Variation in ambulance call rates for care homes in Torbay, UK

Variations in older people's emergency care use by social care setting: a systematic review of international evidence

BACKGROUND

Older adults' use of social care and their healthcare utilization are closely related. Residents of care homes access emergency care more often than the wider older population; however, less is known about emergency care use across other social care settings.

SOURCES OF DATA

A systematic review was conducted, searching six electronic databases between January 2012 and February 2022.

AREAS OF AGREEMENT

Older people access emergency care from a variety of community settings.

AREAS OF CONTROVERSY

Differences in study design contributed to high variation observed between studies.

GROWING POINTS

Although data were limited, findings suggest that emergency hospital attendance is lowest from nursing homes and highest from assisted living facilities, whilst emergency admissions varied little by social care setting.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is a paucity of published research on emergency hospital use from social care settings, particularly home care and assisted living facilities. More attention is needed on this area, with standardized definitions to enable comparisons between studies.

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

Background

care home staff play a crucial role in managing residents’ health and responding to deteriorations. When deciding whether to transfer a resident to hospital, a careful consideration of the potential benefits and risks is required. Previous studies have identified factors that influence staff decision-making, yet few have moved beyond description to produce a conceptual model of the decision-making process.

Objectives

to develop a conceptual model to describe care home staff’s decision-making when faced with a resident who potentially requires a transfer to the hospital.

Methods

data collection occurred in England between May 2018 and November 2019, consisting of 28 semi-structured interviews with 30 members of care home staff across six care home sites and 113 hours of ethnographic observations, documentary analysis and informal conversations (with staff, residents, visiting families, friends and healthcare professionals) at three of these sites.

Results

a conceptual model of care home staff’s decision-making is presented. Except in situations that staff perceived to be urgent enough to require an immediate transfer, resident transfers tended to occur following a series of escalations. Care home staff made complex decisions in which they sought to balance a number of potential benefits and risks to: residents; staff (as decision-makers); social relationships; care home organisations and wider health and social care services.

Conclusions

during transfer decisions, care home staff make complex decisions in which they weigh up several forms of risk. The model presented offers a theoretical basis for interventions to support deteriorating care home residents and the staff responsible for their care.

Multidisciplinary residential home intervention to improve outcomes for frail residents

BACKGROUND

Residential homes provide accommodation and assistance with personal care only and are not required to have registered nurses on site. However, their residents often have a combination of comorbidity, polypharmacy, frailty and mental-health conditions with poor access to healthcare to meet these needs. Integrated healthcare for older people is a key NHS priority in the Long-Term Plan and the Five-Year Forward View. We describe development and implementation of multi-disciplinary intervention to integrate healthcare and promote interprofessional education.

METHODS

A multi-disciplinary residential home quality improvement project in two cycles by a team comprising senior and trainee general practitioners, trainees in geriatrics, psychiatry, pharmacist and residential home senior staff. The intervention was underpinned by the framework for enhanced health in care homes including Comprehensive Geriatric Assessment (CGA) and mental-health review. Each intervention session included an educational presentation by a team member consideration of each resident in a pre-evaluation multi-disciplinary discussion followed by a structured clinical assessment and discussion of proposed management.

RESULTS

Three residential homes participated with a total 34 residents receiving intervention. In one residential home, there was a 75% reduction in admissions for those reviewed and a reduction in overall admission costs. Polypharmacy was reduced by an average of 2 medications per resident across the three sites. There was a 63% increase in cardio-pulmonary resuscitation decisions and 76% increase in advance care planning discussions.

CONCLUSION

This was an effective model for multi-disciplinary trainees working with a perceived impact on physical and mental health, and valuable opportunities for sharing learning.

Using advance and emergency care plans during transfer decisions: A grounded theory interview study with care home staff

BACKGROUND

Advance care planning has been identified as one of few modifiable factors that could reduce hospital transfers from care homes. Several types of documents may be used by patients and clinicians to record these plans. However, little is known about how plans are perceived and used by care home staff at the time of deterioration.

AIM

To describe care home staff experiences and perceptions of using written plans during in-the-moment decision-making about potential resident hospital transfers.

DESIGN

Qualitative semi-structured interviews analysed using the Straussian approach to grounded theory.

SETTING/PARTICIPANTS

Thirty staff across six care homes (with and without nursing) in the East and West Midlands of England.

RESULTS

Staff preferred (in principle) to keep deteriorating residents in the care home but feared that doing so could lead to negative repercussions for them as individuals, especially when there was perceived discordance with family carers' wishes. They felt that clinicians should be responsible for these plans but were happy to take a supporting role. At the time of deterioration, written plans legitimised the decision to care for the resident within the home; however, staff were wary of interpreting broad statements and wanted plans to be detailed, specific, unambiguous, technically 'correct', understood by families and regularly updated.

CONCLUSIONS

Written plans provide reassurance for care home staff, reducing concerns about personal and professional risk. However, care home staff have limited discretion to interpret plans and transfers may occur if plans are not specific enough for care home staff to use confidently.

Effect on secondary care of providing enhanced support to residential and nursing home residents: a subgroup analysis of a retrospective matched cohort study

BACKGROUND

Thirteen residential care homes and 10 nursing homes specialising in older people in Rushcliffe, England, participated in an improvement programme. The enhanced support provided included regular visits from named general practitioners and additional training for care home staff. We assessed and compared the effect on hospital use for residents in residential and nursing homes, respectively.

METHODS

Using linked care home and administrative hospital data, we examined people aged 65 years or over who moved to a participating care home between 2014 and 2016 (n=568). We selected matched control residents who had similar characteristics to the residents receiving enhanced support and moved to similar care homes not participating in the enhanced support (n=568). Differences in hospital use were assessed for residents of each type of care home using multivariable regression.

RESULTS

Residents of participating residential care homes showed lower rates of potentially avoidable emergency admissions (rate ratio 0.50, 95% CI 0.30 to 0.82), emergency admissions (rate ratio 0.60, 95% CI 0.42 to 0.86) and Accident & Emergency attendances (0.57, 95% CI 0.40 to 0.81) than matched controls. Hospital bed days, outpatient attendances and the proportion of deaths that occurred out of hospital were not statistically different. For nursing home residents, there were no significant differences for any outcome.

CONCLUSIONS

The enhanced support was associated with lower emergency hospital use for older people living in residential care homes but not for people living in nursing homes. This might be because there was more potential to reduce emergency care for people in residential care homes. In nursing homes, improvement programmes may need to be more tailored to residents' needs or the context of providing care in that setting.