Care Home Medicine

Introduction

Transition is potentially a stressful incident to individuals as it requires major life adjustment. Older residents living in a nursing home consider it as their last place of life. When the older residents have to be relocated to a new nursing home, they inevitably face a significant transition due to their high dependency on the physical, psychological, and social needs. There is limited empirical evidence revealing the experiences of older residents who anticipate a transition from the existing nursing home to a new nursing home, thereby hampering our understanding of their needs and limiting the health care professionals, families, and friends to provide appropriate support in such major life event. The aim of this study is to explore the experiences of older residents in anticipation of transitioning to a new nursing home.

Method

A descriptive qualitative approach was adopted. Thirty older residents who were going to be relocated from the existing nursing home to a new nursing home were recruited through purposive sampling. Semi-structured interviews, each lasted for around 30-minute, were conducted and audio-taped. Data were analysed through thematic analysis.

Results

Experiences of older residents were summarised in four themes, namely preparing for the transition, having expectations on the new living environment, worrying about changes in daily living, and valuing the support from others. In general, the older residents viewed the transition positively and perceived well-prepared for the transition. Such positive experience was mainly due to the support provided by nursing home staff and families before the transition took place.

Conclusion

The findings significantly expanded our understanding on the experiences of older residents in anticipation of transitioning to a new nursing home, which is largely absent from empirical evidence.

Acknowledgement

The work described in this paper was fully supported by Hong Kong Metropolitan University Research Grant (No. RD/2023/1.18).

Introduction:

Care home residents are increasingly presenting to hospitals. In October 2022, a frailty team was formed in our district general hospital, consisting of two SHOs, one SpR and one consultant, with support from pre-existing care home ANP and community resource team (CRT). Focusing on patients presenting to the Emergency Department, their aims were early identification of care home residents in order to optimise their care by facilitating discharge, tackling polypharmacy and seizing opportunities for advanced care planning.

Method:

Care home residents were highlighted on the ED clinical system, using a unique icon, and reviewed by the frailty team. Anonymised patient statistics were logged into a bespoke e-database. This generated a dashboard of graphs showing trends in outcomes. The statistics from the first 8 months (3/10/22 to 5/6/23) were utilised to show patient demographics, number of reviews and rates of discharge.

Results:

297 care home residents were reviewed. 83.8% of these patients had a Rockwood Clinical Frailty Score of ≥ 7. Delirium was present in 91 (30.6%) patients. 121 (40.7%) had at least 1 medication stopped. 165 (55.6%) were discharged after frailty review. Do not resuscitate forms were completed for 208 (70.0%) patients. Advanced Care Planning was discussed with 138 (46.5%) patients and 6 (2.0%) patients were not for re-admission. End of life care was commenced for 17 (5.7%) patients.

Conclusion:

It is clear that patients attending the Emergency Department would benefit from an early comprehensive geriatric assessment. The benefits this has provided in one North Wales DGH are significant and have made strides in reducing unnecessary admissions, reducing polypharmacy and providing holistic, interdisciplinary and patient centred care including advanced care planning. Whilst the Emergency Department is not an ideal environment for this, the team have demonstrated the benefits to this model.

Introduction: There are approximately 549,000 new fragility fractures each year in the UK and the prevalence of both osteoporosis and risk of falling increases with age. Care home residents are three times more likely to fall and have a 3- to 4-fold higher incidence of fractures than people of the same age living in the community. These older, frailer and multimorbid patients often have the highest fracture risk and therefore the most to gain from anti-osteoporosis treatments to reduce this risk. 

Method: Retrospective audit of residents who were reviewed by the newly started Enhanced Health in Care Homes (EHCH) team within the 5 residential homes for an initial comprehensive geriatric assessment (CGA) between March 2022-June 2024. These initial CGAs were reviewed to determine if a FRAX assessment had been completed and subsequent sub-analysis of those with high/very high FRAX scores to determine whether they were on appropriate bone protection. 

Results: 100% of residents (183) had a bone health assessment including a FRAX score (age-adjusted if appropriate). Prior to CGA, 37% patients with a high/very high FRAX score were on appropriate bone protection, having excluded patients who were not suitable for any treatment for reasons including poor renal function or not clinically appropriate. Following EHCH initial CGA and management plan, this average improved to 85% across the residential homes. The most significant improvement in one residential home was from 0% to 83% post bone health assessment. 

Conclusion: There has been a considerable improvement from 37% to 85% in the number of residents at high and very high risk of fractures who are on appropriate bone health protection following an initial bone health assessment and subsequent management plan initiated by the Enhanced Health in Care Home team. 

Introduction: Functional decline and restricted mobility are common issues among nursing home residents with dementia, resulting in frequent use of physiotherapy services. While these residents can typically articulate their therapy needs and preferences, these have not been investigated properly regarding physiotherapy and exercise, which may compromise therapy adherence. This study aims to explore the needs and preferences of nursing home residents with mild to moderate dementia in relation to physiotherapy and exercise interventions.

Methods: Semi-structured individual interviews were conducted with 15 nursing home residents diagnosed with mild to moderate dementia, who could understand and speak Dutch and were capable of providing informed consent. Thematic analysis was used to analyze interview data.

Results: A total of 82 unique codes were identified from the interviews, leading to four major themes: preferences regarding physiotherapy sessions; defining physiotherapy and exercise; exercise without physiotherapist supervision; communication. Generally, residents preferred physiotherapy that included exercise and advice aimed at maintaining independent physical functioning. Participants perceived physiotherapy as more intense compared to gymnastics classes, and it was not seen as applicable to all individuals. If safety and quality were ensured, exercises could be performed without physiotherapist supervision. While residents wanted their family caregivers to stay informed about their therapy, they mostly preferred to exercise with someone else.

Conclusions: Residents in our study expressed preferences regarding physiotherapy sessions, communication, and family caregiver involvement, which when implemented may enhance therapy adherence and effectiveness. Furthermore, a shift toward a more supervisory role for the physiotherapist, rather than the conventional "hands-on" approach, emerged as a possibility.

1. Introduction

Care home residents have a greater incidence of frailty and co-morbidities. Polypharmacy and inequitable access to integrated healthcare are confounders to positive outcomes in this cohort. Providing proactive care through the Enhanced Health in Care Homes (EHCH) Framework seeks to address these inequalities using multidisciplinary team (MDT) working.

2. Method

A pilot MDT intervention was delivered across eleven older peoples care settings with the most ambulance conveyances in a London borough known for its aging population. MDT members were from general practice (including pharmacist), geriatrics, ambulance service, district nursing, palliative care, psychiatry, social care, integrated care board and senior care home staff. The intervention was refined iteratively over five months via a Plan-Do-Study-Act cycle. The MDT undertook comprehensive geriatric assessments, advance care planning and structured medication reviews. Outcomes were documented in personalised care and support plans (PCSP).

3. Results

Sixty-nine of the most complex patients were selected to receive the intervention. 100% of these patients had a PCSP created post-intervention. A resultant system culture change led to a three-fold increase in the number PCSPs across all care settings. There was a reduction in 999 calls for 57% of MDT patients (across 8 settings) and there was 24% fewer 999 calls and hospital conveyances across the wider patient group in all MDT care settings. MDT professionals and care home staff reported high satisfaction and valued shared learning and clinical decision-making.

4. Conclusion(s)

This intervention addressed health inequalities of care home residents with a clear thread of advocacy for patients. Proactive personalised care planning offered opportunities for earlier diagnoses, treatment, and swifter recognition of the dying phase of life. Primary care interventions within EHCH framework could be augmented by this MDT approach for a more complex cohort of care home residents with severe frailty and greater co-morbidity profile including dementia.

Introduction

We proactively reviewed nursing home residents using a multidisciplinary team (MDT) approach within a Primary Care Network (PCN). We aimed to enhance care coordination, reduce inappropriate medication use and ensure all residents had current advanced care plans in place.

Method

An MDT comprising a geriatrician, prescribing pharmacist, general practitioner, and nurse reviewed residents proactively. This involved reviewing the residents' current health and care needs, falls risk, medication regimens and advance care plans. We then performed medication reviews, reviewed advanced care plans, and identified the need for further interventions. When we repeated the process, we used a proforma that could be pre-populated prior to the meeting by the pharmacist and geriatrician to improve efficiency of the discussion.

Results

The initiative was piloted in two residential nursing homes with a total of 65 residents reviewed, of which 86% (n=56) received interventions. There was a 47% (n=29) increase in completed advanced care plans. 62% (n=40) of residents had medicines optimised, with polypharmacy being reduced in 46% (n=30) by an average of 2 medications per resident. 8% (n=5) were referred to additional services and 8% (n=5) required further investigations.

Conclusion(s)

This proactive MDT model effectively addressed the needs of residents whilst demonstrating immediate positive outcomes. Key facilitators to good practice were teamwork, clarifying the objectives of the MDT, prior reviews of patient records, and ensuring staff who knew the residents well were present. We will use this approach with other nursing homes within the PCN and share our results with colleagues. This has the potential to reduce costs of medications and hospital admissions, as well as improve quality.

Introduction

The fall risk factors in older adults living in residential care homes for the elderly (RCHEs) are multifactorial. In Hong Kong, around 9.5% of RCHEs have a fall rate over 30% (Elderly Health Service, 2022)1. The objective of this survey is to identify the common fall risk factors among frequent fallers in RCHEs in biological, environmental, and behavioural domains, based on the World Health Organization (WHO)’s risk factor model for fall (World Health Organization, 2021)2.

Methods

197 frequent fallers from 67 RCHEs with fall prevalence over 30% in Hong Kong were included in this cross-sectional retrospective survey. Twenty fall risk factors in biological, environmental and behavioural domains were investigated through tailor-made questionnaires and staff interviews. The most common fall risk factors, the time period and places of fall of all fallers were identified. The fall management strategy including fall risk assessment and fall incident report of RCHEs were also examined and compared.

Results

In the biological domain, chronic illnesses, decreased mobility, gait instabilities, lack of physical activities and cognitive impairment are the most common fall risk factors. In the behavioural domain, unsafe behaviour such as over-estimation of self-ability and hesitation to seek assistance are the most prevalent. Key environmental fall risk factors include movable furniture and poor lighting. The most common places of falls are bedsides while the peak hours of falls occurs around meal times. Nearly 24% of RCHEs did not perform fall risk assessments for residents.

Conclusions

Behavioural and biological fall risk factors play a more important role than environmental risk factors in these frequent fallers, and many of them are modifiable. Large variations exist in the fall management of different RCHEs. Interventions to prevent falls in RCHEs should target at improving the fall management protocol and addressing the specific fall risk factors of frequent fallers. 
 

Introduction:

Many UK care home (CH) residents live with multiple long-term conditions, leading to high levels of healthcare utilisation. Previous studies have used routine data to describe their health and social care characteristics separately. Accurately identifying when an individual is admitted to a CH from routine data is challenging. This study aims to provide a combined health and social care profile of a cohort of long-stay CH residents, at the point of admission, using linked primary, secondary and social care data.

Methods:

Individuals aged 65 and over registered to a GP practice contributing to the ‘Connected Bradford’ dataset who were admitted to a CH between January 2016 and December 2019 were included. Start and end dates for social care packages (nursing and residential) were identified from local authority social care data. Respite and reablement packages were excluded. Complete self-funders were not identified with this method. Linked secondary and primary care data were used to describe health characteristics. CH residents identified using primary care records and local authority data will be compared.

Results:

2,801 individuals were admitted to a CH during the study period of whom 1998 (71%) were long-stay residents (>6 weeks). Only 72% of participants identified using local authority data, had a primary care code indicating CH residency in their primary care records. Median length of stay was 272 days (IQR 63 to 480). Mean age at admission was 85 years (SD 8), median Index of Multiple Deprivation decile five. 59% of residents required nursing care from admission. 79% of individuals were taking 5 or more medications.

Conclusions:

Using local authority data offers a novel way to identify and characterise CH residents. Linkage of primary care records to local authority data improves identification of CH residents using routine data. Additional linkage with address history would further improve accuracy.

Introduction

Institutional care for older people is a relatively new social phenomenon in Egypt that is associated with societal stigma. Traditionally dependent older people are looked after by family members at home. There are currently 145 care homes in Egypt, mostly based in Cairo serving 2% of the older population. The aim of this study was to understand the perspectives of paid caregivers on the strengths, weaknesses, opportunities, and threats (SWOT) associated with their professional roles. This knowledge is crucial to deliver a culturally sensitive training program for caregivers, and enhance their job satisfaction, ultimately leading to person-centred high-quality care.

Method

Two focus group meetings, 90 minutes each, were conducted with 39 caregivers in a private care home in Cairo. Each group was further divided into four working sub-groups using a SWOT approach to guide the discussion. Generic themes were identified, analysed, and agreed on by the group participants.

Results

Thirty-nine caregivers (31 % males), age range 18-50 years, were interviewed including undergraduate and qualified nurses and social workers. Five themes were identified: administration, team values, training, place and equipment, and residents and families. SWOT findings related to each theme are summarised below: Theme Strength Weakness Opportunities Threats Administration Support and flexibility Poor incentives Access to healthcare services Lack of rest facilities Team values Peer support Mixed qualities in different leaders Outdoor recreational activities Lone working Training Mentoring program Unfulfilled training needs Regular updates on comprehensive geriatrics assessment No medical cover Place & equipment Resident accommodation Not always fit for purpose Health and safety compliance Cost of accommodation Residents & families Sharing knowledge Discriminatory attitudes towards staff Documentation of residents’ priorities Unfounded complaints

Conclusion

Reflecting on the views of paid caregivers provided valuable insight that could enhance the quality of institutional care for older people in Cairo.

Introduction: In 2021 the NHS Business Services Authority Data Science team openly published the first comprehensive nationwide analysis of over 65 care home versus non-care home prescribing. The analysis has been expanded to include three years of prescribing data and key falls risk prescribing metrics, offering new insight into falls risk prescribing for the over 65s in England.

Method: Patient address information from 1.8bn prescription forms was matched against 35m Ordnance Survey Address Base addresses. Patient addresses from prescription forms were classified as belonging to a care home or otherwise. Prescribing metrics around volume, cost, polypharmacy and falls risk were generated, with falls risk metrics informed by the STOPPFall study drug groups. These metrics were the mean number of falls risk medicines and proportion of patients prescribed three or more falls risk medicines within a given month.

Results: Over 65 care home patients received more prescribing of falls risk drugs than non-care home patients, whilst the proportion of care home patients on three or more falls risk drugs within a given month was double that of non-care home patients. Nearly 40% of care home patients aged 65-69 were prescribed three of more falls risk drugs within a given month, far more than both older care home patients and non-care home patients. Falls risk prescribing metrics displayed a great deal of variation by ICS and Local Authority.

Conclusion: Aside from headline figures and key findings, the analysis (due for public release in September 2023) allows granular analysis of over 65 falls risk prescribing, by patient age band, gender, geography and care home setting. The exploratory nature of the analysis lends itself to further investigation by healthcare analysts and clinicians, with the aim to gather feedback, iterate and expand the content annually.