Primary and Community Care

Improving Advance Care Planning Within Residential Homes

Introduction:

As care home residents are living with advancing frailty and multi-morbidity, it is important to initiate advance care planning as part of the comprehensive geriatric assessment and create universal care plans (UCPs). There is evidence that it can reduce inappropriate escalations of care, reduce hospital admissions, increase the proportion of residents dying in their preferred place and improve both resident and relative satisfaction.

Method:

Retrospective audit in June 2024 of residents within the five residential homes covered by the newly formed enhanced health in care home (EHCH) team who had an initial comprehensive geriatric assessment (CGA) between March 2022-May 2024 to review if they had a universal care plan in place (UCP).

Further sub-analysis to review whether they had an existing UCP prior to EHCH review or this was created/edited by the EHCH team. Both the CGA and UCP would have either been completed by the EHCH matron or consultant geriatrician.

Results:

There was an average increase from 26% to 89% in the number of residents with a UCP following an EHCH CGA. We have created/edited a total of 117 UCPs across the care homes in addition to those already in place across the 177 CGAs completed over this time period.

Conclusions:

Advance care planning is a vital part of a comprehensive geriatric assessment and it is often not completed for many reasons including its time-consuming nature, lack of awareness and apprehension in having these discussions both amongst residents, relatives and staff and a lack of training and education.

As an EHCH team, we have managed to improve the number of residents with UCPs to 89%. We hope this will mean a greater proportion of residents receive appropriate personalised care according to their wishes in their chosen place as well as dying in their place of preference.

Background: Clinical pharmacists are increasingly working as part of primary care teams in UK. Many people living with dementia live at home with the support of primary care. Given the complexity of their health problems and their use of several medications, clinical pharmacists may potentially play a crucial role in their support Aims: To explore clinical pharmacists’ experiences of working in primary care with people living with dementia and identify any specific training needs to provide effective support for this patient group.

Methods: An online survey sent via email in 2023 through professional organisations, social media, and utilising research team contacts. The survey covered topics including clinical pharmacists’ background, experience of working with people with dementia, and training needs.

Results: 57 clinical pharmacists responded to the survey; the meantime working as a clinical pharmacist was 9.6 years (standard deviation 8.6) and within a primary care setting was 6.1 years (standard deviation 6.1). Just over three-quarters of respondents (n=31, 77%) work with people living with dementia. While almost two thirds (n=35, 61%) had undertaken training for dementia care, such training often lasted a few hours (less than a day) (n=17, 49%). Most respondents (n=39, 89%) wanted further information or training; including non-pharmacological interventions to improve quality of life in dementia and how to support carers and relatives. Practice challenges reported included a lack of face-to-face consultations and getting assurance that the patient could safely take medications.

Conclusions: These findings indicate an interest in dementia care, a willingness to undertake further training but practice uncertainties that suggest a system approach might be beneficial.

Introduction: Fracture liaison services (FLS) aim to prevent secondary fractures by ensuring high-quality care to all patients with fragility fractures above 50 years. The standard recommendation by FLS Database (FLS-DB) is to identify 80% of the expected fragility fractures, commencing treatment for 50% and monitoring 80% at 16 weeks and 52 weeks.

Methods: FLS team noted that only 18.4% (n=92) patients were followed at one-year of the total 875 patients identified in the year 2021 (National benchmark=22.3%). Whilst FLS team identified 42.6% (n=1649) patients in the year 2022, an 88% increase as compared to the year 2021. But there was reduction in the one-year follow-up from 18.4% to 13.8% (n=149) in 2022. Quality improvement methodology based on the model of improvement; Plan-Do-Study-Act cycles, was used. Process mapping for the existing FLS showed that follow-up was only ad-hoc and not formalised. Our objective was to improve follow-up at one-year.

Results: Process mapping supported the development of a separate clinic code for annual review of patients, led by a geriatrics specialty trainee and supported by the FLS Clinical Lead. The patient lists were drawn from the FLS-DB and new patients booked for one-year follow-up clinic. FLS identified more fragility fracture patients (n=2181, 61.4%) in 2023, a further increase of 32.2% as compared to previous year. Clinical leadership and dedicated one-year follow-up clinic supported improved performance (21.4%, n=310) in the year 2023, which is comparable to the national benchmark (22.2%).

Conclusion: Several challenges were identified including lack of accurate telephone numbers for many patients; patients are transferred to primary care at one-year but there but the is osteoporosis knowledge gap in the community and need for dedicated time for follow-up clinic. This quality initiative has streamlined our follow-up clinics but need dedicated time to meet the service demand and increased capacity.

Introduction

University Hospitals Dorset (UHD) wants to provide hospital level care to patients with frailty, in their own home. Our frailty virtual ward (VW) team consists of a consultant geriatrician, lead nurse, pharmacist, advanced nurse practitioner, nurses and therapists. We have a capacity of 20 patients across Bournemouth, Christchurch and Poole localities. Our patients receive care at home for acute medical conditions supported by remote monitoring, blood testing, face to face assessments and daily Geriatrician input. We are collaboratively working with our community partners seeking to provide complete CGA in the patient’s home.

Methods

Establishing the service was non-linear and required multiple improvement cycles. Our VW fits alongside our frailty SDEC, day hospital and interim care team. We developed a SOP, a patient flow pathway and processes for medication prescribing and delivery supported by the Royal Voluntary Service. We screened our frailty wards for suitable patients and in May 2023 we tested by taking our first patient home. Subsequently our processes have developed around the patient’s needs. Through multiple PDSA cycles we tested various screening techniques, 7 day Geriatrician input, nurse recruitment, remote monitoring and used patient feedback to guide further service development and improvement.

Results

We are an established frailty virtual ward with 20 beds.

Conclusion

The UHD Frailty VW has developed out of a need for an early supported discharge and admission avoidance for our older patients. Through multiple PDSA cycles, we have established a virtual model that we feel is providing safe, hospital level care for patients with acute medical presentations. We hope to expand through recruitment and funding with an aim to deliver excellent quality care to patients with frailty in their in their own home. Our ambition includes closely working with South West Ambulance Service for further admission avoidance and developing a home IV pathway.

Introduction The Chandlers Ford, Eastleigh and Southern Parishes Frailty Support Team (FST) identified pockets of high referral rates within independent living facilities. It was hypothesised that this may be because independent living facilities do not have a contractual arrangement for proactive intervention, unlike care homes and nursing homes. This leaves individuals and carers unsure how, when, and where to seek support. In turn, this potentially has a high healthcare burden through unplanned access to GP’s, 999, 111 or admissions to hospital.

Methods: An independent living facility was identified, and participants were invited to have a proactive, holistic review. Medical notes were reviewed for 12 calendar months prior the project and all unplanned contacts recorded. Each participant then received a face-to-face review which identified, addressed and rectified any findings/ concerns. A follow-up review of medical notes and a telephone call to participants was completed 3 months later; 3 months after telephone review medical notes were reviewed to identify incidents of unplanned care.  

Results: This project has decreased unplanned medical contacts by an average of 52% in all participants which equates to an average 6-month gross saving of £431 per person and a 6-month net saving of £383 *Net savings allowed for 3 hours of Agenda for Change 23/24 mid band 7 pay. Trend shows face to face contact has the best impact at reducing unplanned care incidents, however this does not affect the emergency needs secondary to trauma.

Conclusions: The project suggests that in independent living facilities switching from a reactive to a proactive model may allow for better holistic care, in turn reducing the burden on the local health services. It is acknowledged that this is a small sample and therefore may not be representative or generalisable and a larger study is recommended.

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

Zoledronic acid, a bisphosphonate used primarily for treating osteoporosis and other bone-related conditions, traditionally requires hospital visits for administration, which can be burdensome, especially for frail older patients. The administration of intravenous (IV) Zoledronic acid at home via Community Rapid Response Teams (CRT) represents an innovative approach to enhance patient care and accessibility while offering significant benefits to patients and healthcare services. Service Delivery CRT team is typically composed of highly trained nurses and doctors, equipped to handle potential adverse reactions promptly and effectively, ensuring patient safety. The involvement of CRT in administering IV Zoledronic acid ensures high-quality immediate care, maintaining the standards of good medical practice. In Caerphilly, our team has been successfully administering IV Zoledronic acid at home, having treated several patients without any complications, using a thorough, easy-to-use checklist process developed by our pharmacists. This checklist helps deliver prompt care in a safe and user-friendly manner.

Benefits

1. This approach enhances patient convenience and comfort, allowing them to receive necessary treatments without travelling, thereby reducing the physical and emotional distress associated with hospital visits.

2. It minimises exposure to hospital-associated infections, an essential consideration for immunocompromised individuals.

3. It can lead to improved adherence to treatment regimens, as patients are more likely to continue with therapy delivered in the comfort of their homes.

4. The reduction in hospital visits also alleviates the burden on secondary care facilities, allowing resources to be allocated more efficiently.

Conclusion

Administering IV Zoledronic acid at home via CRT not only enhances patient convenience and safety but also supports better healthcare resource management, potentially leading to improved treatment adherence and overall patient outcomes. We aim to develop this service further and extend it to other hospital requiring services like parenteral iron for heart failure.

Introduction: Inadequate patient selection for transfer to community hospitals disrupts care continuity and compromises patient safety and outcomes. The SBAR communication tool presents a promising solution to address this challenge. This study investigated the impact of SBAR on quality of care and patient outcomes.

Methods: Retrospective study involving patients admitted to Samuel Johnson and Sir Robert Peel Community Hospitals from October to November 2023. Data regarding the completion of the SBAR forms, accepted and rejected patients and reasons for rejection, and repatriation numbers were gathered. Comparisons were made against our previous study in 2021.

Results: 403 patient referrals have been made. 266 were accepted, 137 (34%) were rejected. Of the rejected patients 52 were due to medical reasons, while 85 were non-medical reasons. Compared to data from 2021, 137 out of 403 referrals (34%) were rejected in 2023, 3 out of 155 (2%) were rejected in 2021. There were 76 repatriations in 2023 (average of 26/month), whereas there were 139 repatriations in 2021 (average of 46.33/month). The decrease from 139 repatriations in 2021 to 78 in 2023 indicates a notable improvement in patient outcomes and healthcare management strategies. The decrease in repatriations not only reflects potential cost savings but also underscores the efficacy of interventions aimed at minimizing healthcare disruptions and optimizing patient well-being.

Conclusion: By facilitating a standardized and comprehensive handover between acute and community providers, SBAR ensures patients receive the appropriate level of care at the community setting. Moreover, SBAR empowers healthcare staff to confidently make decisions regarding transfer acceptance or rejection, prioritizing patient well-being throughout the process. The findings revealed significant improvements in both the quality of care and patient safety following the adoption of SBAR. Additionally, SBAR utilization demonstrated a notable reduction in the financial burden on the NHS.

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:

Older patients attending the Emergency Department (ED) and discharged home are at higher risk of adverse outcomes. Geriatric Ambulatory ED services were developed with the aim to deliver goal-directed care of older patients from ED using onward referral to Community Providers.

Method:

A retrospective review was undertaken from 13th January 2022 to 23rd December 2022 in older patients discharged from the ED following a targeted geriatric assessment and recommended community follow-up interventions. Demographic information, functional ability, hospital utilisation and mortality (up to one year), and any post-visit fragility fractures were reviewed. Data collection included identification of osteoporosis or osteopenia during or following the index ED visit.

Results:

108 patients were assessed, of whom, 74% were female, average age 76 years, range 61-93 years. 65% of patients were CFS scored, 9% were CFS 6 or 7, 15% CFS 4 or 5 and 41% CFS 1-3. GP review was advised for 76% of patients and 61% attended and therapy interventions were recommended for 9.3%, of whom, 3% attended. The majority presented with falls (82%) and half of those who fell, sustained a fracture. Osteoporosis or osteopenia was newly identified in 30% but in 44% of patients bone health remained unevaluated and only 8% had newly initiated anti-resorptive and 9% existing treatment. 4% experienced fragility fracture following their ED visit. Uptake was low for therapy (30%) and nursing interventions (14%). Following the index ED visit, 7% patients attended ED within 7-days, and 5% admitted to hospital within 30-days. 35% of patients re-attended ED and 22% were hospitalised within one year. One year mortality was 5%.

Conclusion:

ED targeted geriatric assessment can identify patients with falls and fragility fractures but better collaboration and communication between primary and secondary care is needed. Recommended bone health assessment occurred in a relatively small proportion of patients.