Geriatric care in the United Kingdom: aligning services to needs

Geriatricians and care homes: perspectives from geriatric medicine departments and primary care trusts

Older people in care homes are clinically complex and particularly vulnerable to the effects of poor care and poor medicine. They are also a group to whom the NHS seems least committed. Geriatricians have become disengaged over the past two decades, as a result of social policies rather than clinical judgements. In 2000, the Royal College of Physicians, with the Royal College of Nursing and the British Geriatrics Society, issued guidance and recommendations for improving clinical practice. This paper reports progress since then based on results of national surveys of geriatric medicine departments and primary care trusts in England. The results show that important deficiencies persist, though most respondents were in favour of greater specialist involvement. Some suggestions are made for ways to improve the shared care of residents in care homes.

Older persons' experiences of whole systems: the impact of health and social care organizational structures

AIMS

An in-depth case study of whole systems working.

BACKGROUND

This paper reports on the second part of a two-part study exploring whole systems working. Part 1 of the study focused on an in-depth review of the literature pertaining to continuity of care and service integration. The second part, reported here, focused on an in-depth case study of one whole system. Evaluation Informed by the findings of part 1 of the study, data collection methods included in-depth interviews, real-time tracking of 18 older people, focus groups and consensus conferencing. Different data sets were analysed individually and synthesized using matrices derived from the literature review findings.

KEY ISSUE

Key themes from data synthesis include: (1) access to the most appropriate services; (2) service fragmentation; (3) continuity of care; and (4) routinized care.

CONCLUSIONS

The four themes of the case study reflect the need to address issues of demarcation of professional responsibilities, complicated channels of communication, information flows, assessment and reassessment in whole systems working.

IMPLICATIONS FOR NURSING MANAGEMENT

The impact of disempowering relationships on actual continuity of care and perceptions of quality among service users and providers. Lessons need to be learnt from specialist services and applied to service delivery in general.

Integrated care for older people: methodological issues in conducting a systematic literature review

INTRODUCTION

Systematic reviews are a useful approach for nurses to take in exploring issues important to their practice, and in this article the process of conducting a systematic literature review on integrated care for older people is described. The review was conducted as one strand of a research project aiming to inform the development of locality-based integrated care for older people in Northern Ireland, a development driven by observations of user needs.

METHODOLOGY

Systematic literature review methodology is summarized and critiqued. The process of undertaking the review in this study is described with a focus on the first stage of identifying literature, and the challenges that this presents in a review which draws on multiple bodies of work.

RESULTS

Producing a systematic literature review in integrated care is a complex undertaking, comprising a variety of different sectors, organizations, care settings, professionals, and other users, with their own bodies of knowledge; the need for an inclusive approach; the need to search a wide range of databases; nonspecific terminology; and the inappropriateness of study design hierarchies as selection criteria.

CONCLUSIONS

While such a literature review might provide a basis for research and practice, the ability of the review team to call upon a wide range of skills, experience, and knowledge across the information management field and the care system is crucial.

Challenges for care homes: education and training of healthcare assistants

The spotlight is increasingly on all care homes, including those catering specifically for older people, to deliver on quality targets in an attempt to drive up the standards of care provision. These targets include the education, training and supervision of care staff. Representing a major component of the care staff workforce in care homes are healthcare assistants and they play a key role in care provision and will continue so to do. However, pivotal to their effective role performance is preparation and support - the provision of which has been patchy to date. For care homes that provide nursing care the challenges of delivering on these targets by 2005 are significant, particularly as the majority of these homes are run as private enterprises and in the absence of any form of central funding. This article examines key issues to education and training provision. A strategic nationwide approach to education and training for healthcare assistants in care homes is recommended, coupled with robust evaluation of outcomes. Such initiatives will need to be supported by significant financial investment if the Government's targets are to be achieved.

Nurse-led inpatient care: opening the 'black box'

With recent evaluations contradicting early reports of improved outcomes from nurse-led inpatient care, the 'black box' of nurse-led care must be opened in order to examine the model of treatment. We present findings on the processes of care in one nurse-led unit (NLU), compared with an acute ward. Patterns and quality of nursing care were quantified using bar-code technology to measure type, frequency and duration of nursing activities and Quality Patient Care Scale to measure the quality of care. NLU quality matched, but did not exceed, quality on the acute ward. Patterns of care differed between wards, but activities associated with therapeutic nursing were no more frequent on the NLU. These findings support the hypothesis that disappointing outcomes in recent evaluations may be linked to failure to implement a therapeutic model of nursing.

Applying community-oriented primary care methods in British general practice: a case study

BACKGROUND

The '75 and over' assessments built into the 1990 contract for general practice have failed to enthuse primary care teams or make a significant impact on the health of older people. Alternative methods for improving the health of older people living at home are being sought.

AIM

To test the feasibility of applying community-oriented primary care methodology to a relatively deprived sub-population of older people in a relatively deprived area.

DESIGN OF STUDY

A combination of developmental and triangulation approaches to data analysis.

SETTING

Four general practices in an inner London borough.

METHOD

A community-oriented primary care approach was used to initiate innovative care for older people, supported financially by the health authority and practically by primary care academics.

RESULTS

All four practices identified problems needing attention in the older population, developed different projects focused on particular needs among older people, and tested them in practice. Patient and public involvement were central to the design and implementation processes in only one practice. Innovations were sustained in only one practice, but some were adopted by a primary care group and others extended to a wider group of practices by the health authority.

CONCLUSION

A modified community-oriented primary care approach can be used in British general practice, and changes can be promoted that are perceived as valuable by planning bodies. However, this methodology may have more impact at primary care trust level than at practice level.

A new model of integrated home care for the elderly: impact on hospital use

The objective of the present study was to examine the effect of a home care program based on comprehensive geriatric assessment-Minimum Data Set for Home Care-and case management on hospital use/cost of frail elderly individuals. We determined all hospital admissions and days spent in hospital during the first year since the implementation of the home care program, and compared them to the rate of hospitalization that the same patients had experienced in the year preceding the implementation of such program. Following the implementation of this program, there was a significant reduction of the number of hospitalizations (pre 44% vs. post 26%, P < 0.001), associated with a reduction of hospital days, both at the individual patient level and for each admission. In conclusion, an integrated home care program based on the implementation of a comprehensive geriatric assessment instrument guided by a case manager has a significant impact on hospitalization and is cost-effective.

Acute hospital admissions from nursing homes: some may be avoidable

A retrospective survey of acute hospital admissions from nursing homes over a year to a district hospital revealed high overall hospital admission rates and wide variations of admission rates from similar homes. Medical admissions dominated, infections and poorly controlled heart failure being notably common. A significant proportion of admissions may have been avoided by active chronic disease management, together with better information for doctors responding to emergency calls and specialist support programmes facilitating in situ treatment.

The right person? the right place? the right time? a pilot study of the appropriateness of nursing home placements

The appropriate use of health services is a key challenge for the NHS. Older people have been consistently identified as being disproportionately represented amongst those defined as 'inappropriately' located within the acute health sector. Prior to the introduction of community care it was hypothesised that older people were entering nursing home care inappropriately. With the requirement for assessment prior to entry into nursing homes now a feature of the system such 'inappropriate' admissions should not occur. This pilot study investigates the feasibility of determining inappropriate admissions and the extent of this phenomenon in nursing homes used by three inner London Boroughs. To determine the number of 'inappropriate' placements in nursing homes in three London Boroughs (Lambeth, Southwark & Lewisham). Retrospective audit of nursing home case notes using standardised data collection method. New local authority funded admissions to nursing homes from LSL during the period 1 April 1993-31 March 1995. One hundred and fifty seven people entered the 25 nursing homes identified. For 65% nursing home placement was appropriate, 14% were apparently more suited to residential care and 17% for community care. Documentation concerning clients held by the nursing homes was generally poor. Despite the introduction of the Community Care Act and the clear requirement for assessment before entry into nursing home care, approximately one-third of the placements reviewed were inappropriate and did not meet the individual's care needs. Further research is underway to determine if these findings apply nationally.