Care Home Medicine

Introduction: 

Primary care-based frailty identification and proactive comprehensive geriatric assessment (CGA) remains challenging. Our Devon-based Primary Care Network has developed and introduced an innovative, community-based IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We wished to see if this process could improve effectiveness of ACP in residential care home (CH) residents.

Methods/Intervention:

1) GPs clinically assessed all CH residents for frailty.

2) Proactive i-CGAs completed using our IT-assisted CGA tool, which prompts to review/consider/address:

• Previous i-CGA-related entries
• Traditional CGA-domains/risks
• High-risk drugs/deprescribing
• ACP discussions (hospitalisation/resuscitation/place of death preferences)

3) ACPs shared with relevant healthcare services/Out-Of-Hours.

Interim analysis focused on adherence to ACP-documentation in severely frail residents, comparing groups:

• i-CGA (1-year post-i-CGA completion)
• Control (1-year post-frailty diagnosis, no i-CGA, usual care)

Results:

i-CGA group: 196 residents(16 mild, 69 moderate,111 severe frailty)

Control group: 100(13 mild,31 moderate,56 severefrailty ).

No significant baseline differences.

Advance care planning:

• i-CGA: 100% residents had documented resuscitation decisions. 97% (191/196) preferred to "allow a natural death. Patients with severe frailty: 85%(94/111) preferred not to be hospitalised. 55%(52/94) died, 90%(47/52) in their CH.
• Control:  72%(72/100) had documented resuscitation decisions or which 97% in this group (70/72) preferred to "allow a natural death". Patients with severe frailty: 29%(16/56) had no hospitalisation preferences documented and in this group 25%(4/16) died in hospital.

Hospitalisation in residents with severe frailty:

• i-CGA: compared to the preceding year, unplanned hospitalisation rates fell:0.86 to 0.68/person years alive.
• Control: Unplanned hospitalisations increased:0.87 to 2.05/person years alive.

Survival: significant group mortality difference was seen at one year: 55%(62/111) severely frail i-CGA residents died compared to 77%(43/56) controls, p=0.0013.

Conclusions:

Proactive primary care-led i-CGA in severely frail CH residents promotes up-to-date discussions regarding preferred place of care and death. Most prefer not to be hospitalised, despite traditionally high rates of unplanned admissions. Our i-CGA/ACP process improves adherence to preferences, reduces unplanned hospitalisations and mortality rates. Progressive i-CGA completion and annual/opportunistic reviews should confer progressive benefits.

Introduction

Care home residents can have variable access to eye care services & treatments. We developed a collaborative approach between optometrists, care homes, and primary & secondary care to enable personalised patient-centred care. Objective To develop and evaluate an integrated model of eye care for care home residents.

Methods

Small scale plan-do-study-act (PDSA) service tests were completed in three care-homes in Southwark (2 residential, 1 nursing) between November 2021 to May 2022. Processes were compared to historical feedback & hospital-based ophthalmology clinic attendances (Mar 2019-2020). Hospital-like assessments were piloted at two care homes for feasibility & acceptability. Further piloting utilised usual domiciliary optometry-led assessment with multidisciplinary meeting access (including optometrist, GP, geriatrician, ophthalmologist and care home nurse) to reduce duplication of assessments and to evaluate MDM processes and referral rates.

Results

Examination was 100% successful at home (visual acuity & pressure measurement) compared to hospital outpatients (71.7% success visual acuity, 54.5% pressures). Examination was faster than in hospital settings (16 minutes vs 45 minutes-1 hour). Residents were away from usual activities for 32 minutes vs 6 hours for hospital visits including transport. Residents were less distressed with home-based assessments. Did-Not-Attend (DNA) rates reduced (26.7% to 0%), secondary care discharge rates improved (8.4% to 32%). Hospital eye service referral were indicated in 19% -23%, half of which were for consideration of cataract surgery. Alternative conservative plans were agreed at MDM for nursing home residents who were clinically too frail or would not have been able to comply with treatments avoiding 33% unnecessary referrals.

Conclusions

Home-based eye care assessments appear better tolerated & are more efficient for residents, health & care staff. Utilising an MDM for optometrists to discuss residents with ophthalmologists and wider MDT members enabled personalised patient-centred decision-making. Future work to test this borough wide is in progress.