Improving healthcare support in care homes

Overview

This study describes the model of healthcare support currently being delivered to nursing homes in South Manchester. The service proactively reviews all registered nursing home residents in the area and has significantly reduced the number of emergency medical admissions to hospital. The service commenced in 2004 and was fully commissioned in 2010.

Challenges

The service commenced with virtually no dedicated resources in an attempt to reduce the high numbers of unscheduled nursing home residents being admitted to local hospitals. Demonstrating local health economy benefit for a relatively small population of patients proved extremely difficult, but became necessary to ensure interest from local general practices and health commissioners. Once this had been achieved, it was possible to secure adequate resource for a fully developed, resilient and credible model of care.

The nine homes provided for are owned and managed by eight different private sector organisations. Ensuring clear lines of responsibility and addressing a multitude of governance issues continues to present a challenge.

Solutions

The service covers 300 nursing home beds in nine homes1 and its objectives are:

• To deliver patient-centred and continuous health care for all residents of nursing care beds in south Manchester
• Enhance clinical networks to develop condition-specific and end of life services.
• Reduce the number of unscheduled admissions and re-admissions to hospital from nursing homes
• Reduce the demand on general practice by replacing input with a combination of planned and urgent care responses from a dedicated service.

The service is staffed by a team of three geriatricians, two advanced practitioners, a GP, nurse case manager and doctors in training together with a dedicated administrative team. The service acts on two levels:

Planned (scheduled) proactive care. All patients in a nursing care bed are reviewed using methods described below. This is a continuous, adaptive process. For those identified as at risk of unscheduled hospital admission, a senior clinical review occurs and anticipatory care planning is undertaken.

• Risk stratification into a long-term conditions model, assisting in determining the frequency of proactive review
• Undertake planned proactive reviews within all nursing homes once a week
• Full medication review for each patient at least every six months.
• Develop and implement integrated and personalised care plans covering health and social care needs for all patients, and share these with out of hours care providers.
• Provide up-to-date information, advice and support for rehabilitation and for relatives of patients with long-term conditions.
• Provide care homes and patients with access to and/or advice about any assistive technology/equipment to support activities of daily living and more independent lifestyles.
• Provide (or refer to) a comprehensive range of palliative care services in line with the Gold Standards Framework.
• Reactive (unscheduled) care. In office hours a same day call out service is operated for residents identified by the care home staff to have become unwell and in need of urgent assessment.

Outcomes

The service has set the following outcome measures:³

Service activity – Number of patients who have had formal reviews.

Clinical outcomes – Regular analysis and interpretation of clinical outcomes data.

Quality and governance – Results of clinical audits undertaken within the service have been used to inform service development going forwards.

Value for money – Cost effectiveness or ‘best value’ analysis of the primary service outcomes in relation to comparative costs of hospital activity e.g. attendance rates.

A pilot for the service showed the following outcomes. These results were collected within the first two years of service and used historical benchmarks to demonstrate improvements.

Positive results have also been achieved for end of life care. 80% of deaths occurred in the nursing homes (2008-9 data), 47% were GSF coded on the front of notes, 58% had an advance care plan in place at time of death and there was 93% compliance with expressed wishes.4

Next steps

The service continues to provide care during office hours to around 300 residents across nine care homes. It is recurrently funded and fully commissioned by NHS Manchester. Following the implantation of Transforming Community Services in 2011 it was fully vertically integrated into the local acute Foundation Trust (FT) whose local department of elderly medicine established the service in partnership with the PCT provider organisation. It is now managed by the FT Directorate of Complex Health and Social Care which also manages and provides all other geriatric medicine services in the locality.