (2) condition-specific care pathway and (3) Situation, Background, Assessment and Recommendation tool to enhance communication with primary care. Implementation was supported by Practice Development Champions, a Practice Development Support Group and regular telephone coaching with external facilitators.

OUTCOME MEASURES

Data on NH (quality ratings, size, ownership), residents, family carers and staff demographics during the month prior to intervention and subsequently, numbers of admissions, accident and emergency visits, and unscheduled general practitioner visits monthly for 6 months during intervention. We collected data on how the intervention was used, healthcare resource use and quality of life data for economic evaluation. We assessed recruitment and retention, and whether a full trial was warranted.

RESULTS

We recruited 14 NHs, 148 staff, 95 family carers and 245 residents. We retained the majority of participants recruited (95%). 15% of residents had an unplanned hospital admission for one of the four study conditions. We were able to collect sufficient questionnaire data (all over 96% complete). No NH implemented intervention tools as planned. Only 16 S&W forms and 8 care pathways were completed. There was no evidence of harm.

CONCLUSIONS

Recruitment, retention and data collection processes were effective but the intervention not implemented. A full trial is not warranted.

TRIAL REGISTRATION NUMBER

ISRCTN74109734 (https://doi.org/10.1186/ISRCTN74109734). ORIGINAL PROTOCOL: BMJ Open. 2019;9(5):e026510. doi:10.1136/bmjopen-2018-026510.

"To do or not to do": Treatment fidelity to a complex training intervention

BACKGROUND AND PURPOSE

When a complex intervention is examined it is viewed necessary to perform a qualitative process evaluation paired with an outcome evaluation. The purpose is to provide insights into the fidelity of the experimental intervention and thereby strengthen the validity of the study. In "Recovery after hip fracture" (the HIPFRAC study), the effect of a complex functional training intervention was examined by a randomized controlled trial design. The training was initiated by the physiotherapist and performed by the nurses/nurse assistants (NAs), as part of their daily, habitual routine when the patients with hip fracture were in a short-term stay after discharge from hospital. The aim of the present process evaluation was to explore how contextual factors facilitated or complicated the nurses'/NAs' fidelity to the experimental intervention in the HIPFRAC study.

METHODS

A descriptive thematic analysis was used. Data was collected through semi-structured in-depth interviews with three nurses and three NAs working with the HIPFRAC patients in a short-term stay. The interviews were transcribed and analyzed.

FINDINGS

Six subthemes, two main themes and one overall theme were identified. The overall theme was: Barriers affecting the implementation process. The main themes related to the barriers were identified as follows: (1) Attitudes within the nurses/NAs and (2) Structural factors.

DISCUSSION

The nurses/NAs in the short-term stay experienced contextual barriers, which contributed to complicate fidelity to the experimental intervention. There is a need of further research to investigate whether increased physiotherapy resources at short-term stay will improve the level of physical activity among the patients with hip fracture.

COVID-19 highlights the need for universal adoption of standards of medical care for physicians in nursing homes in Europe

The nursing home sector has seen a disproportionately high number of deaths as part of the COVID-19 pandemic. This reflects, in part, the frailty and vulnerability of older people living in care homes but has also, in part, been a consequence of the failure to include care homes in the systematic planning of a response to COVID, as well as a measure of neglect of standards and quality improvement in the sector. In response, the EUGMS published a set of medical standards of care developed in consultation with experts across its member national societies in 2015. The standards consisted of seven core principles of medical care for physicians working in nursing homes as a first step in developing a programme of clinical, academic and policy engagement in improving medical care for older people who are living and frequently also dying as residents in nursing homes. The gravity of the concerns arising for nursing home care from the COVID-19 pandemic, as well as emerging insights on care improvement in nursing homes indicate that an update of these medical standards is timely. This was performed by the writing group from the original 2015 guidelines and is intended as an interim measure pending a more formal review incorporating a systematic review of emerging literature and a Delphi process.

Protocol for a realist review of General Practitioners' Role in Advancing Practice in Care Homes (GRAPE study)

INTRODUCTION

Older people who live in care homes have a high level of need with complex health conditions. In addition to providing medical care to residents, general practitioners (GPs) play a role as gatekeeper for access to services, as well as leadership within healthcare provision. This review will describe how GPs were involved in initiatives to change arrangements of healthcare services in order to improve quality and experience of care.

METHODS AND ANALYSIS

Following RAMESES quality and publication guidelines standards, we will proceed with realist review to develop theories of how GPs work with care home staff to bring about improvements. We identify when improvement in outcomes does not occur and why this may be the case. The first stage will include interviews with GPs to ask their views on improvement in care homes. These interviews will enable development of initial theories and give direction for the literature searches. In the second stage, we will use iterative literature searches to add depth and context to the early theories; databases will include Medline, Embase, CINAHL, PsycINFO and ASSIA. In stage 3, evidence that is judged as rigorous and relevant will be used to test the initial theories, and through the process, refine the theory statements. In the final stage, we will synthesise findings and provide recommendations for practice and policy-making.During the review, we will invite a context expert group to reflect on our findings. This group will have expertise in current trends in primary care and the care home sector both in UK and internationally.

ETHICS AND DISSEMINATION

The study was approved by University of Nottingham Faculty of Medicine and Health Sciences Research Ethics Committee: 354-1907. Findings will be shared through stakeholder networks, published in National Institute for Health Research journal and submitted for peer-reviewed journal publication.

What lies beneath: a retrospective, population-based cohort study investigating clinical and resource-use characteristics of institutionalized older people in Catalonia

Background

Planning population care in a specific health care setting requires deep knowledge of the clinical characteristics of the target care recipients, which tend to be country specific. Our area virtually lacks any descriptive, far-reaching publications about institutionalized older people (IOP). We aimed to investigate the demographic and clinical characteristics of institutionalized older people (IOP) ≥65 years old and compare them with those of the rest of the population of the same age.

Methods

Retrospective analysis (total cohort approach) of clinical and resource-use characteristics of IOP and non-IOP older than 65 years in Catalonia (North-East Spain). Variables analysed included age and sex, diagnoses, morbidity burden—using Adjusted Morbidity Groups (GMA, Grupos de Morbilidad Ajustada)—, mortality, use of resources, and medications taken. All data were obtained from the administrative database of the local healthcare system.

Results

This study included 93,038, 78,458, 68,545 and 67,456 IOP from 2011, 2013, 2015 and 2017, respectively. In this interval, an increase in median age (83 vs. 87 years), in women (68.64% vs. 72.11%) and in annual mortality (11.74% vs. 20.46%) was observed. Compared with non-IOP (p < 0.001 in all comparisons), IOP showed a higher annual mortality (20.46% vs. 3.13%), a larger number of chronic diseases (specially dementia: 46.47% vs. 4.58%), higher multimorbidity (15.2% vs. 4.2% with GMA of maximum complexity), and annual admissions to acute care (47.6% vs. 27.7%) and skilled nursing facilities (27.8% vs. 7.4%), mean length of hospital stay (10.0 vs. 7.2 days) and mean of medications taken (11.7 vs. 8.0).

Conclusions

There is a growing gap between the clinical and demographic characteristics of age-matched IOP and non-IOP, which overlaps with a higher mortality rate of IOP. The profile of resources utilization of IOP compared with non-IOP strongly suggests a deficiency of preventive actions and stresses the need to rethink the care model for IOP from a social and health care perspective.

Care home residents who die in hospital: exploring factors, processes and experiences

BACKGROUND

Care home residents are increasingly frail with complex health and social care needs. Their transfer to hospital at the end-of-life can be associated with unwanted interventions and distress. However, hospitals do enable provision of care that some residents wish to receive. We aimed to explore the factors that influence hospital admission of care home residents who then died in hospital.

METHODS

This study combined in-depth case note review of care home residents dying in two Scottish teaching hospitals during a 6-month period and semi-structured interviews with a purposive sample of 26 care home staff and two relatives.

RESULTS

During the 6-month period, 109 care home residents died in hospital. Most admissions occurred out-of-hours (69%) and most were due to a sudden event or acute change in clinical condition (72%). Length of stay in hospital before death was short, with 42% of deaths occurring within 3 days. Anticipatory Care Planning (ACP) regarding hospital admission was documented in 44%.Care home staff wanted to care for residents who were dying; however, uncertain trajectories of decline, acute events, challenges of ACP, relationship with family and lack of external support impeded this.

CONCLUSIONS

Managing acute changes on the background of uncertain trajectories is challenging in care homes. Enhanced support is required to improve and embed ACP in care homes and to provide rapid, 24 hours-a-day support to manage difficult symptoms and acute changes.

Care home nursing: Co-creating curricular content with student nurses

BACKGROUND

Meeting the complex care needs of an ageing population is a global issue and long term care settings, such as care homes, play an essential role. However, there is a crisis in the recruitment of registered nurses within care homes. Higher educational institutions have a critical part to play in addressing the crisis in recruitment in care homes and it is argued that student nurses can have a significant role to play in co-creating curricular content responsive to population need.

OBJECTIVE

To co-create curricular content on care home nursing with student nurses.

DESIGN

Co-creation through collaborative enquiry and a three stage thematic analysis.

SETTING

Undergraduate, preregistration nursing programme in a university in the United Kingdom.

PARTICIPANTS

Student nurses from Years One to Four undertaking a Bachelor in Nursing with Honours degree.

METHODS

Six focus groups and two one to one interviews.

RESULTS

Findings revealed predominantly negative attitudes towards care home nursing. Teaching and practice placements appeared to play a minor role in shaping students' attitudes but rather, gave the unspoken message that for the acquisition of necessary knowledge and skills, care homes were less important than other settings. Most students were initially averse to care home nursing as a career choice. During focus groups/interviews, views shifted from seeing care homes as places where you 'lose clinical skills' to places where there is 'a lot of responsibility', and also a potentially rewarding career choice. From this attitudinal shift, students made suggestions for developing better curricular content and more positive learning opportunities.

CONCLUSIONS

A co-creative framework can create a space for mutual learning between students and staff about challenges and opportunities for equipping nurses to meet the needs of ageing populations. Student nurses are open to learning about care home nursing as part of their education and keen to have a more positive exposure.

In search for gold - The relevance of realist reviews and evaluations to pharmacy research and policy development

Pharmacy services and programs can be regarded as complex interventions which are developed and implemented within the open, complex system of overall healthcare. Realist research considers matters of complexity and provides insights into what programs and interventions work, why and in which contexts. Based on the philosophy of science of critical realism, realist evaluations and realist reviews generate causative explanations which inform pharmacy practitioners, educators and policy makers in which context programs and services achieve particular outcomes. This more nuanced understanding of how pharmacy services contribute to overall healthcare provides guidance for the refinement and targeting of programs, interventions and practice models. This article outlines key aspects of realist research approaches and provides insight into how realism can contribute to research in and the practice of pharmacy.

Monitoring work well-being, job confidence and care provided by care home staff using a self-report survey

Background and method

In care homes, staff well-being, job confidence and opinion of the care provided to residents are central to morale and care quality. In this study, care home staff in the East Midlands region of England completed self-reported outcome and experience surveys in two rounds. Mean scores for each home are shown using a scale from 0 (all chose lowest option) to 100 (all chose highest option). High scores are good.

Results

In round 1, 332 staff in 15 homes submitted responses; in round 2, 207 staff in 9 homes. Mean scores in round 1 and round 2 were similar, although those of some homes scores differed significantly, cancelling each other out. Overall, Work Wellbeing mean score was 83 (care home range 48-97), with worthwhileness (92) the highest ranked item and anxiety at work (78) the lowest. Job Confidence mean score was 84 (range 59-94), with able to manage the work (86) highest and involvement in decisions that affect staff (79) lowest. Care Provided mean score was 86 (range 59-97), with treat people kindly (91) highest and well organised (80) lowest. Homes rated as outstanding by the Care Quality Commission had higher scores on average than those rated good, which were higher than those rated as needing improvement.

Conclusions

This study has demonstrated the practicality of measuring staff views of their Work Wellbeing, Job Confidence and Care Provided in care homes. Rather than wait for adverse quality outcomes to be detected, this approach offers a way to track staff morale and declared capability over time.

Care of the Elderly, Quo Vadis?

Financial and Competing Interests: CB is a NED to a care home provider and is Chair of a technology company engaged in medicines management software

Role of comprehensive geriatric assessment in healthcare of older people in UK care homes: realist review

OBJECTIVES

Comprehensive geriatric assessment (CGA) may be a way to deliver optimal care for care home residents. We used realist review to develop a theory-driven account of how CGA works in care homes.

DESIGN

Realist review.

SETTING

Care homes.

METHODS

The review had three stages: first, interviews with expert stakeholders and scoping of the literature to develop programme theories for CGA; second, iterative searches with structured retrieval and extraction of the literature; third, synthesis to refine the programme theory of how CGA works in care homes.We used the following databases: Medline, CINAHL, Scopus, PsychInfo, PubMed, Google Scholar, Greylit, Cochrane Library and Joanna Briggs Institute.

RESULTS

130 articles informed a programme theory which suggested CGA had three main components: structured comprehensive assessment, developing a care plan and working towards patient-centred goals. Each of these required engagement of a multidisciplinary team (MDT). Most evidence was available around assessment, with tension between structured assessment led by a single professional and less structured assessment involving multiple members of an MDT. Care planning needed to accommodate visiting clinicians and there was evidence that a core MDT often used care planning as a mechanism to seek external specialist support. Goal-setting processes were not always sufficiently patient-centred and did not always accommodate the views of care home staff. Studies reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare resource use and objective measures of quality of care.

CONCLUSION

The programme theory described here provides a framework for understanding how CGA could be effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care homes. All three components are required to make CGA work-this may explain why attempts to implement CGA by interventions focused solely on assessment or care planning have failed in some long-term care settings.

TRIAL REGISTRATION NUMBER

CRD42017062601.

Quality improvement collaborative aiming for Proactive HEAlthcare of Older People in Care Homes (PEACH): a realist evaluation protocol

INTRODUCTION

This protocol describes a study of a quality improvement collaborative (QIC) to support implementation and delivery of comprehensive geriatric assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching and assistance with project evaluation.

METHODS AND ANALYSIS

The QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in four local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as context-mechanism-outcome configurations describing what needs to be in place to use QICs to implement service improvements in care homes.

ETHICS AND DISSEMINATION

The study protocol was reviewed by the National Health Service Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham (reference: LT07092016) ethics committees. Both determined that the Proactive HEAlthcare of Older People in Care Homes study was a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphical illustration and a dissemination video.