Care Home Medicine

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.

Introduction

As a response to the increased demand for nursing home services for older adults, there are new initiatives include building larger nursing homes to accommodate greater numbers of residents. This initiative can be detrimental to those older residents who required to be relocated from their current nursing home to a new one. However, there is limited understanding about how older residents adapt to this relocation, particularly on how they tackle the various issues after relocation. Thereby hindering healthcare personnel to identify appropriate strategies to support older residents during the process of relocation. The aim of this poster is to present the experiences of older residents in the immediate period after relocating to a new nursing home.

Method

A descriptive qualitative approach was adopted. Purposive sampling was used to recruit twenty-four older residents, who were relocated from existing nursing home to a new nursing home, upon ethical approval was sought. Semi-structured interviews were conducted based on the “process of adjustment” framework after consent was obtained. Each interview lasted for around thirty minutes and audio-recorded. Data were analysed using thematic analysis.

Results

Four themes were identified namely: adaptation to the new environment, interaction with other residents, interaction with healthcare personnel, and changes to their daily life. In particular, participants highlighted changes to their daily routines and interactions with others, but most of them expressed positivity about their relocation to the new nursing home.

Conclusion

The results illuminate the initial experiences of older residents required to relocate from their nursing ‘home’ to another with no choice. These findings will inform further interviews over time to help inform person-centred care for residents, the role of carers and service providers, and the care environment.

Introduction

End-of-life (EOL) care in care homes includes patients experiencing "ordinary dying" from dementia or frailty, alongside those with chronic diseases and cancer. Recognizing non-specific decline is complex. The One Weston Care Home Hub (CHH) implements comprehensive EOL care, achieving 95% of deaths in the preferred place and prioritising a "good death". Whilst "Just in Case" (JIC) injectable medications are commonly prescribed, a broader understanding of prescribing patterns is useful for learning about medicines waste and recognition of dying. This study investigates the prevalence of common prescriptions and explores the need to re-evaluate anticipatory medications for care home residents.

Method

A qualitative audit evaluated EOL care prescribing practices in 100 care home deaths by examining medication management in patient notes. Data were collected retrospectively on parameters including the completion of palliative drug charts, issuing JIC medications, and the timeline from prescribing JIC medications to death. Information on medications administered within the last two weeks of life and the cause of death was also recorded.

Results

34% received no additional medications. Antibiotics were the most commonly issued medications; 31% patients received them, half in liquid form. Other prescriptions included oral or topical analgesia (21%), laxatives (9%), benzodiazepines (8%), and oral steroids (5%). Liquid preparations comprised half of the issued medications. 74% of patients had JIC medications issued a median of 23 days before death (range: 1-1244 days).

Discussion

The use of antibiotics in this cohort is complex: are they prescribed for successful treatment, or could braver decisions be made not to prescribe when recovery chances are limited? Injectable JIC medications are a timely proxy for recognizing the terminal phase, but 26% of patients who died did not have these in place. Further study is required to determine if they were indeed not needed and how many of those prescribed were used.

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

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: Many countries are facing an ageing population, and this is also evident in Singapore. To alleviate this matter and to cope with the increasing number of older persons today, nursing homes are also expanding. Residents of nursing homes are often frail and are at higher risk of multiple hospital admissions. On many occasions, the benefit of conveying the frail residents to acute hospitals is unclear and may even cause more harm. We implemented an acute hospital-nursing home collaborative pilot in two nursing homes with an objective to reduce emergency department visit and inpatient hospitalization among nursing home residents. We aim to study the experiences of healthcare personnel who were involved in an acute hospital-nursing homes collaboration in managing acutely ill residents.

Methods: Explorative qualitative interviews were conducted with fifteen nursing staff from two nursing homes involved in the pilot collaboration. The interview transcripts were thematically analyzed.

Results: The study delved into five key thematic areas: knowledge and understanding, service satisfaction, challenges, enablers, and service improvements. It revealed that a significant portion of staff lacked a comprehensive understanding of the collaboration's objectives. Nevertheless, there was a consensus that they found reassurance in the accessibility of hospital providers without immediate activation of emergency services. Nursing home staff acknowledged enhancing their ability to identify residents requiring escalated care through this collaboration. The interventions utilized, such as the NEWS assessment tool, hospital transfer forms, and teleconsultation portal, were noted for their user-friendliness. Challenges encountered included pressure from next-of-kin favouring treatments in acute hospitals over nursing homes and insufficient on-site resources. Identified enablers included a robust support system and the competency and motivation of nursing home staff to enhance residents' care, facilitating collaboration. Recommendations for improvement highlighted the need for training and skill development among nursing staff and workforce enhancement to bolster collaboration adherence.

Conclusion: These key themes highlight the significance of the collaboration between nursing homes and hospitals in improving care for residents, while also acknowledging the challenges and areas for future improvements.

Introduction

Prevalence of malnutrition in care homes is high and oral nutritional supplements (ONS) often prescribed. Prescription and monitoring of ONS use varies considerably within residential settings. Locally dietetics are not funded to visit care homes and input is limited. This project explored dietetic ONS prescribing within care homes in one primary care network within Devon, recording the potential impact on costs.

Methods

All patients prescribed ONS (n=50) across 16 care homes were reviewed, alongside referrals to dietetics (n=39) from November 2022-March 2023. Supplements were switched to first-line formulary supplements where possible, stopped where unnecessary according to dietetic assessment, and a “food first” approach encouraged within homes. Cost of supplements prescribed pre-dietetic assessment, cost of new prescriptions, dietetic staff time and mileage costs were recorded. Supplement cost was calculated from the local formulary and staff cost from NHS oncosts.

Results

Patients seen represented 20% of all residents (89/436) within the 16 care homes, suggesting high suspected clinical need. Mean age was 90 years, ranging from 73-103 years. Female patients accounted for the majority (n=68). Addressing inappropriate prescribing saved £57.62 per day in prescriptions through stopping or changing ONS. Cost of dietetic staff time and milage totalled £3105.80 over the five-month period meaning that after 54 days the dietetic review service was saving money. Patients often preferred first line powder-based supplements, and these were either similar or more appropriate in nutrient content than initially prescribed ONS. For example, one patient affected by pressure ulcers was prescribed a fat emulsion supplement. It contained no protein or micronutrients to promote skin healing (cost £3.15) whilst first-line supplements provided macronutrient and micronutrient needs (cost 52p each and £1.04 total prescription).

Discussion

Dedicated dietetic input for care home residents appears to save costs on ONS prescribing whilst providing specialist nutritional expertise.

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.