Care Home Medicine

Unlike nursing homes, which have a qualified nurse on duty 24 hours, residential homes offer a social care model and are managed by a senior care assistant. This may increase the risk of admission to the emergency department (ED). The 45 bedded residential care home and associated GP medical practice in this pilot reported poorly communicated, inappropriate, and duplicate referrals to the practice, with nearly half of admissions to the emergency department occurring without professional assessment of any kind. The pilot aimed to enable care home staff to improve identification of residents at risk of deterioration and to make appropriate referrals to GP and other services. Method Intervention: A nursing team from the Northern Health and Social Care Trust – the Responsive Support, Education, and Anticipatory Care with Care Homes (REACH Team) – delivered an educational programme to home staff focused on early detection of decline. This included: • Recording of vital signs. • Recognition of ‘soft signs’ of decline (such as change in diet, reduced mobility, and agitation) using the ‘RESTORE2 Mini’ tool. • Using the SBARD structured communication tool when referring residents to the GP or other services. Results Over a three-month period: • 14 of 28 staff (50%) took part in the training. • 43 of 45 residents (96%) assessed for frailty and referred to a pharmacist for medication review. • Anticipatory care plans were completed with 38 of 50 residents. • When residents were referred to their GP using SBARD, about 60 % were managed within the home. • 63% of admissions to the emergency department (ED) occurred after professional assessment, although overall attendance rate was not affected in the first 6 months. Conclusions A short, nurse-led, educational intervention enables residential staff to effectively identify residents at risk of of deterioration, improve communication, and make referrals to appropriate health services. .

Introduction

The World Health organisation states that polypharmacy is a major global challenge. Older people in care homes are at risk of harm with 91% taking 5 or more medications. Pharmacists play an essential role in conducting medication reviews, identifying potential drug related problems, and implementing appropriate interventions to optimise treatment.

Method

As part of a pilot project for The Welsh Government Six Goals For Urgent and Emergency Care Pharmacists in Swansea Bay University Health Board’s Medicines Management team worked in collaboration with Consultant Geriatricians at Morriston hospital to review and optimise care home residents medication. Polypharmacy reviews were conducted assessing falls risk medication, anticholinergic burden and appropriateness of medication. Pharmacists engaged with the care homes to complete holistic clinical reviews and collaborated with consultant geriatricians to review recommendations. Pharmacists then actioned interventions and supported ongoing monitoring, working closely with the care homes. A total of five care homes have been chosen for the project with an estimated 200 residents. The team are still undertaking these reviews and conducting education.

Results

Thus far 79 residents totalling 855 medications have been reviewed. 288 interventions have been identified averaging 3.6 interventions per resident. Of the 288 interventions 132 (15.4%) medications have been stopped that were identified as inappropriate or no longer required, 16.7% of the medication stopped were classed as medications that may increase the risk of falls. In addition to safety measures results from medication reviews have shown financial benefit through cost savings.

Conclusion

Problematic polypharmacy continues to be a challenge that needs to be addressed and with nearly a quarter of medications prescribed in this cohort being stopped the benefit of specialist older people polypharmacy review for care home residents is apparent.

Introduction Older adults are at risk of falls, which increases further in care homes. Due to the complexity of care home residents’ conditions and an increasing ageing population, it is important for care staff to have knowledge and understanding in falls awareness, prevention, and management in order to support their residents. Literature searches identified that barriers to care staff implementing falls prevention strategies included limited knowledge of staff and insufficient resources (including lack of staff training). There is scarce research regarding methods to deliver training to care staff, however emerging research in Virtual Reality (VR) as a training method had promise due to increased knowledge retention, and application into practice. Stakeholder patient and public involvement and engagement determined that VR as a training method had potential value.

Methods The second study as part of a multi-phase project, including two research phases and one technology development phase. The second research study was a mixed methods pragmatic study exploring the feasibility of the VR proof-of-concept, across seven care homes across the North West (n=40).

Results Engagement, immersion and enjoyment were key factors for acceptability of a training method. The training suited the learning styles of care staff, and VR was accepted as a training method. Utilisation of a case study resident increased empathy for the resident experience. Feedback for development included additional locations, scenarios, and interactable items. Barriers and facilitators of acceptability and adoption were identified.

Conclusion Identifying a potentially effective method of training for a complex intervention may influence the creation of future training programmes for care homes: to assist in increasing care staff knowledge, retention of information, and application of knowledge into practice. This in turn may improve the quality of care delivered and resident outcomes. Additional research is required to develop the proof-of-concept further, and feasibility tested further.

Introduction

Teaching and Research in Care Homes (ToRCH) is a living labs partnership between University of Nottingham and three nursing homes in Derbyshire and Nottinghamshire. We aim to engage care home teams in research, including knowledge exchange and co-designing research proposals.

Methods

We conducted 7 workshops / focus groups with 10 staff members. These were supplemented by site visits, where the researcher observed staff meetings and met with residents and relatives (for patient and public involvement). We elicited discussion by appreciative inquiry method and recorded findings through field notes. Ideas built over time, iteratively, through ongoing discussion.

Results

Digital care records, in place in all member care homes, were a focus of discussion and we identified three topics for improvement projects and accompanying research: A) Emerging from lockdown, care homes identified newly appointed staff may have missed aspects of training about digital documentation, e.g. using language consistent with the model of care. Additional support may optimise use of digital records consistent with relationship-based practice. B) Using digital care record for benchmarking to support improvement projects. C) Realtime analysis of digital care records to identify deterioration and deliver proactive care. Our partnership is working with the software providers to develop these projects to improve continuity of proactive care and to develop indicators to assess outcomes of improvement projects.

Conclusion

Our living labs partnership has enabled care home teams to reflect on their use of digital care records and how these mediate communication within the care team as well as with family carers and primary care colleagues. Fresh perspectives have emerged which may accelerate the impact of digitalisation of care homes.

Introduction: Incontinence affects a significant proportion of older adults who reside in care homes. Incontinence symptoms have been linked to comorbidities, an increased risk of infection and reduced quality of life and mental wellbeing of residents. However, continence care provision can often be poor for residents, further compromising the health and wellbeing of this vulnerable population.

Method: A systematic qualitative evidence synthesis and thematic analysis established the current evidence-base of barriers and facilitators for the provision of continence care in care homes.

Results: The evidence synthesis revealed complex barriers and facilitators at three influencing levels: macro (structural, societal and external influences), meso (organisational and institutional influences) and micro (day-to-day actions of individuals impacting care provision). Macro-level barriers included negative stigmas relating to incontinence, aging and working in the older adult social care sector, restriction of continence care resources such as containment products (i.e. pads), short staffing in care facilities, shortfalls in the professional education and training of care home staff and the complex health and social care needs of older adult residents. Meso-level barriers included task-centred organisational cultures, ageist institutional perspectives regarding old age and incontinence, inadequate care home management and poor communication and teamwork among care staff. Micro-level barriers included both staff and residents’ poor knowledge of continence care and negative attitudes towards incontinence symptoms, management and treatment.

Conclusions: These findings help to outline the complexities of continence care provision in older adult care homes. Macro, meso and micro level influences demonstrate problematic and interrelated barriers across international contexts, indicating that improving continence care in this setting is extremely challenging due to the multiple levels at which care provision, services and individuals are impacted. Older adult social care policy-makers, researchers and service-providers must recognise this complexity in any intervention that aims to improve continence care in care homes.

Background

West Lothian has 17 care homes with 881 residents. General Practitioners (GP) undertake annual review of all residents, including medication review, with variability between practitioners.

Introduction

Multidisciplinary team (MDT) working is the cornerstone of comprehensive geriatric assessment. MDT meetings are an excellent environment for shared learning and discussion. We applied this principle to a 2-year project delivering structured MDT medication reviews of care home residents.

Methods

Funding was secured for a consultant geriatrician (0.5PA for 2 years, £6500 per year) to join the Lead GP, Integrated Care Pharmacist and care home nursing staff in setting up an MDT for each care home. Complex patients were discussed in monthly MDT meetings, focusing on medication reviews. Shared decisions were documented on primary care clinical notes and amendments made to prescriptions. Where necessary, further GP review assessed subsequent impact of medication changes. Annual cost savings were calculated based on the current Scottish Drug Tariff(1). Qualitative feedback was sought from all members of the MDT.

Results

43 residents from 9 Care Homes were discussed in 11 MDT meetings between Jan-Dec 2022. Average age was 83.3 years (64.9-101.3), 63.4% were females. In total 6 new medications were started, while 87 medications were stopped. The dose was increased in 5 medications but decreased in 37 medications. Total annual savings were estimated at £6657, an average of £155 per resident discussed. Feedback from all members of the MDT was positive, particularly for improving patient care and increasing knowledge and confidence in managing this frail population.

Conclusion

Structured MDT reviews ensured patients were on appropriate medications focusing on improving symptoms and quality of life, in keeping with principles of realistic medicine. The estimated annual savings exceeded the funding invested, making this intervention cost-effective. We plan to scale this up further in Year 2 of this project.

Reference

1.            Public Health Scotland, Scottish Drug Tariff,

Aims:

i) Develop and test a theory-based diagnostic instrument to assess barriers and facilitators accurately and prospectively; and ii) survey barriers and facilitators to the delivery of skin hygiene care in care homes.    

Background:

There is an ageing population and an increasing number of people residing in care homes. As skin ages it become vulnerable to dryness, itching, cracks, and tears. These are experienced by many older people and cause discomfort, compromised quality of life, skin breakdown, increased dependency, longer hospital stays, and greater financial and human costs. These problems can be prevented through adequate skin hygiene care, however despite best practice guidance, concordance may be sub-optimal.  

Methods:

Barriers and facilitators identified from a literature review and pilot study were categorised in a Delphi survey of experts (psychology or skin health) (n=8) to the Theoretical Domains Framework. This model was tested in three rounds for face validity (n=38), construct validity (n=235), and test-retest reliability (n=11).  Barriers and facilitators were surveyed in round two. 

Results:

A 29-item valid and reliable instrument resulted (χ2/df=1.539, RMSEA=0.047, CFA=0.872).  Key barriers were delivering skin hygiene care to agitated or confused residents, pressure to rush or engage in other tasks from colleagues, high workload, and difficulties meeting often unrealistic expectations of relatives. A key facilitator was knowledge of how to perform effective skin hygiene care. 

Conclusions:

This study identified a comprehensive list of barriers and facilitators to skin hygiene care including barriers previously unreported.  

Relevance to clinical practice:

Efforts to improve care tend to be based on information giving. However, our work illustrates that barriers other than knowledge need to be addressed.  Use of the SHELL-CH Index will allow identification of barriers and facilitators in local contexts and this understanding will support the development of interventions tailored according to need. 

Introduction: The ageing population poses challenges to the health care industry worldwide. The huge demand for residential care home for the elderly (RCHE) services induces pressure on health care workers (HCWs) recruitment and retention. HCWs are personnel who have prominent roles in direct basic care to the older adults, and all kinds of hands-on care. Due to the “unpleasant” work nature, shift work, and physical demands for HCWs, it is essential to unfold how HCWs comprehend their working experiences. Methods: An integrative review was conducted to synthesize various streams of literature in order to generate new knowledge. Multiple databases such as CINAHL, ERIC, LWW nursing were adopted to search for relevant literature published between 2012 and 2022. Results: A total of 24 articles were retrieved at the initial stage, and 7 articles were sorted after in-depth review. In general, results supported that HCWs experienced positively on the works at RCHEs though there were job stresses. The HCWs perceived the roles at RCHEs as routinized and task-oriented by providing direct care to older adults. They perceived their roles at RCHEs as care providers who provided direct care to older adults. Also, their responsibilities to maintain the safety and dignity of older adults was expressed as utmost importance. The meaning of works lay on three levels: interpersonal (e.g. self-achievement), interpersonal (e.g. communication with team members), and job performance (e.g. task compliance). Conclusions: This study reveals the experiences of working at RCHE from the HCWs’ perspective. The HCWs’ experiences reflected in this study as well as the meaning of works discovered can generate insights for policy-makers on HCWs recruitment and retention. Acknowledgement: The work described in this abstract was fully supported by a grant from the Research Grants Council of HKSAR, China [RGC: UGC/FDS16/M12/20].

Introduction: Moving into a care home is a significant, life-changing experience which occurs to address care needs which cannot be supported elsewhere. UK health policy recommends against moving into a care home from the acute hospital. However, this occurs in practice. Better understanding pathways into care homes could improve support for individuals and families, service planning and policymaking. Our aim was to characterise individuals who move-in to a care home from hospital and those moving-in from the community, identifying factors associated with moving-in from hospital.

Method: A retrospective observational cohort study was conducted involving adults moving into care homes in Scotland between 1/3/13-31/3/16 using the Scottish Care Home Census (SCHC), a national individual-level social care dataset. SCHC data were linked to routine data sources including hospital admissions, community prescribing and mortality. The data were split into those moving-in from hospital and those moving-in from the community. Descriptive statistics characterising the two groups were generated and multivariate regression undertaken to identify factors associated with moving-in from hospital.

Results: A total of 23,892 individuals were included in the analysis, of whom 13,564 (56.8%) moved-in from hospital. A third came directly from an acute hospital, with 57.7% from rehabilitation or community hospitals and 7.1% from inpatient psychiatry. Being male, receiving nursing care, high frailty risk, increasing numbers of hospital admissions and diagnoses of any fracture or stroke in the six months before moving-into the care home were all significant predictors of moving-in from hospital.

Conclusions: The population moving-in to care homes from hospital are clinical distinct from those moving-in from the community. National cross-sectoral data linkage of health and social care data is feasible, but the available data are dominated by health characteristics. There is an urgent need to operationalise other meaningful variables which shape care pathways to enhance understanding and evidence.

Introduction

The prevalence of eye disease and visual impairment in care home residents is disproportionately higher compared to the general population. Access to eye care services and treatment can be variable for this vulnerable population.

Objective

This narrative synthesis reviews the available evidence of services and interventions for delivering eye care to care home residents. The key review questions: 1. What is the existing evidence for eye care interventions or services (including service configuration) for care home residents? 2. Does the provision of these interventions or services improve outcomes?

Methods

Literature search of EMBASE/MEDLINE for original papers published since 1995. Two reviewers independently reviewed abstracts/papers. Data was extracted and evaluated using narrative synthesis.

Results

13 original papers met the inclusion criteria. On-site optometrist-led services improved diagnosis and management of eye conditions, with one study showing 53% of residents benefited from direct ophthalmology intervention. Provision of interventions such as cataract surgery, refractive error correction and low vision rehabilitation improved visual acuity and vision-related quality of life but did not improve cognitive or physical function, depression or health-related quality of life. There was little UK-based literature to inform eye service design or interventions to improve outcomes.

Conclusion

Care home based eye assessments improve the management of eye conditions. Interventions improve visual acuity and vision-related quality of life. Further research and/or clinical service scoping is needed to better understand current UK services, access difficulties or examples of good practice as well as to identify and test cost-effective service models for this vulnerable group.