Effective healthcare for older people living in care homes. Guidance on commissioning and providing healthcare services across the UK

In the UK 405,000 older people (65+) currently live in care homes. This represents 16% of older people over the age of 85. The term care home includes homes both with and without nursing provision. Data from population and cohort studies suggest that older people living in care homes have complex healthcare needs. The average care home resident has multiple long-term conditions, functional dependency and frailty. 75-80% of those people living in care homes have cognitive impairment. Residents are likely to have better health outcomes if health services reflect these needs, with attention to comprehensive, multidisciplinary assessment, case management and input from appropriately trained specialists in care of complex medical problems in later life. In 2011 BGS published its report Quest for Quality which makes recommendations for how care home residents’ quality of care can be improved, and we continue to promote these.

Content

Why is specialist commissioning needed?

• What are the benefits of specialist commissioning?
• How can beneficial outcomes be achieved?
• Who should provide the services?
• Monitoring and evaluation

Why are specific services important for older people in care homes?

Health needs are complex and most residents have multiple long term conditions, significant disability and frailty which affect both their physical and mental health. Dementia affects the majority of residents in care homes to some degree, and depression is common.

Disability from late stage conditions is complicated, for example in neurodegenerative conditions including Parkinsonism, dementia and severe stroke. Care home staff need support and training from health professionals to identify, understand and respond to the everyday impacts of providing essential care. This includes providing the right types of food and drink, preserving skin integrity and preventing contractures (shortening of muscle tissue). Medical treatment requires a systematic approach and attention to detail, which can be difficult for GPs to deliver under existing time and resource constraints. Some medical treatment may need specialist support from geriatricians.

Person and relationship-centred models of care are needed for people who have co-existing, late stage, diseases.  Disease based models are insufficient.  An individualised approach which addresses shorter term priorities of alleviating systems may outweigh the longer term value of disease control.  Frailty and age have a significant impact on a person’s response to drugs so that the burden and risks of adverse events may be increased.  Community pharmacists and specialist nurses play a key role, but it should be recognised that an individualised model is needed and adherence to standard protocols is not enough to meet the needs of older people living in care homes. 

Standard services do not provide sufficiently accessible support because access to GP surgeries and outpatient clinics is difficult and less effective than assessment and care planning that takes place in the care home.  Out of hours services are often unable to access sufficient information to help decision making which supports continuity of care. This can result in the overuse of hospital attendance and admissions.  There is wide variation in levels of access to community-based therapies, and waiting times are variable and often long. 

Support from geriatricians can enhance the effectiveness of interventions.  There is evidence that the inclusion of geriatricians, where they are available, in the care home support team enhances the effectiveness of health and care outcomes for care home residents. 

Access and advocacy is key as older care home residents are unable to initiate their own access to doctors or community healthcare.  This means that care home staff must become both advocates and facilitators, and have the skills needed for that.  

A reactive approach is not enough.  Proactively establishing the objectives of care is the basis for success.  This means a pro-active and planned approach should be in place from the outset, when an older person first moves to a care home.  Palliative approaches may be needed from the time of admission, or the balance of approach may need to change over time.  Patient- and relationship-centred health care  and support plans are needed and should include advance care planning.   

Integrated provision is required to meet the needs of care home residents who require co-ordinated input from generalists and specialists in multiple disciplines, in partnership with social care professionals and care home staff.  Partnerships are essential to integration, and need  to build on shared goals, reliable communication and  mutual trust. 

What are the benefits of specialist commissioning?

For older people themselves

• Improved experience through high quality essential care, resulting in reduced distress from depression, disorientation, agitation, pressure sores, muscle contractures, constipation, pain and sleeplessness
• Minimisation of predictable acute events such as urinary infections, aspiration and pneumonia
• Avoidance of unnecessary progression of long-term conditions, coupled with a reduction in adverse drug events and the unnecessary burdens of irrelevant treatments
• Reduced risks of falls, fractures and other injuries
• Greater autonomy and involvement in decisions about care, place of care and place of dying
• Reduced fear of dying and enhanced experience of dying for residents and their families.

For the local NHS

• Enhanced equity in care by ensuring that care home residents are not inadvertently excluded from services which they are unable to access
• More efficient use of local resources through reduction in non-elective hospital admissions, and a proactive collaborative approach to community healthcare
• Reduction in the costs and risks of prescribing
• Improvements to safety of care by reducing harm from falls, falls-related injuries, and infections contracted while receiving medical care.

For a sustainable care home sector

• A culture of partnership, support and shared clinical governance
• Reliable and consistent access to health professionals, including GPs
• Agreed goals of care based on proactive multidisciplinary review with residents and families
• Clarity on mutual obligations and responsibilities with regard to equipment and expertise
• Optimum access and uptake of immunisation against influenza for staff and residents
• Agreed systems of communication, including for out of hours and urgent needs.

How can these outcomes be achieved?

These outcomes can be achieved by:

• Carrying out comprehensive assessments of new residents on admission, and developing a patient-centred care plan within a specified time period
• Ensuring prompt recognition of residents requiring imminent end of life care, identifying issues and goals and making appropriate treatment plans within a shorter specified time period
• Conducting regular, structured, multi-dimensional reviews at least every six months, or sooner if clinical needs require it. These should be used to modify healthcare goals, and guide clinical interventions both in and out of hours
• Assessments to include medication review in partnership with the community or care home’s pharmacist, at a frequency over and above the basic requirements of the General Medical Services contract, at least every six months. A medication review should also be completed following discharge from an acute hospital admission • Assessment to include structured risk assessment, for example for pressure ulcers, continence and nutrition
• Creation of an advanced care plan for acute events and for preferred end of life care, in partnership with residents, their families and advocates
• Agreement of reliable systems with appropriate support tools to enable effective telephone consultation and use of out of hours referrals
• Regular scheduled visits by an appropriate GP or specialist nurse to review particular residents with new needs, perform routine reviews and to liaise with other health and social care professionals
• Clarification of referral pathways and response times for specialist input including community rehabilitation services, palliative care teams, specialist nurses (for example, regarding tissue viability), community mental health teams and geriatricians
• When and where feasible and beneficial, extending the scope of enhanced clinical interventions, for example, through the use of sub-cutaneous fluids and intravenous antibiotics according to locally agreed protocols
• Use of a robust interdisciplinary and interagency clinical governance system which promotes quality improvement and involves the care home manager and relevant staff. The system should support education and training in both core clinical skills and quality improvement methodology and encourage the development or use of clinical tools, protocols and service improvements. It should also allow for review of individual cases involving complaints and adverse incidents, as well as reviewing overall performance of the local system by regular monitoring of chosen outcome measures (see examples under Monitoring and Evaluation).

Who should develop and provide the services?

Many services provided for care homes are relatively shortlived. It has been suggested that this is a consequence of failure to engage the care home sector in the design, development and day-to-day running of services. We would recommend that commissioners consider early involvement of local care home representatives in commissioning discussions. Evidence has shown the importance of making the most of existing relationships between health and social care providers and care home staff to broker new or enhanced care arrangements. If, for example, continence services have a specific role in care homes, their staff should then be used as advisors and collaborators to help implement broader arrangements, making the most of trusted relationships already built with the sector.

It is likely that a combination of approaches which provide residents with access to a range of specialist services, such as community geriatricians, old age psychiatrists, allied health professionals and community pharmacists will deliver the best outcomes. There is no definitive evidence which dictates whether these activities should be provided by enhanced primary care or specialist services.

Monitoring and Evaluation

The complex nature of the needs of older people with frailty means that there is no single way in which a commissioner of health services for older people living in care homes can know if an older person is receiving optimal health care.

However, likely indicators are:

• A defined and separately identified register of individual patients who the service provider or practice is contracted to provide services under a commissioned contract
• Evidence that individualised health care plans, and advanced care plans are in place that have been developed with patients and their families. They are being used as key documents which means that all clinicians, allied professionals and care home staff are familiar with and following them
• Reviews of health care and advanced care plans are conducted every six months as a minimum, and more often if a person’s health care needs are likely to change rapidly
• Evidence that on-going and relevant training and development is taking place
• Consideration should be given to using an agreed national or international tool, such as the LPZ-i, to benchmark care across and between regions (https:// gb.lpz-um.eu/en) - this has been used successfully in some parts of the UK
• Evidence of preventative medicine, for example % of care home residents covered by immunisation against influenza and pneumococcus (either vaccinated or been offered vaccination and declined). A target of 90% could be a useful indicator
• Improved safety of residents, for example a % reduction in the rate of fracture or reported falls
• Integrated services delivering patient-centred care: for example % of people dying in preferred place • Evidence of reduction in residents’ unplanned hospital services use, for example, % reduction in the number of Accident and Emergency attendances and nonelective hospital admissions • Evidence of reduction in residents’ use of unplanned community services: for example, % reduction in emergency ambulance use or out of hours GP call outs.