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McCarthy L, Borley K, Ancelin T, Carroll R, Chadborn N, Blundell AG, Gordon AL. Developing a list of core competencies for medical aspects of healthcare delivery in care homes: scoping review and Delphi process. Age Ageing 2023; 52:afad237. [PMID: 38156880 PMCID: PMC10756078 DOI: 10.1093/ageing/afad237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/28/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Care home residents live with frailty and multiple long-term conditions. Their medical management is complex and specialised. We set out to develop a list of core competencies for doctors providing medical care in long-term care homes. METHODS A scoping review searched MEDLINE, EMBASE and CAB Abstracts, supplemented by grey literature from the Portal of Online Geriatrics Education and the International Association of Geriatrics and Gerontology, looking for core competencies for doctors working in care homes. These were mapped to the UK nationally mandated Generic Professional Competencies Framework. A Delphi exercise was conducted over three rounds using a panel of experts in care homes and medicine of older people. Competencies achieving 80% agreement for inclusion/exclusion were rejected/accepted, respectively. RESULTS The scoping review identified 22 articles for inclusion, yielding 124 competencies over 21 domains. The Delphi panel comprised 23 experts, including 6 geriatricians, 4 nurses, 3 general practitioners, 2 advanced clinical practitioners, 2 care home managers, and one each of a patient and public representative, palliative care specialist, psychiatrist, academic, physiotherapist and care home audit lead. At the end of three rounds, 109 competencies over 19 domains were agreed. Agreement was strongest for generic competencies around frailty and weaker for sub-specialist knowledge about specific conditions and competencies related to care home medical leadership and management. CONCLUSION The resulting competencies provide the basis of a curriculum for doctors working in long-term care homes for older people. They are specialty agnostic and could be used to train general practitioners or medical specialty doctors.
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Affiliation(s)
- Lauren McCarthy
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, Nottingham, UK
| | - Kayla Borley
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, Nottingham, UK
| | - Thomas Ancelin
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, Nottingham, UK
| | - Rachael Carroll
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, Nottingham, UK
- NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK
| | - Neil Chadborn
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, Nottingham, UK
- NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK
| | - Adrian G Blundell
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, Nottingham, UK
- Department of Health Care of Older People, Nottingham University Hospitals, Nottingham, UK
| | - Adam L Gordon
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, Nottingham, UK
- NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK
- Department of Medicine of the Elderly, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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2
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Chambers D, Cantrell A, Preston L, Marincowitz C, Wright L, Conroy S, Lee Gordon A. Reducing unplanned hospital admissions from care homes: a systematic review. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-130. [PMID: 37916580 DOI: 10.3310/klpw6338] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Background Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost. Objectives Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings. Data sources We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked. Methods We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect. Results We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence. Conclusions Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation. Limitations Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible. Future work We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes. Study registration This study is registered as PROSPERO database CRD42021289418. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Louise Preston
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Carl Marincowitz
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Simon Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Adam Lee Gordon
- Academic Unit of Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham, UK
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3
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Hughes M, Butchard S, Giebel C. The role of identity in the experiences of dementia care workers from a minority ethnic background during the COVID-19 pandemic: A qualitative study. Health Expect 2023; 26:1668-1678. [PMID: 37078475 PMCID: PMC10349238 DOI: 10.1111/hex.13772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Care home staff working during the COVID-19 pandemic experienced higher levels of stress and increased workloads. People from diverse ethnic backgrounds were disproportionately affected by the COVID-19 pandemic. This study explored the identity experiences of care home staff from diverse ethnic backgrounds in the context of working during the COVID-19 pandemic. METHODS Fourteen semistructured interviews were conducted between May 2021 and April 2022 with ethnic minority care home staff in England, who worked during the pandemic. Participants were recruited using convenience and theoretical sampling. Interviews were conducted via telephone or online platforms. A social constructivist grounded theory methodology was utilised in analysing the data. FINDINGS Participants described five key processes which facilitated or hindered the impact that their experiences had on their identity: dealing with uncertainty and transitioning into a COVID-19 world; difficult emotions; experiences of discrimination and racism; the response from the care home and societal systems; and the personal vs collective responsibility. When participants' physical and psychological needs went unmet by support structures within the care home and/or society, they experienced a sense of injustice, lack of control and being unvalued or discriminated against by others. CONCLUSIONS This study highlights the importance of recognising the unique needs of staff from diverse ethnic backgrounds working in care homes and adapting working practices to improve impact on identity, job satisfaction and staff retention. PATIENT AND PUBLIC INVOLVEMENT One care home worker was involved in developing the topic guide and helping to interpret the findings.
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Affiliation(s)
- Mishca Hughes
- Department of Primary Care and Mental HealthUniversity of LiverpoolLiverpoolUK
| | - Sarah Butchard
- Department of Primary Care and Mental HealthUniversity of LiverpoolLiverpoolUK
- Mersey Care NHS TrustLiverpoolUK
| | - Clarissa Giebel
- Department of Primary Care and Mental HealthUniversity of LiverpoolLiverpoolUK
- NIHR Applied Research Collaboration North West CoastLiverpoolUK
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4
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Woodward A, Ruston A. Empowerment of care home staff through effective collaboration with healthcare. J Interprof Care 2023; 37:109-117. [PMID: 35403543 DOI: 10.1080/13561820.2022.2047015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Integrative local health delivery models in the UK, under the framework of Enhanced Health in Care Homes (EHICH), have been developed to improve joint working between health and social care to benefit the patient. Despite this drive toward health and social care integration, research on the barriers, facilitators, and impact of partnership working on role of care home staff is underdeveloped. This study set out to explore views on how closer working between health and social care can impact on the role of care home staff and any barriers to effective integration. Staff from 25 care homes and GPs from their partnered practices were interviewed to explore the impact of the partnership. Homes receiving regular visits from the same health professional found the relationship between the two sectors had benefitted both residents and staff. The development of trusting relationships, access to support and information, and recognition and respect were all seen as facilitating the partnership and enhancing patient care. Regular and effective interactions with health-care professionals were key and had the potential to empower and increase confidence of care home staff in their role around health care. Factors negatively impacting on strength of relationship such as visits by inconsistent professional and high turnover of care home staff were a barrier to successful partnerships. Experiences of poor interactions with those from health-care services where there was an absence of a trusting relationship were disempowering to care home staff and remain a barrier to effective wider health and social care collaboration.
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Affiliation(s)
- Amelia Woodward
- College of Health, Psychology and Social Care University of Derby, Derby, UK
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5
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Heinrich CH, McHugh S, McCarthy S, Donovan MD. Barriers and enablers to deprescribing in long-term care: A qualitative investigation into the opinions of healthcare professionals in Ireland. PLoS One 2022; 17:e0274552. [PMID: 36520798 PMCID: PMC9754218 DOI: 10.1371/journal.pone.0274552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/31/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The prevalence of polypharmacy increases with age, increasing the exposure of older adults to potentially inappropriate medications (PIMs). Deprescribing has been shown to reduce PIMs for older residents in long-term care; however, deprescribing is not universally implemented. This study aims to identify the barriers and enablers to deprescribing in Irish long-term care facilities from the healthcare professionals' (HCPs) perspective. METHODS A qualitative descriptive approach was conducted using semi-structured interviews with HCPs working in long-term care (general practitioners, pharmacists and nurses). Purposive sampling with maximum variation was applied to select long-term care sites to identify HCPs, supplemented with convenience sampling of post-graduate HCPs from University College Cork. Data was thematically analysed and mapped to a framework of deprescribing barriers and enablers informed by the Theoretical Domains Framework. RESULTS Twenty-six HCPs participated from 13 long-term care facilities. The main barriers and enablers identified mapped to five domains. Barriers included insufficient resources, lack of co-ordination between healthcare settings and negative social influences. Additional barriers exist in private settings including deprescribing awareness, commitment and the need for incentives. Deprescribing enablers included interprofessional support and patient social influence. To encourage deprescribing, potential enablers include HCP education, pharmacist role expansion and tailored deprescribing guidelines within a structured process. CONCLUSION Interventions to support deprescribing should build on existing systems, involve stakeholders and utilise guidelines within a structured process. Any intervention must account for the nuanced barriers and enablers which exist in both public and private settings.
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Affiliation(s)
- Clara H. Heinrich
- School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland
- * E-mail:
| | - Sheena McHugh
- School of Public Health, University College Cork, Cork City, Co. Cork, Ireland
| | - Suzanne McCarthy
- School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland
| | - Maria D. Donovan
- School of Pharmacy, University College Cork, Cork City, Co. Cork, Ireland
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6
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Leighton PA, Darby J, Allen F, Cook M, Evley R, Fox C, Godfrey M, Gordon A, Gladman J, Horne J, Robertson K, Logan P. A realist evaluation of a multifactorial falls prevention programme in care homes. Age Ageing 2022; 51:6872690. [PMID: 36469088 PMCID: PMC9721241 DOI: 10.1093/ageing/afac263] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/17/2022] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Paul A Leighton
- Lifespan and Population Health, School of Medicine (LPH), University of Nottingham, Nottingham UK
| | - Janet Darby
- Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham UK
| | - Frances Allen
- Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham UK
| | - Marie Cook
- College of Health and Psychology, University of Derby, Derby UK
| | - Rachel Evley
- Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham UK
| | - Chris Fox
- College of Medicine and Health, University of Exeter, Exeter UK.,Norfolk and Suffolk NHS Foundation Trust, Norwich UK
| | | | - Adam Gordon
- Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham UK
| | - John Gladman
- Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham UK.,Nottingham University Hospitals NHS Trust, Nottingham UK.,NIHR Nottingham Biomedical Research Centre, Queens Medical Centre, Nottingham UK.,NIHR Applied Research Collaboration East Midlands (ARC-EM), Nottingham UK
| | - Jane Horne
- Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham UK
| | - Kate Robertson
- Nottinghamshire Healthcare NHS Foundation Trust, Nottingham UK
| | - Pip Logan
- Injury, Recovery and Inflammation Sciences (IRIS), School of Medicine, University of Nottingham, Nottingham UK
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7
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Stevens E, Clarke SG, Harrington J, Manthorpe J, Martin FC, Sackley C, McKevitt C, Marshall IJ, Wyatt D, Wolfe C. The provision of person-centred care for care home residents with stroke: An ethnographic study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e5186-e5195. [PMID: 35869786 PMCID: PMC10084099 DOI: 10.1111/hsc.13936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/31/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
Care home residents with stroke have higher levels of disability and poorer access to health services than those living in their own homes. We undertook observations and semi-structured interviews (n = 28 participants) with managers, staff, residents who had experienced a stroke and their relatives in four homes in London, England, in 2018/2019. Thematic analysis revealed that residents' needs regarding valued activity and stroke-specific care and rehabilitation were not always being met. This resulted from an interplay of factors: staff's lack of recognition of stroke and its effects; gaps in skills; time pressures; and the prioritisation of residents' safety. To improve residential care provision and residents' quality of life, care commissioners, regulators and providers may need to re-examine how care homes balance safety and limits on staff time against residents' valued activity, alongside improving access to specialist healthcare treatment and support.
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Affiliation(s)
- Eleanor Stevens
- School of Life Course & Population SciencesKing's College LondonLondonUK
| | - Stephanie G. Clarke
- School of Life Course & Population SciencesKing's College LondonLondonUK
- Guy's and St Thomas' NHS Foundation TrustLondonUK
- University Hospitals BirminghamDepartment of PhysiotherapyBirminghamUK
| | - Jean Harrington
- School of Life Course & Population SciencesKing's College LondonLondonUK
| | - Jill Manthorpe
- National Institute for Health and Care Research (NIHR) Policy Research Unit in Health & Social Care Workforce, King's College LondonLondonUK
| | - Finbarr C. Martin
- School of Life Course & Population SciencesKing's College LondonLondonUK
- Guy's and St Thomas' NHS Foundation TrustLondonUK
| | - Catherine Sackley
- School of Life Course & Population SciencesKing's College LondonLondonUK
- Faculty of Medicine and Health SciencesUniversity of NottinghamNottinghamUK
| | - Christopher McKevitt
- School of Life Course & Population SciencesKing's College LondonLondonUK
- National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) South LondonLondonUK
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC)Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | - Iain J. Marshall
- School of Life Course & Population SciencesKing's College LondonLondonUK
- National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) South LondonLondonUK
| | - David Wyatt
- School of Life Course & Population SciencesKing's College LondonLondonUK
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC)Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | - Charles Wolfe
- School of Life Course & Population SciencesKing's College LondonLondonUK
- Guy's and St Thomas' NHS Foundation TrustLondonUK
- National Institute for Health and Care Research (NIHR) Applied Research Collaboration (ARC) South LondonLondonUK
- National Institute for Health and Care Research (NIHR) Biomedical Research Centre (BRC)Guy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
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8
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Devi R, Daffu‐O'Reilly A, Haunch K, Griffiths A, Jones L, Meyer J, Spilsbury K. A qualitative exploration of the clinical presentation, trajectory, management and recovery of COVID-19 in older people: Learning from frontline staff experiences. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e5223-e5233. [PMID: 35962626 PMCID: PMC9538525 DOI: 10.1111/hsc.13941] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 05/26/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Reena Devi
- School of HealthcareUniversity of LeedsLeedsUK
- Nurturing Innovation in Care Home Excellence in Leeds (NICHE‐Leeds)LeedsUK
| | | | - Kirsty Haunch
- School of HealthcareUniversity of LeedsLeedsUK
- Nurturing Innovation in Care Home Excellence in Leeds (NICHE‐Leeds)LeedsUK
| | - Alys Griffiths
- Nurturing Innovation in Care Home Excellence in Leeds (NICHE‐Leeds)LeedsUK
- Department of Primary Care & Mental HealthUniversity of LiverpoolLiverpoolUK
| | | | - Julienne Meyer
- The National Care ForumCoventryUK
- School of Health SciencesCity University of LondonLondonUK
| | - Karen Spilsbury
- School of HealthcareUniversity of LeedsLeedsUK
- Nurturing Innovation in Care Home Excellence in Leeds (NICHE‐Leeds)LeedsUK
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9
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Garden G, Usman A, Readman D, Storey L, Wilkinson L, Wilson G, Dening T, Gordon AL, Gladman JRF. Advance care plans in UK care home residents: a service evaluation using a stepped wedge design. Age Ageing 2022; 51:6555262. [PMID: 35348604 PMCID: PMC8963445 DOI: 10.1093/ageing/afac069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction advance care planning (ACP) in care homes has high acceptance, increases the proportion of residents dying in place and reduces hospital admissions in research. We investigated whether ACP had similar outcomes when introduced during real-world service implementation. Methods a service undertaking ACP in Lincoln, UK care homes was evaluated using routine data. Outcomes were proportion of care homes and residents participating in ACP; characteristics of residents choosing/declining ACP and place of death for those with/without ACP. Hospital admissions were analysed using mixed-effects Poisson regression for number of admissions, and a mixed-effects negative binomial model for number of occupied hospital bed days. Results About 15/24 (63%) eligible homes supported the service, in which 404/508 (79.5%) participants chose ACP. Residents choosing ACP were older, frailer, more cognitively impaired and malnourished; 384/404 (95%) residents choosing ACP recorded their care home as their preferred place of death: 380/404 (94%) declined cardiopulmonary resuscitation. Among deceased residents, 219/248 (88%) and 33/49 (67%) with and without advance care plan respectively died in their care home (relative risk 1.35, 95% confidence interval [CI] 1.1–1.6, P < 0.001). Hospital admission rates and bed occupancy did not differ after implementation. Discussion About 79.5% participants chose ACP. Those doing so were more likely to die at home. Many homes were unwilling or unable to support the service. Hospital admissions were not reduced. Further research should consider how to enlist the support of all homes and to explore why hospital admissions were not reduced.
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Affiliation(s)
- Gill Garden
- Lincoln Medical School, University of Lincoln, Lincoln, UK.,United Lincolnshire Hospitals Trust, Lincoln, UK
| | - Adeela Usman
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | | | | | - Graham Wilson
- Lincolnshire Community Health Services Trust, Lincoln, UK
| | - Tom Dening
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Adam L Gordon
- School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Applied Research Centre-East Midlands (ARC-EM), Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - John R F Gladman
- School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Applied Research Centre-East Midlands (ARC-EM), Nottingham, UK.,NIHR Nottingham Biomedical Research Centre, Nottingham, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
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10
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Romano V, Minns Lowe CJ. The experiences of dietitian's working in care homes in England: a qualitative study. Age Ageing 2022; 51:6527734. [PMID: 35165689 DOI: 10.1093/ageing/afac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The provision of appropriate nutritional care in care homes is a priority for health services in England. There is limited evidence demonstrating the role of dietitians within older people care homes. This study explores the experiences of dietitians working with care homes for older people in England. METHODS A qualitative study using semi-structured face-to-face or telephone interviews was conducted. Criterion and snowball purposive sampling recruited six dietitian participants. Interviews were audio recorded and transcribed verbatim. A reflexive diary was completed, and data analyses followed interpretative phenomenological analyses. Constant comparison, code-recode audits, independent coding by a supervisor, supervisory support and peer review were used to promote rigour. RESULTS Two key themes and three subthemes were identified: Theme 1 is collaboration with multidisciplinary team (MDT) professionals and its two subthemes are as follows: using support strategies (pathway/standards implementation, training/education and resident dietetic assessment) and delivering value (by benefitting more residents, demonstrating unique dietetic skills, nutritional prescription savings and meeting other professional's knowledge gap). Theme 2 is communication with MDT professionals and its subtheme is the understanding of the dietitian's role and of nutritional care. CONCLUSION Dietitians believe that they play a key role in supporting care homes with nutritional care, identifying themselves as experts and leaders, working with MDT professionals. The findings highlight the importance of a consistent approach to managing nutrition and the need for dietitians to share outcome data to improve the limited evidence-base. There is a need to agree a defined dietetic service provision to care homes in England.
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Affiliation(s)
- Vittoria Romano
- Nutrition and Dietetics Department, Central London Community Healthcare NHS Trust, Lisson Grove Health Centre, Gateforth Street, NW8 8EG
| | - Catherine J Minns Lowe
- Department of Allied Health Professions, Midwifery and Social Work, School of Health and Social Work, University of Hertfordshire, Hatfield, UK
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11
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Heinrich CH, Hurley E, McCarthy S, McHugh S, Donovan MD. Barriers and enablers to deprescribing in long-term care facilities: a 'best-fit' framework synthesis of the qualitative evidence. Age Ageing 2022; 51:6514232. [PMID: 35077555 DOI: 10.1093/ageing/afab250] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION older adults are at risk of adverse outcomes due to a high prevalence of polypharmacy and potentially inappropriate medications (PIMs). Deprescribing interventions have been demonstrated to reduce polypharmacy and PIMs. However, deprescribing is not performed routinely in long-term care facilities (LTCFs). This qualitative evidence synthesis aims to identify the factors which limit and enable health care workers' (HCWs) engagement with deprescribing in LTCFs. METHODS the 'best-fit' framework approach was used to synthesise evidence by using the Theoretical Domains Framework (TDF) as the a priori framework. Included studies were analysed qualitatively to identify LTCF barriers and enablers of deprescribing and were mapped to the TDF. Constructs within domains were refined to best represent the LTCF context. A conceptual model was created, hypothesising relationships between barriers and enablers. RESULTS of 655 records identified, 14 met the inclusion criteria. The 'best-fit' framework included 17 barriers and 16 enablers, which mapped to 11 of the 14 TDF domains. Deprescribing barriers included perceptions of an 'established hierarchy' within LTCFs, negatively affecting communication and insufficient resources which limited HCWs' engagement with deprescribing. Enablers included tailored deprescribing guidelines, interprofessional support and working with a patient focus, allowing the patients' condition to influence decisions. DISCUSSION this study identified that education, interprofessional support and collaboration can facilitate deprescribing. To overcome deprescribing barriers, change is required to a patient-centred model and HCWs need to be equipped with necessary resources and adequate reimbursement. The LTCF organisational structure must support deprescribing, with communication between health care systems.
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Logan PA, Horne JC, Allen F, Armstrong SJ, Clark AB, Conroy S, Darby J, Fox C, Gladman JR, Godfrey M, Gordon AL, Irvine L, Leighton P, McCartney K, Mountain G, Robertson K, Robinson K, Sach TH, Stirling S, Wilson EC, Sims EJ. A multidomain decision support tool to prevent falls in older people: the FinCH cluster RCT. Health Technol Assess 2022; 26:1-136. [PMID: 35125131 PMCID: PMC8859771 DOI: 10.3310/cwib0236] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Philippa A Logan
- School of Medicine, University of Nottingham, Nottingham, UK
- Community Rehabilitation Team, Nottingham CityCare Partnership, Nottingham, UK
- National Institute for Health Research Applied Research Collaboration East Midlands, Leicester General Hospital, Leicester, UK
- National Institute for Health Research Nottingham Biomedical Research Centre, Queen's Medical Centre, Nottingham, UK
| | - Jane C Horne
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Frances Allen
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Allan B Clark
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Janet Darby
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Chris Fox
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
| | - John Rf Gladman
- School of Medicine, University of Nottingham, Nottingham, UK
- National Institute for Health Research Applied Research Collaboration East Midlands, Leicester General Hospital, Leicester, UK
- National Institute for Health Research Nottingham Biomedical Research Centre, Queen's Medical Centre, Nottingham, UK
- Health Care of the Elderly Directorate, Nottingham University Hospitals, Nottingham, UK
| | - Maureen Godfrey
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Adam L Gordon
- School of Medicine, University of Nottingham, Nottingham, UK
- National Institute for Health Research Applied Research Collaboration East Midlands, Leicester General Hospital, Leicester, UK
- National Institute for Health Research Nottingham Biomedical Research Centre, Queen's Medical Centre, Nottingham, UK
- Medical School, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Lisa Irvine
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
| | - Paul Leighton
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Karen McCartney
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Gail Mountain
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Kate Robertson
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Katie Robinson
- School of Medicine, University of Nottingham, Nottingham, UK
- Health Care of the Elderly Directorate, Nottingham University Hospitals, Nottingham, UK
| | - Tracey H Sach
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
| | - Susan Stirling
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Erika J Sims
- Norwich Clinical Trials Unit, University of East Anglia, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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Healthcare barriers, what about older age? A comment on Malik-Soni et al. Pediatr Res 2022; 91:1025-1027. [PMID: 34108624 PMCID: PMC9122813 DOI: 10.1038/s41390-021-01596-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 02/01/2023]
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Chadborn NH, Devi R, Williams C, Sartain K, Goodman C, Gordon AL. GPs’ involvement to improve care quality in care homes in the UK: a realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Neil H Chadborn
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
- NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK
| | - Reena Devi
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | | | - Kathleen Sartain
- Dementia and Frail Older Persons Patient and Public Involvement Group, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
- NIHR Applied Research Collaboration – East of England (ARC-EoE), Cambridge, UK
| | - Adam L Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
- NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK
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Costa-Font J, Jiménez Martin S, Viola A. Fatal Underfunding? Explaining COVID-19 Mortality in Spanish Nursing Homes. J Aging Health 2021; 33:607-617. [PMID: 33818164 PMCID: PMC8236671 DOI: 10.1177/08982643211003794] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The COVID-19 pandemic has exerted a disproportionate effect on older European populations living in nursing homes. This article discusses the 'fatal underfunding hypothesis', and reports an exploratory empirical analysis of the regional variation in nursing home fatalities during the first wave of the COVID-19 pandemic in Spain, one of the European countries with the highest number of nursing home fatalities. We draw on descriptive and multivariate regression analysis to examine the association between fatalities and measures of nursing home organisation, capacity and coordination plans alongside other characteristics. We document a correlation between regional nursing home fatalities (as a share of excess deaths) and a number of proxies for underfunding including nursing home size, occupancy rate and lower staff to a resident ratio (proxying understaffing). Our preliminary estimates reveal a 0.44 percentual point reduction in the share of nursing home fatalities for each additional staff per place in a nursing home consistent with a fatal underfunding hypothesis.
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Affiliation(s)
- Joan Costa-Font
- Joan Costa-Font, Department of Health Policy, London School of Economics, Houghton Street, London WC2A 2AE, UK.
| | - Sergi Jiménez Martin
- London School of Economics IZA & CESIfo London, UK
- Universitat Pompeu Fabra, Barcelona GSE & FEDEA, Barcelona (Spain)
- institution-id-type="Ringgold" />Universidad Nacional de Educacin a Distancia (UNED) & FEDEA, Spain
| | - Analía Viola
- London School of Economics IZA & CESIfo London, UK
- Universitat Pompeu Fabra, Barcelona GSE & FEDEA, Barcelona (Spain)
- institution-id-type="Ringgold" />Universidad Nacional de Educacin a Distancia (UNED) & FEDEA, Spain
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Koerner J, Johnston N, Samara J, Liu WM, Chapman M, Forbat L. Context and mechanisms that enable implementation of specialist palliative care Needs Rounds in care homes: results from a qualitative interview study. BMC Palliat Care 2021; 20:118. [PMID: 34294068 PMCID: PMC8299598 DOI: 10.1186/s12904-021-00812-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
Background Improving quality of palliative and end of life care in older people’s care homes is essential. Increasing numbers of people die in these settings, yet access to high quality palliative care is not routinely provided. While evidence for models of care are growing, there remains little insight regarding how to translate evidence-based models into practice. Palliative Care Needs Rounds (hereafter Needs Rounds) have a robust evidence base, for providing palliative care in care homes, reducing resident hospitalisations, improving residents’ quality of death, and increasing staff confidence in caring for dying residents. This study aimed to identify and describe the context and mechanisms of change that facilitate implementation of Needs Rounds in care homes, and enable other services to reap the benefits of the Needs Rounds approach to care provision. Methods Qualitative interviews, embedded within a large randomised control trial, were conducted with a purposive sample of 21 staff from 11 care homes using Needs Rounds. The sample included managers, nurses, and care assistants. Staff participated in individual or dyadic semi-structured interviews. Implementation science frameworks and thematic analysis were used to interpret and analyse the data. Results Contextual factors affecting implementation included facility preparedness for change, leadership, staff knowledge and skills, and organisational policies. Mechanisms of change that facilitated implementation included staff as facilitators, identifying and triaging residents, strategizing knowledge exchange, and changing clinical approaches to care. Care home staff also identified planning and documentation, and shifts in communication. The outcomes reported by staff suggest reductions in hospitalisations and problematic symptoms for residents, improved staff skills and confidence in caring for residents in their last months, weeks and days of life. Conclusions The significance of this paper is in offering care homes detailed insights into service contexts and mechanisms of change that will enable them to reap the benefits of Needs Rounds in their own services. The paper thus will support the implementation of an approach to care that has a robust evidence base, for a population under-served by specialist palliative care. Trial registration ACTRN12617000080325. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00812-4.
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Affiliation(s)
- Jane Koerner
- Health Research Institute, University of Canberra, Canberra, Australia
| | - Nikki Johnston
- Faculty of Health, University of Canberra, Canberra, Australia
| | | | - Wai-Man Liu
- College of Business and Economics, Australian National University, Canberra, Australia
| | - Michael Chapman
- Department of Palliative Care, Canberra Health Services, Canberra, Australia.,College of Health and Medicine, Australian National University, Canberra, Australia
| | - Liz Forbat
- Faculty of Social Sciences, University of Stirling, Stirling, Scotland, UK.
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17
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Marshall F, Gordon A, Gladman JRF, Bishop S. Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study. BMC Geriatr 2021; 21:102. [PMID: 33546612 PMCID: PMC7863040 DOI: 10.1186/s12877-021-02053-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/18/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Fiona Marshall
- NIHR Applied Research Collaboration - East Midlands (ARC-EM), Nottingham, UK.
- School of Medicine, University of Nottingham, Nottingham, UK.
- Division of Medical Sciences and Graduate Entry Medicine, Derby Medical School, Royal Derby Hospital, Derby, DE22 3NE, UK.
| | - Adam Gordon
- NIHR Applied Research Collaboration - East Midlands (ARC-EM), Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham, UK
| | - John R F Gladman
- NIHR Applied Research Collaboration - East Midlands (ARC-EM), Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Nottingham Biomedical Research Centre (BRC), Nottingham, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Simon Bishop
- Nottingham University Business School, University of Nottingham, Nottingham, UK
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Downs M, Blighe A, Carpenter R, Feast A, Froggatt K, Gordon S, Hunter R, Jones L, Lago N, McCormack B, Marston L, Nurock S, Panca M, Permain H, Powell C, Rait G, Robinson L, Woodward-Carlton B, Wood J, Young J, Sampson E. A complex intervention to reduce avoidable hospital admissions in nursing homes: a research programme including the BHiRCH-NH pilot cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2021. [DOI: 10.3310/pgfar09020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Murna Downs
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Alan Blighe
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Robin Carpenter
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Alexandra Feast
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Katherine Froggatt
- International Observatory on End of Life Care, Lancaster University, Lancaster, UK
| | - Sally Gordon
- National Institute for Health Research Clinical Research Network Yorkshire and Humber, York Teaching Hospital NHS Foundation Trust, York, UK
| | - Rachael Hunter
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Liz Jones
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Natalia Lago
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Brendan McCormack
- Division of Nursing and Division of Occupational Therapy and Arts Therapies, School of Health Sciences, Queen Margaret University, Edinburgh, UK
| | - Louise Marston
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | | | - Monica Panca
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Helen Permain
- Research Department, Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Catherine Powell
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK
| | - Greta Rait
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Louise Robinson
- Institute for Ageing and Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - John Wood
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - John Young
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Leeds, UK
- Bradford Institute for Health Research, Bradford, UK
| | - Elizabeth Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
- Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
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19
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Hodge SY, Ali MR, Gordon AL. Recognizing and responding to deterioration in care homes: a scoping review protocol. JBI Evid Synth 2020; 19:447-453. [PMID: 33230017 DOI: 10.11124/jbisrir-d-19-00413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To identify the available published primary research and any relevant policies, guidelines, or protocols regarding how care home staff recognize and respond to an acutely deteriorating resident. INTRODUCTION Older people living in care homes have complex health care needs. Chronic illnesses, comorbidities, frailty, cognitive impairment, and physical dependency can contribute to unpredictable changes in their health status that can lead to residents becoming unwell and acutely deteriorating. Exploring how care home staff recognize and respond to acutely deteriorating health among residents is important to understand whether opportunities exist to minimize these unpredictable changes in health. INCLUSION CRITERIA This scoping review will consider studies that feature the recognition and response to acute deterioration in care home residents. This review will consider qualitative and quantitative primary research. Non-indexed and gray literature such as policies, deterioration tools, and reports from health policy organizations will also be included. METHODS The searches will be conducted using bibliographic databases, university repositories, and non-indexed and gray literature, such as reports by health care and health policy organizations. The studies will be independently selected from the inclusion criteria by two researchers based on their title and abstract. In case of disagreement, a third researcher will be consulted. An adapted version of the JBI data extraction form will be used to extrapolate data from included studies. The results will be presented in tabular form, accompanied by a narrative summary related to the objectives of the scoping review.
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Affiliation(s)
- Sevim Y Hodge
- Division of Rehabilitation, Ageing and Well Being, University of Nottingham, Nottingham, UK.,Institute of Nursing and Midwifery Care Excellence, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Mohammad R Ali
- Nottingham Respiratory Research Unit, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Adam L Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
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Implementation of the National Early Warning Score in UK care homes: a qualitative evaluation. Br J Gen Pract 2020; 70:e793-e800. [PMID: 33020168 DOI: 10.3399/bjgp20x713069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/01/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The National Early Warning Score (NEWS) is a tool for identifying and responding to acute illness. When used in care homes, staff measure residents' vital signs and record them on a tablet computer, which calculates a NEWS to share with health services. This article outlines an evaluation of NEWS implementation in care homes across one clinical commissioning group area in northern England. AIM To identify challenges to implementation of NEWS in care homes. DESIGN AND SETTING Qualitative analysis of interviews conducted with 15 staff members from six care homes, five health professionals, and one clinical commissioning group employee. METHOD Interviews were intended to capture people's attitudes and experiences of using the intervention. Following an inductive thematic analysis, data were considered deductively against normalisation process theory constructs to identify the challenges and successes of implementing NEWS in care homes. RESULTS Care home staff and other stakeholders acknowledged that NEWS could enhance the response to acute illness, improve communication with the NHS, and increase the confidence of care home staff. However, the implementation did not account for the complexity of either the intervention or the care home setting. Challenges to engagement included competing priorities, insufficient training, and shortcomings in communication. CONCLUSION This evaluation highlights the need to involve care home staff and the primary care services that support them when developing and implementing interventions in care homes. The appropriateness and value of NEWS in non-acute settings requires ongoing monitoring.
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Improving the Quality of Care in Care Homes Using the Quality Improvement Collaborative Approach: Lessons Learnt from Six Projects Conducted in the UK and The Netherlands. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17207601. [PMID: 33086576 PMCID: PMC7589164 DOI: 10.3390/ijerph17207601] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/05/2020] [Accepted: 10/13/2020] [Indexed: 01/08/2023]
Abstract
The Breakthrough Series Quality Improvement Collaborative (QIC) initiative is a well-developed and widely used approach, but most of what we know about it has come from healthcare settings. In this article, those leading QICs to improve care in care homes provide detailed accounts of six QICs and share their learning of applying the QIC approach in the care home sector. Overall, five care home-specific lessons were learnt: (i) plan for the resources needed to support collaborative teams with collecting, processing, and interpreting data; (ii) create encouraging and safe working environments to help collaborative team members feel valued; (iii) recruit collaborative teams, QIC leads, and facilitators who have established relationships with care homes; (iv) regularly check project ideas are aligned with team members’ job roles, responsibilities, and priorities; and (v) work flexibly and accept that planned activities may need adapting as the project progresses. These insights are targeted at teams delivering QICs in care homes. These insights demonstrate the need to consider the care home context when applying improvement tools and techniques in this setting.
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Chadborn NH, Devi R, Hinsliff-Smith K, Banerjee J, Gordon AL. Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes. Eur Geriatr Med 2020; 12:17-26. [PMID: 32888183 PMCID: PMC7472942 DOI: 10.1007/s41999-020-00389-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/26/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE We conducted a scoping review of quality improvement in care homes. We aimed to identify participating occupational groups and methods for evaluation. Secondly, we aimed to describe resident-level interventions and which outcomes were measured. METHODS Following extended PRISMA guideline for scoping reviews, we conducted systematic searches of Medline, CINAHL, Psychinfo, and ASSIA (2000-2019). Furthermore, we searched systematic reviews databases including Cochrane Library and JBI, and the grey literature database, Greylit. Four co-authors contributed to selection and data extraction. RESULTS Sixty five studies were included, 6 of which had multiple publications (75 articles overall). A range of quality improvement strategies were implemented, including audit feedback and quality improvement collaboratives. Methods consisted of controlled trials, quantitative time series and qualitative interview and observational studies. Process evaluations, involving staff of various occupational groups, described experiences and implementation measures. Many studies measured resident-level outputs and health outcomes. 14 studies reported improvements to a clinical measure; however, four of these articles were of low quality. Larger randomised controlled studies did not show statistically significant benefits to resident health outcomes. CONCLUSION In care homes, quality improvement has been applied with several different strategies, being evaluated by a variety of measures. In terms of measuring benefits to residents, process outputs and health outcomes have been reported. There was no pattern of which quality improvement strategy was used for which clinical problem. Further development of reporting of quality improvement projects and outcomes could facilitate implementation.
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Affiliation(s)
- Neil H Chadborn
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK. .,NIHR Applied Research Collaboration East Midlands, Nottingham, UK.
| | - Reena Devi
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - Jay Banerjee
- School of Life Sciences, University of Leicester, Leicester, UK
| | - Adam L Gordon
- Division of Medical Science and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Applied Research Collaboration East Midlands, Nottingham, UK
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Hurley MV, Wood J, Smith R, Grant R, Jordan J, Gage H, Anderson LW, Kennedy B, Jones F. The feasibility of increasing physical activity in care home residents: Active Residents in Care Homes (ARCH) programme. Physiotherapy 2020; 107:50-57. [DOI: 10.1016/j.physio.2019.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 05/05/2019] [Accepted: 06/21/2019] [Indexed: 10/26/2022]
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Alcorn G, Murray SA, Hockley J. Care home residents who die in hospital: exploring factors, processes and experiences. Age Ageing 2020; 49:468-480. [PMID: 32091569 DOI: 10.1093/ageing/afz174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 11/11/2019] [Accepted: 12/04/2019] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Gemma Alcorn
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh
| | - Scott A Murray
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh
| | - Jo Hockley
- Primary Palliative Care Research Group, Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh
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Manson J, Gardiner C, McTague L. Barriers and facilitators to palliative care education in nursing and residential homes: a rapid review. Int J Palliat Nurs 2020; 26:32-44. [PMID: 32022638 DOI: 10.12968/ijpn.2020.26.1.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is insufficient high-quality evidence to suggest that palliative care education can impact care home settings. AIMS To identify, appraise and synthesise all available evidence on the barriers and facilitators to providing palliative care education in residential and nursing care homes and to generate recommendations to increase the effectiveness of future palliative care education programmes in care homes. METHODS A rapid review searching CINAHL, Medline and ProQuest. One author screened full-text articles for inclusion. Any uncertainties were discussed with a second author. FINDINGS Twenty-two articles were included in the full review. Analysis of the included articles revealed the following overlapping themes: structural systems; cultural and personal issues; and knowledge translation issues with interaction. CONCLUSION Addressing the barriers and facilitators when designing palliative care education programmes for care homes will lead to more successful outcomes.
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Affiliation(s)
- Jane Manson
- Leadership Fellow for Extension of Community Health Outcomes, St Luke's Hospice, Sheffield
| | - Clare Gardiner
- Senior Research Fellow, School of Nursing and Midwifery, University of Sheffield
| | - Laura McTague
- Consultant in Palliative Medicine, St Luke's Hospice, Sheffield
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Craig L. The role of the registered nurse in supporting frailty in care homes. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2019; 28:833-837. [PMID: 31303040 DOI: 10.12968/bjon.2019.28.13.833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
People in nursing and residential homes are more likely to suffer frailty. Registered nurses are a crucial component of the care delivery service and can offer support to patients who have complex care needs and comorbidities and are at risk of unplanned admissions to secondary care. This article explores frailty and the role of the nurse in assessing for frailty. Three aspects of patient care-nutrition status, polypharmacy and exercise and cognitive function-are discussed as areas where nurses can target their interventions in order to support those considered as frail, aiming to reduce the impact of frailty and negative health outcomes.
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Affiliation(s)
- Lynn Craig
- Senior Lecturer, Northumbria University, Newcastle upon Tyne/Clinical Development Manager, North Tyneside Clinical Commissioning Group
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27
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Devi R, Meyer J, Banerjee J, Goodman C, Gladman JRF, Dening T, Chadborn N, Hinsliff-Smith K, Long A, Usman A, Housley G, Bowman C, Martin F, Logan P, Lewis S, Gordon AL. Quality improvement collaborative aiming for Proactive HEAlthcare of Older People in Care Homes (PEACH): a realist evaluation protocol. BMJ Open 2018; 8:e023287. [PMID: 30420349 PMCID: PMC6252778 DOI: 10.1136/bmjopen-2018-023287] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/05/2018] [Accepted: 07/24/2018] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Reena Devi
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Julienne Meyer
- School of Health Sciences, City University London, London, UK
| | - Jay Banerjee
- University Hospitals of Leicester NHS Trust, University of Leicester, Leicester, UK
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | | | - Tom Dening
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Neil Chadborn
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kathryn Hinsliff-Smith
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Annabelle Long
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Adeela Usman
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Gemma Housley
- Health Analytics and Informatics, East Midlands Academic Health Science Network, Nottingham, Nottingham, UK
| | - Clive Bowman
- School of Health Sciences, City University London, London, UK
| | - Finbarr Martin
- Ageing and Health, Guy’s and St Thomas' NHS Foundation Trust, London, UK
- Population Health Sciences, King’s College London, London, UK
| | - Phillipa Logan
- Division of Rehabilitation and Ageing, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Adam Lee Gordon
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Nottingham, UK
- School of Health Sciences, City University London, London, UK
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Sina M, Graffy J, Simmons D. Associations between barriers to self-care and diabetes complications among patients with type 2 diabetes. Diabetes Res Clin Pract 2018; 141:126-131. [PMID: 29689320 DOI: 10.1016/j.diabres.2018.04.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 04/17/2018] [Indexed: 10/17/2022]
Abstract
AIMS To determine which barriers to care are associated with type 2 diabetes complications in an area in rural East England. METHODS 3649 individuals with type 2 diabetes from 62 general practices were contacted via postal invitation which included a 33 item Barriers-to-Diabetes-Care Survey. Barriers were grouped into five priori major categories: educational, physical, psychological, psychosocial, and systems. The associations of reported barriers, both individually and as a group, with self-reported complications were assessed using logistic regression. RESULTS 39.5% of participants had self-reported diabetes complications. Physical health barriers (OR = 3.3; 95%CI: 2.7, 4.0), systems barriers (OR = 1.6; 95%CI: 1.3, 2.0) and psychological barriers (OR = 1.3 (95%CI: 1.1, 1.5) were associated with diabetes complications. In subcategories, presence of comorbidities (OR = 4.8; 95%CI: 3.9, 5.9), financial difficulties (OR = 1.7; 95%CI: 1.3, 2.1), absence of services (OR = 2.0; 95%CI: 1.4, 3.0), feeling others should bear more financial responsibility for their care (OR = 1.6 (95%CI: 1.1, 2.1), no access to diabetes service (OR = 1.3; 95%CI: 1.1, 1.5), feeling worried about their diabetes (OR = 1.5; 95%CI: 1.2, 2.0) and lack of readiness to exercise (OR = 1.4; 95%CI: 1.2, 1.7) were associated with diabetes complications. CONCLUSIONS Barriers to self-care are significantly more common among those with, than those without, diabetes complications. Systematic identification and management of different barriers to self-care could help personalise care for those with diabetes related complications.
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Affiliation(s)
- Maryam Sina
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
| | - Jonathan Graffy
- Primary Care Unit, Dept of Public Health and Primary Care, University of Cambridge, Cambridge CB2 0SR, United Kingdom
| | - David Simmons
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia.
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Clarkson P, Hays R, Tucker S, Paddock K, Challis D. Healthcare support to older residents of care homes: a systematic review of specialist services. QUALITY IN AGEING AND OLDER ADULTS 2018. [DOI: 10.1108/qaoa-08-2017-0029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
A growing ageing population with complex healthcare needs is a challenge to the organisation of healthcare support for older people residing in care homes. The lack of specialised healthcare support for care home residents has resulted in poorer outcomes, compared with community-dwelling older people. However, little is known about the forms, staff mix, organisation and delivery of such services for residents’ physical healthcare needs. The paper aims to discuss these issues.
Design/methodology/approach
This systematic review, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aimed to provide an overview of the range of healthcare services delivered to care homes and to identify core features of variation in their organisation, activities and responsibilities. The eligibility criteria for studies were services designed to address the physical healthcare needs of older people, permanently residing in care homes, with or without nursing. To search the literature, terms relating to care homes, healthcare and older people, across ten electronic databases were used. The quality of service descriptions was appraised using a rating tool designed for the study. The evidence was synthesised, by means of a narrative summary, according to key areas of variation, into models of healthcare support with examples of their relative effectiveness.
Findings
In total, 84 studies, covering 74 interventions, identified a diverse range of specialist healthcare support services, suggesting a wide variety of ways of delivering healthcare support to care homes. These fell within five models: assessment – no consultant; assessment with consultant; assessment/management – no consultant; assessment/management with consultant; and training and support. The predominant model offered a combination of assessment and management. Overall, there was a lack of detail in the data, making judgements of relative effectiveness difficult. Recommendations for future research include the need for clearer descriptions of interventions and particularly of data on resident-level costs and effectiveness, as well as better explanations of how services are implemented (review registration: PROSPERO CRD42017081161).
Originality/value
There is considerable debate about the best means of providing healthcare to older people in care homes. A number of specialist initiatives have developed and this review seeks to bring these together in a comparative approach deriving models of care of value to policy makers and commissioners.
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Nunez KM, Khan Z, Testad I, Lawrence V, Creese B, Corbett A. Current practice and challenges in night-time care for people with dementia living in care homes: a qualitative study. Int J Geriatr Psychiatry 2018; 33:e140-e149. [PMID: 28556389 DOI: 10.1002/gps.4737] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 04/19/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To explore the current practices and challenges in night-time care for people with dementia living in care homes in the UK. METHODS Focus group discussions (FGD) were held with care staff and family carers from five care homes in South London. To supplement the FGD data, an online survey was circulated to family carers (n = 16), and informal interviews were conducted with night-time care staff and nurses (n = 19). The questions for the online survey were designed to specifically explore the themes that emerged from the FGD. RESULTS Thematic analysis revealed eight key themes in the management of sleep disturbance in people with dementia living in care homes: current night-time care practices, dissonance in perceived causes of sleep disturbances, inconsistencies in treatment options, insufficient staffing levels, working relationships between shifts, nurse burden and responsibility, communication as a critical challenge, connecting with residents and one overarching theme of balance. CONCLUSIONS The findings of this study highlight the need for an evidence-based sleep disturbance management programme designed for use in care homes and informed by stakeholders. The key themes identified represent the major barriers to good quality care and areas which future programmes will need to address to improve the quality of night-time care in care homes. There are clearly opportunities for future examination of non-pharmacological night-time care management programmes for use in the population. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Zunera Khan
- Wolfson Centre for Age-Related Diseases, King's College London, London, UK
| | - Ingelin Testad
- Centre for Age-Related Medicine (SESAM), Stavanger University, Stavanger, Norway
| | - Vanessa Lawrence
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Byron Creese
- Wolfson Centre for Age-Related Diseases, King's College London, London, UK.,Exeter University Medical School, University of Exeter, Exeter, UK
| | - Anne Corbett
- Wolfson Centre for Age-Related Diseases, King's College London, London, UK.,Exeter University Medical School, University of Exeter, Exeter, UK
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New horizons in geriatric medicine education and training: The need for pan-European education and training standards. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.07.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Goodman C, Davies SL, Gordon AL, Dening T, Gage H, Meyer J, Schneider J, Bell B, Jordan J, Martin F, Iliffe S, Bowman C, Gladman JRF, Victor C, Mayrhofer A, Handley M, Zubair M. Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05290] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundCare homes are the institutional providers of long-term care for older people. The OPTIMAL study argued that it is probable that there are key activities within different models of health-care provision that are important for residents’ health care.ObjectivesTo understand ‘what works, for whom, why and in what circumstances?’. Study questions focused on how different mechanisms within the various models of service delivery act as the ‘active ingredients’ associated with positive health-related outcomes for care home residents.MethodsUsing realist methods we focused on five outcomes: (1) medication use and review; (2) use of out-of-hours services; (3) hospital admissions, including emergency department attendances and length of hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed the evidence to develop an explanatory theory of what supported good health-care provision for further testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents. The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care provision to care homes was distinctive in each site.FindingsPhase 1 found that health-care provision to care homes is reactive and inequitable. The realist review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and implement agreed approaches to health care. Phase 2 tested this further and found that, although there were few differences between the sites in residents’ use of resources, the differences in service integration between the NHS and care homes did reflect how these institutions approached activities that supported relational working. Key to this was how much time NHS staff and care home staff had had to learn how to work together and if the work was seen as legitimate, requiring ongoing investment by commissioners and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work. Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care home staff were equipped to provide appropriate care.LimitationsFindings were constrained by the numbers of residents recruited and retained in phase 2 for the 12 months of data collection.ConclusionsNHS services work well with care homes when payments and role specification endorse the importance of this work at an institutional level as well as with individual residents. GP involvement is important but needs additional support from other services to be sustainable. A focus on strategies that promote co-design-based approaches between the NHS and care homes has the potential to improve residents’ access to and experience of health care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Claire Goodman
- Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
| | - Sue L Davies
- Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
| | - Adam L Gordon
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Tom Dening
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Heather Gage
- School of Economics, University of Surrey, Guildford, UK
| | - Julienne Meyer
- School of Health Sciences, City, University of London, London, UK
| | - Justine Schneider
- School of Sociology and Social Policy, University of Nottingham, Nottingham, UK
| | - Brian Bell
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Jake Jordan
- School of Economics, University of Surrey, Guildford, UK
| | | | - Steve Iliffe
- Research Department of Primary Care and Population Health (PCPH), University College London, London, UK
| | - Clive Bowman
- School of Health Sciences, City, University of London, London, UK
| | - John RF Gladman
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Christina Victor
- Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Andrea Mayrhofer
- Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
| | - Melanie Handley
- Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
| | - Maria Zubair
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
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Verbeek H, Tucker And S, Wilberforce M, Brand C, Abendstern M, Challis D. What makes extra care housing an appropriate setting for people with dementia? An exploration of staff decision-making. DEMENTIA 2017; 18:1710-1726. [PMID: 28875736 DOI: 10.1177/1471301217724966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extra care housing facilities in the UK are intended to offer a community-based alternative to care home placement. However, little is known about staff’s views of the appropriateness of extra care housing for people with dementia. This paper describes a mixed-methods study which explored this issue using statistical modelling of frontline staff’s recommendations of the best care setting for care home entrants; thematic analysis of transcripts from a simulated Resource Allocation Management Panel meeting; and content analysis of care coordinators’ reasons for not considering extra care housing in actual care home applications. Frontline practitioners saw extra care housing as a valuable alternative for a significant minority of care home entrants. However, extra care housing was not recommended if people needed care at night. Social care managers expressed general support for the idea of extra care housing, but appeared overwhelmingly focused on maintaining people at home and unsure where in the care pathway extra care housing sat. More evidence is needed on whether extra care housing can be an alternative to care homes and how services should be arranged to meet the needs of people living in extra care housing.
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Affiliation(s)
| | | | | | - Christian Brand
- University of Manchester, UK; London School of Hygiene and Tropical Medicine, UK
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Svensson E, Kåhlin I, Kjellberg A. Residential environment impact scale: Utilization of the Swedish version. Scand J Occup Ther 2017; 25:419-427. [DOI: 10.1080/11038128.2017.1369158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Elise Svensson
- Division of Occupational Therapy, Department of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, Norrköping, Sweden
| | - Ida Kåhlin
- Division of Occupational Therapy, Department of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, Norrköping, Sweden
| | - Anette Kjellberg
- Division of Occupational Therapy, Department of Social and Welfare Studies, Faculty of Health Sciences, Linköping University, Norrköping, Sweden
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Whybrow P, Moffatt S, Kay L, Thompson B, Aspray T, Duncan R. Assessing the need for arthritis training among paid carers in UK residential care homes: A focus group and interview study. Musculoskeletal Care 2017; 16:82-89. [PMID: 28804995 DOI: 10.1002/msc.1211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The aim of the study was to perform an educational and training needs assessment for arthritis care in residential homes. METHODS Qualitative data were collected from three purposively selected residential homes: one independent, one in a regional chain and one in a national chain. Three researcher-led focus groups were conducted with paid carers (N = 22) using vignette exercises; interviews were undertaken with 12 residents with joint pain (N = 12), five managerial staff and two general practitioners (GPs). Data were compared and analysed thematically around care practices, communication and training. RESULTS There is a lack of arthritis awareness among paid carers, although they regularly identify and manage arthritic symptoms. Residents rely on paid carers to recognize when pain and mobility problems are treatable. Senior staff and GPs rely on carers to identify arthritic problems. However, paid carers themselves undervalued the health significance of their activities and lacked the confidence to communicate important information to healthcare professionals. Few of the paid carers had received training in arthritis and many expressed a strong desire to learn about it, to improve their ability to provide better care. CONCLUSIONS Education for paid carers regarding arthritis is lacking and lags behind education about conditions such as dementia and diabetes. To meet the expectations of their care roles fully, paid carers require an awareness of what arthritis is and how to recognize symptoms. We suggest that training should be aimed at improving confidence in communicating with colleagues, residents and health professionals, with senior care staff receiving more in-depth training.
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Affiliation(s)
- Paul Whybrow
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Suzanne Moffatt
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Lesley Kay
- The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ben Thompson
- The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Terry Aspray
- The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Rachel Duncan
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.,The Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK
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Gladman JR. Delivering comprehensive geriatric assessment in new settings: advice for frontline clinicians. J R Coll Physicians Edinb 2016; 46:174-179. [PMID: 27959354 DOI: 10.4997/jrcpe.2016.309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Over the decades, as the principles of comprehensive geriatric assessment have been established, there have been attempts to apply its principles to settings other than acute hospital medical wards or the general communitydwelling older population, for example, to other settings where older people with infirmity are found. The purpose of this paper is to describe and reflect upon the application of and evidence for comprehensive geriatric assessment in these new settings and give some advice to clinicians about how to optimise their contributions to these processes. I will state my advice having first discussed intermediate care, emergency surgery (hip fracture), elective surgery, dementia and delirium care, emergency care, cancer care, and the care of residents of care homes (mindful of the irony of calling the latter a new setting, given that geriatric medicine originated in long term care).
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Affiliation(s)
- J R Gladman
- JRF Gladman, Division of Rehabilitation and Ageing, B Floor Medical School, Queen's Medical Centre, Nottingham NG7 2UH, UK, E-mail
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Cook G, McNall A, Thompson J, Hodgson P, Shaw L, Cowie D. Integrated Working for Enhanced Health Care in English Nursing Homes. J Nurs Scholarsh 2016; 49:15-23. [PMID: 28094909 PMCID: PMC5298045 DOI: 10.1111/jnu.12261] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2016] [Indexed: 11/30/2022]
Abstract
Background The increasingly complex nature of care home residents’ health status means that this population requires significant multidisciplinary team input from health services. To address this, a multisector and multiprofessional enhanced healthcare programme was implemented in nursing homes across Gateshead Council in Northern England. Study Aims To explore the views and experiences of practitioners, social care officers, and carers involved in the enhanced health care in care home programme, in order to develop understanding of the service delivery model and associated workforce needs for the provision of health care to older residents. Methods A qualitative constructivist methodology was adopted. The study had two stages. Stage 1 explored the experiences of the programme enhanced healthcare workforce through group, dyad, and individual interviews with 45 participants. Stage 2 involved two workshops with 28 participants to develop Stage 1 findings (data were collected during February–March 2016). Thematic and content analysis were applied. Findings The enhanced healthcare programme provides a whole system approach to the delivery of proactive and responsive care for nursing home residents. The service model enables information exchange across organizational and professional boundaries that support effective decision making and problem solving. Clinical Relevance Understanding of the processes and outcomes of a model of integrated health care between public and independent sector care home services for older people.
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Affiliation(s)
- Glenda Cook
- Professor of Nursing, Northumbria University, Newcastle upon Tyne, UK
| | - Anne McNall
- Enterprise Fellow, Northumbria University, Newcastle upon Tyne, UK
| | | | - Philip Hodgson
- Senior Research Assistant, Northumbria University, Newcastle upon Tyne, UK
| | - Lynne Shaw
- Nurse Consultant older persons care, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Daniel Cowie
- Clinical Director of Transformation, Newcastle Gateshead CCG, Newcastle upon Tyne, UK
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Effective health care for older people living and dying in care homes: a realist review. BMC Health Serv Res 2016; 16:269. [PMID: 27422733 PMCID: PMC4947336 DOI: 10.1186/s12913-016-1493-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 06/29/2016] [Indexed: 11/10/2022] Open
Abstract
Background Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes. Methods We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group. Results Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change. Conclusion How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.
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La Frenais F, Stone P, Sampson EL. Analgesic prescribing in care home residents: how epidemiological studies may inform clinical practice. Pain Manag 2016; 6:561-568. [PMID: 27383004 DOI: 10.2217/pmt-2016-0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Care home residents are often frail with multiple comorbidities and cognitive impairment, most commonly caused by dementia. This population is under-represented in clinical trials, leading to a lack of valid and reliable evidence to inform clinicians' prescribing practice. This paper summarizes how epidemiological research conducted in similar populations can inform pain management by describing pain prevalence, risk factors, typical features and functional consequences. This evidence can help overcome the numerous barriers to optimal pain management in care home residents.
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Affiliation(s)
- Francesca La Frenais
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.,Barnet Enfield & Haringey Mental Health Trust Liaison Team, North Middlesex University Hospital, Sterling Way, London, N18 1QX, UK
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40
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Garden G, Green S, Pieniak S, Gladman J. The Bromhead Care Home Service: the impact of a service for care home residents with dementia on hospital admission and dying in preferred place of care. Clin Med (Lond) 2016; 16:114-8. [PMID: 27037378 PMCID: PMC4952962 DOI: 10.7861/clinmedicine.16-2-114] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
People with dementia have worse outcomes associated with hospital admission, are more likely to have interventions and are less likely to be offered palliative care than people without dementia. Advance care planning for care home residents has been shown to reduce hospital admissions without increasing mortality. Studies have shown that staff confidence in managing delirium, a common reason for admission, improves with training. A service combining education for care home staff and advance care planning for care home residents with dementia was introduced to care homes in Boston, UK. There were improvements in staff confidence in recognition, prevention, management and knowledge of factors associated with delirium and dysphagia. 92% of carers rated the service >9/10. Admissions fell by 37% from baseline in the first year and 55% in the second and third years. All but one resident died in the preferred place of care.
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Affiliation(s)
- Gill Garden
- United Lincolnshire Hospitals NHS Trust, Pilgrim Hospital, Boston, UK
| | - Suzanne Green
- Care Home Liaison Service, United Lincolnshire Hospitals NHS Trust, Pilgrim Hospital, Boston, UK
| | - Susan Pieniak
- Care Home Liaison Service, United Lincolnshire Hospitals NHS Trust, Pilgrim Hospital, Boston, UK
| | - John Gladman
- CLAHRC East Midlands 'Caring for Older People and Stroke Survivors' theme lead, East Midlands AHSN Frail Older People Programme lead, Queens Medical Centre, Nottingham, UK; deceased 20 June 2014
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Gladman JRF, Conroy SP, Ranhoff AH, Gordon AL. New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the 'know-do' gap. Age Ageing 2016; 45:194-200. [PMID: 26941353 DOI: 10.1093/ageing/afw012] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In this paper, we outline the relationship between the need to put existing applied health research knowledge into practice (the 'know-do gap') and the need to improve the evidence base (the 'know gap') with respect to the healthcare process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in CGA; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base that requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed.
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Affiliation(s)
- John R F Gladman
- B111, Division of Rehabilitation and Ageing, B Floor Medical School, Queen's Medical Centre, Nottingham NG7 2UH, UK
| | | | - Anette Hylen Ranhoff
- Kavli Research Centre for Ageing and Dementia, Haraldsplass Deaconess Hospital, Bergen, Norway Institute of Medicine, University of Bergen, Bergen, Norway
| | - Adam Lee Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Derby Royal Hospital, Derby, DE22 3NE, UK
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Stanyon MR, Griffiths A, Thomas SA, Gordon AL. The facilitators of communication with people with dementia in a care setting: an interview study with healthcare workers. Age Ageing 2016; 45:164-70. [PMID: 26764403 PMCID: PMC4711655 DOI: 10.1093/ageing/afv161] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives: to describe the views of healthcare workers on the facilitators of communication with people with dementia in a care setting. Design: thematic analysis of semi-structured interviews. Setting: all participants were interviewed in their place of work. Participants: sixteen healthcare workers whose daily work involves interacting with people with dementia. Results: four overarching categories of themes were identified from the interviews that impact on communication: the attributes of a care worker, communication strategies used, organisational factors and the physical characteristics of the care environment. Conclusion: many strategies used by healthcare workers to facilitate communication have not yet been studied in the research literature. Participants' views on training should be incorporated into future dementia training programmes.
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Affiliation(s)
- Miriam Ruth Stanyon
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Amanda Griffiths
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shirley A Thomas
- Division of Rehabilitation and Ageing, University of Nottingham, Medical School Queens Medical Centre, Nottingham NG7 2UH, UK
| | - Adam Lee Gordon
- Division of Rehabilitation and Ageing, University of Nottingham, Medical School Queens Medical Centre, Nottingham NG7 2UH, UK
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Luff R, Laybourne A, Ferreira Z, Meyer J. A guide to research with care homes. QUALITY IN AGEING AND OLDER ADULTS 2015. [DOI: 10.1108/qaoa-06-2015-0027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– A growing older population with complex care needs, including dementia, are living in care homes. It is important to support researchers in conducting ethical and appropriate work in this complex research environment. The purpose of this paper is to discuss key issues in care homes research including examples of best practice. The intention is to inform researchers across disciplines, leading to more sensitive and meaningful care home research practice.
Design/methodology/approach
– Experienced care homes researchers were invited to provide methodological insights and details not already reported in their publications. These have been analysed, creating key themes and linked to project publications.
Findings
– The need for reflexivity was a key finding. In particular, researchers need to: appreciate that the work is complex; see participants as potential research partners; and consider how cognitive and physical frailty of residents, staffing pressures and the unique environments of care homes might impact upon their research. Other challenges include recruitment and consenting people who lack mental capacity.
Research limitations/implications
– As the care homes research landscape continues to develop and grow, there still remains limited reflection and discussion of methodological issues with a need for a “safe space” for researchers to discuss challenges.
Originality/value
– This review is an updated methodological guide for care homes researchers, also highlighting current gaps in the mechanisms for continuing to share best research practice.
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45
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Wade V, Whittaker F, Hamlyn J. An evaluation of the benefits and challenges of video consulting between general practitioners and residential aged care facilities. J Telemed Telecare 2015; 21:490-3. [DOI: 10.1177/1357633x15611771] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This research evaluated a project that provided video consultations between general practitioners (GPs) and residential aged care facilities (RACFs), with the aim of enabling faster access to medical care and avoidance of unnecessary hospital transfers. GPs were paid for video consultations at a rate equivalent to existing insurance reimbursement for supporting telehealth services. Evaluation data were gathered by direct observation at the project sites, semi-structured interviews and video call data from the technical network. Three pairs of general practices and RACFs were recruited to the project. 40 video consultations eligible for payment occurred over a 6 month period, three of which were judged to have avoided hospital attendance. The process development and change management aspects of the project required substantially more effort than was anticipated. This was due to problems with RACF technical infrastructure, the need for repeated training and awareness raising in RACFs, the challenge of establishing new clinical procedures, the short length of the project and broader difficulties in the relationships between GPs and RACFs. Video consulting between GPs and RACFs was clinically useful and avoided hospital attendance on a small scale, but further focus on process development is needed to embed this as a routine method of service delivery.
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Affiliation(s)
- Victoria Wade
- Discipline of General Practice, The University of Adelaide, South Australia, Australia
| | | | - Jeremy Hamlyn
- Discipline of General Practice, The University of Adelaide, South Australia, Australia
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Walker GM, Armstrong S, Gordon AL, Gladman J, Robertson K, Ward M, Conroy S, Arnold G, Darby J, Frowd N, Williams W, Knowles S, Logan PA. The Falls In Care Home study: a feasibility randomized controlled trial of the use of a risk assessment and decision support tool to prevent falls in care homes. Clin Rehabil 2015; 30:972-983. [PMID: 26385358 PMCID: PMC5052695 DOI: 10.1177/0269215515604672] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 08/15/2015] [Indexed: 11/17/2022]
Abstract
Objective: To explore the feasibility of implementing and evaluating the Guide to Action Care Home fall prevention intervention. Design: Two-centre, cluster feasibility randomized controlled trial and process evaluation. Setting: Purposive sample of six diverse old age/learning disability, long stay care homes in Nottinghamshire, UK. Subjects: Residents aged over 50 years, who had fallen at least once in the past year, not bed-bound, hoist-dependent or terminally ill. Interventions: Intervention homes (n = 3) received Guide to Action Care Home fall prevention intervention training and support. Control homes (n = 3) received usual care. Outcomes: Recruitment, attrition, baseline and six-month outcome completion, contamination and intervention fidelity, compliance, tolerability, acceptance and impact. Results: A total of 81 of 145 (56%) care homes expressed participatory interest. Six of 22 letter respondent homes (27%) participated. The expected resident recruitment target was achieved by 76% (52/68). Ten (19%) residents did not complete follow-up (seven died, three moved). In intervention homes 36/114 (32%) staff attended training. Two of three (75%) care homes received protocol compliant training. Staff valued the training, but advised greater management involvement to improve intervention implementation. Fall risks were assessed, actioned and recorded in care records. Of 115 recorded falls, 533/570 (93%) of details were complete. Six-month resident fall rates were 1.9 and 4.0 per year for intervention and control homes, respectively. Conclusions: The Guide to Action Care Home is implementable under trial conditions. Recruitment and follow-up rates indicate that a definitive trial can be completed. Falls (primary outcome) can be ascertained reliably from care records.
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Affiliation(s)
- Gemma M Walker
- Division of Psychiatry, University of Nottingham Innovation Park, Nottingham, UK Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Sarah Armstrong
- Research Design Service, University of Nottingham, Nottingham UK
| | - Adam L Gordon
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - John Gladman
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | | | - Marie Ward
- Nottingham Citycare Partnership, Nottingham, UK
| | - Simon Conroy
- Geriatric Medicine, University Hospitals of Leicester, Leicester, UK
| | - Gail Arnold
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Janet Darby
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Nadia Frowd
- Division of Rheumatology, Orthopaedics and Dermatology, University of Nottingham, Nottingham, UK
| | | | - Sue Knowles
- Rushcliffe Community & Voluntary Service, Nottingham, UK
| | - Pip A Logan
- Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK Nottingham Citycare Partnership, Nottingham, UK
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Gladman J, Harwood R, Conroy S, Logan P, Elliott R, Jones R, Lewis S, Dyas J, Schneider J, Porock D, Pollock K, Goldberg S, Edmans J, Gordon A, Bradshaw L, Franklin M, Whittamore K, Robbins I, Dunphy A, Spencer K, Darby J, Tanajewski L, Berdunov V, Gkountouras G, Foster P, Frowd N. Medical Crises in Older People: cohort study of older people attending acute medical units, developmental work and randomised controlled trial of a specialist geriatric medical intervention for high-risk older people; cohort study of older people with mental health problems admitted to hospital, developmental work and randomised controlled trial of a specialist medical and mental health unit for general hospital patients with delirium and dementia; and cohort study of residents of care homes and interview study of health-care provision to residents of care homes. PROGRAMME GRANTS FOR APPLIED RESEARCH 2015. [DOI: 10.3310/pgfar03040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BackgroundThis programme of research addressed shortcomings in the care of three groups of older patients: patients discharged from acute medical units (AMUs), patients with dementia and delirium admitted to general hospitals, and care home residents.MethodsIn the AMU workstream we undertook literature reviews, performed a cohort study of older people discharged from AMU (Acute Medical Unit Outcome Study; AMOS), developed an intervention (interface geriatricians) and evaluated the intervention in a randomised controlled trial (Acute Medical Unit Comprehensive Geriatric Assessment Intervention Study; AMIGOS). In the second workstream we undertook a cohort study of older people with mental health problems in a general hospital, developed a specialist unit to care for them and tested the unit in a randomised controlled trial (Trial of an Elderly Acute care Medical and mental health unit; TEAM). In the third workstream we undertook a literature review, a cohort study of a representative sample of care home residents and a qualitative study of the delivery of health care to care home residents.ResultsAlthough 222 of the 433 (51%) patients recruited to the AMIGOS study were vulnerable enough to be readmitted within 3 months, the trial showed no clinical benefit of interface geriatricians over usual care and they were not cost-effective. The TEAM study recruited 600 patients and there were no significant benefits of the specialist unit over usual care in terms of mortality, institutionalisation, mental or functional outcomes, or length of hospital stay, but there were significant benefits in terms of patient experience and carer satisfaction with care. The medical and mental health unit was cost-effective. The care home workstream found that the organisation of health care for residents in the UK was variable, leaving many residents, whose health needs are complex and unpredictable, at risk of poor health care. The variability of health care was explained by the variability in the types and sizes of homes, the training of care home staff, the relationships between care home staff and the primary care doctors and the organisation of care and training among primary care doctors.DiscussionThe interface geriatrician intervention was not sufficient to alter clinical outcomes and this might be because it was not multidisciplinary and well integrated across the secondary care–primary care interface. The development and evaluation of multidisciplinary and better-integrated models of care is justified. The specialist unit improved the quality of experience of patients with delirium and dementia in general hospitals. Despite the need for investment to develop such a unit, the unit was cost-effective. Such units provide a model of care for patients with dementia and delirium in general hospitals that requires replication. The health status of, and delivery of health care to, care home residents is now well understood. Models of care that follow the principles of comprehensive geriatric assessment would seem to be required, but in the UK these must be sufficient to take account of the current provision of primary health care and must recognise the importance of the care home staff in the identification of health-care needs and the delivery of much of that care.Trial registrationCurrent Controlled Trials ISRCTN21800480 (AMIGOS); ClinicalTrials.gov NCT01136148 (TEAM).FundingThis project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 3, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- John Gladman
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Rowan Harwood
- Health Care of Older People, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Pip Logan
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Rachel Elliott
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Rob Jones
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sarah Lewis
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Jane Dyas
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Justine Schneider
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Davina Porock
- University at Buffalo School of Nursing, Buffalo, NY, USA
| | - Kristian Pollock
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Sarah Goldberg
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Judi Edmans
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Adam Gordon
- Health Care of Older People, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK
| | - Lucy Bradshaw
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Matthew Franklin
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Katherine Whittamore
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Isabella Robbins
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Aidan Dunphy
- Clinical Research Unit, Leicester Royal Infirmary, Leicester, UK
| | - Karen Spencer
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Janet Darby
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Lukasz Tanajewski
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Vladislav Berdunov
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Georgios Gkountouras
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Pippa Foster
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Nadia Frowd
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
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The optimal study: describing the key components of optimal health care delivery to UK care home residents: a research protocol. J Am Med Dir Assoc 2014; 15:681-6. [PMID: 25086691 DOI: 10.1016/j.jamda.2014.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/12/2014] [Accepted: 06/13/2014] [Indexed: 11/23/2022]
Abstract
Long-term institutional care in the United Kingdom is provided by care homes. Residents have prevalent cognitive impairment and disability, have multiple diagnoses, and are subject to polypharmacy. Prevailing models of health care provision (ad hoc, reactive, and coordinated by general practitioners) result in unacceptable variability of care. A number of innovative responses to improve health care for care homes have been commissioned. The organization of health and social care in the United Kingdom is such that it is unlikely that a single solution to the problem of providing quality health care for care homes will be identified that can be used nationwide. Realist evaluation is a methodology that uses both qualitative and quantitative data to establish an in-depth understanding of what works, for whom, and in what settings. In this article we describe a protocol for using realist evaluation to understand the context, mechanisms, and outcomes that shape effective health care delivery to care home residents in the United Kingdom. By describing this novel approach, we hope to inform international discourse about research methodologies in long-term care settings internationally.
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Gordon AL, Masud T, Gladman JRF. Now that we have a definition for physical frailty, what shape should frailty medicine take? Age Ageing 2014; 43:8-9. [PMID: 24148267 DOI: 10.1093/ageing/aft161] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Adam L Gordon
- Department of Health Care of Older People, Nottingham University Hospitals NHS Trust, Queens Medical Centre, Nottingham, UK
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