Quest for Quality British Geriatrics Society Joint Working Party Inquiry into the Quality of Healthcare Support for Older People in Care Homes: a call for Leadership, Partnership and Quality Improvement

Professional perspectives on healthcare in care homes

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5. Professional perspectives on healthcare in care homes

There is little published research available on the professional views of GPs, geriatricians and old age psychiatrists about care home medicine and healthcare. Several recent surveys are helpful in providing some perspective from the key professionals involved in the care of older people.

a) What do general practitioners think?

The October 2010 Pulse survey of GPs112 found that:

  • 61% believed that current arrangements for the medical care of patients in care homes were not satisfactory.

  • Regarding access to local geriatricians and specialist older peoples’ nurses: 23% considered such access to be very good/good, 39% acceptable, 35% poor and 4% very poor.

  • 68% said that care home work was a major source of stress to the GP.

  • 67% did not carry out a medication review on each resident every six months.

  • 37% said that new residents would have a medical and nursing care plan within one month, but 26% said no and 37% did not know whether or not it was done.

  • 37% said that local healthcare provision for care home residents had been cut in the last year. This affected mental health care (53%), incontinence management (34%) and pharmacist support (21%).

The earlier Pulse General Election survey reported that 73% of the 876 GPs felt they lacked sufficient support or resources to manage older patients in care homes safely.113

The recent joint BGS Scotland and RCGP Scotland report Frailty, Older People and Care Homes, Can we do better?114 observed that:

  • The availability and skills of Comprehensive Geriatric Assessment are not universal in community and/or hospital settings. Those with frailty-related problems may not be accessing appropriate assessment and rehabilitation opportunities.

  • The skill mix of staffing in care homes at times fails to meet the changing needs of individual residents.

  • Education and training opportunities for care home staff are often inadequate.

  • The ability to up-skill nurse staffing to manage inter-current illness and palliative care requirements is identified as a deficit and resulting in some inappropriate hospital admissions.

  • Early multi-disciplinary reviews following placement often fail to ask whether a return to the community is possible.

  • Key clinical information and summaries regarding individual residents are often not available at the time of admission and often not held within care homes.

  • Allied health professional support for assessment and therapy are, as yet, insufficiently available through community or outreach services.

  • Pharmacy support is not uniform.

  • Involvement through an integrated specialist service to support the practices, residents and care homes is limited, and in some areas non-existent.

  • The specialist support of end of life care is lacking in some areas.

  • Consultant community sessions are not routinely available to support practices and care homes or prevent inappropriate use of unscheduled care when appropriate.

b) What do old age psychiatrists think?

Old age psychiatric community mental health teams have always gone into care homes partly because of the considerable number of referrals that come from them. They have long been interested in improving the mental health of residents in the care homes and improving the abilities of the homes to manage residents with mental health issues.
The interim report by the National Audit Office (2009) Improving Dementia Services in England included a survey on old age psychiatrists. In this, 87% of respondents said they did work with care homes although 64% were not specifically commissioned to do so.115 However, old age psychiatrists thought that care homes were important for implementation of the National Dementia Strategy in England.116

c) What do geriatricians think?

All departments of geriatric medicine (65% response) and PCTs in England (45% response) were surveyed in late 2006 to assess their attitudes and clinical input to care homes, using the recommendations in the 2000 report by the BGS, RCP and RCN117 as a template118. Findings included:

  • In England, only 1% of total consultant geriatrician time in job plans was allocated to care home work, but 73% of departments favoured greater involvement.

  • 14% of geriatric medicine departments reported a regular forum where GPs, geriatricians and nurses could discuss challenging or complex patients.

  • Thirty-three departments (30%) reported participation in various initiatives to support ongoing care in care homes, of which only half were supported by allocated time in consultant job plans.

  • Further evidence of this general commitment showed another 20 departments (18%) had tried to secure PCT funding for an initiative but had been unsuccessful.

  • In contrast, 45% of departments reported local PCT initiatives in which their department was not involved. And 128 PCTs (90%) also reported such initiatives, mostly involving community matrons.

These findings reveal a difference between the aspirations of clinicians and PCTs, highlighting the need for further guidance and discussion about the way forward.

The 2011 BGS membership survey found119 that:

  • Over 40% of the 330 respondents felt that medical support to care homes was below average or poor in quality.

  • Over 70% believed that depression and dementia affecting residents of care homes were not optimally managed.

  • Over half thought that incontinence and end of life care could be better managed.

  • 80% of respondents give telephone advice to local GPs on request, but less than 20% make care home visits.

  • Over half said they were not aware of care pathways or protocols used by GPs and geriatrician teams to support collaborative work in care homes.

  • 56% of consultants considered care home medical work important but over 90% spent under 10% of their time on it.

  • 72% of geriatric trainees considered care home medicine important, which is encouraging for the future.

d) Tackling the challenge: what can we learn from professional opinion?

There are an estimated 37,000 GPs120, just over 1,200 consultant geriatricians121, and over 600 old age consultant psychiatrists122 in the UK, many of whom are delivering healthcare to care homes across the UK. In addition there are other specialists such as palliative care physicians and consultants in rehabilitation medicine whose skills are highly relevant to many care home residents. As part of the in-depth interviews carried out, we sought opinions on ways health professionals and care homes could ‘do things better.’ These themes emerged:

  • Developing proactive working. All the interviewees advocated proactive working so that residents’ health could be monitored, problems anticipated, crisis situations avoided. One GP said: “Proactive is better in terms of trying to prepare people. Because the reality is that once you get into a nursing home there is a high chance of dying in the next year. People are unwell. We try to prepare families that their loved ones are likely to die.” Another explained: “We have a plan for each of our residents to identify what would potentially cause this person to go into hospital so look at what can be done to prevent this happening. I don’t want them in casualty and coming out with drugs which I am going to stop again.”

  • Continuity in care. One GP explained: “It’s the continuity of care that really counts for the patient. The home knows me and I know them. I can tell if they’re not feeling well. And so if I get called by the home it will be something that’s relevant. They know I’m coming on a weekly basis so little things that can cause a lot of work for the practice now don’t happen because they can talk to me over the telephone. And they know I’m coming so it saves us and them time, and the resident gets a better service.”

  • Valuing the staff in the home. Most of the interviewees emphasised that the staff in the care homes are the most important contributors to the health and wellbeing of residents because they are with them all the time. They also emphasised the importance of care staff in supporting healthcare regimes and the decisions of healthcare professionals.

  • Building relationships. Building relationships between homes and healthcare professionals, and particularly developing trust, is important. An old age psychiatrist said: “Building relationships and trust are essential. Knowing whom to trust for accurate information. You have to try to get some degree of continuity and some sort of relationship and that’s the best way. Also, it is important that you acknowledge you have to understand the culture of the place.” A GP said: “It’s important to increase the confidence of care home staff…previously the nurses would say a minimum about why they wanted a patient to be seen and wait for the doctor to see them. Now they say ‘this is what’s going on’ and if you could do xyz, this is how we should be dealing with this.”

  • Greater understanding between care homes and secondary care. An older persons’ specialist nurse in mental health said: “We need to increase awareness of the needs of care homes throughout health and social care and through general hospitals.” One geriatrician commented: “It’s really important that the secondary sector understands much better than it does now what goes on in care homes because we are still having the usual interface wars…We need to have a bit of a campaign…if they can understand the limitations of what can be done in care homes and also opportunities for better healthcare into care homes.”

  • More effective information technology and sharing data. A geriatrician reported: “Patients’ notes are sometimes difficult to access. For example, patients who have moved into the care home and have changed GP or have been discharged from hospital. Sometimes out of hours GPs have little or no information of that kind, despite the fact that electronic records exist in care homes.” An older person nurse specialist in mental health said: “Records are really important. There was a patient who had an advanced care plan and DNAR agreement but this was not clearly visible in the records so the paramedics tried to resuscitate him. Not a good situation.”

  • Reviews, protocols, advanced clinical planning and advanced care planning for end of life. Several of the interviewees described how reviews and advanced clinical planning can help healthcare be more effective and support care home staff in their decision making. A geriatrician explained: “An advanced clinical plan is made within the first few weeks after admission. We use one which we’ve developed from a number of different sources and trialed and on which we have now settled on. It has three pages. First page is basic information about the resident and their interested/relevant others and whether there is or is not a living will. The second page regards health [and] what are the things you are particularly concerned about. The third page is really the essence of it, which is similar to other end of life strategies. We have categories of response which are there to guide out of hours doctors who would be called upon to see a resident by a nurse and would never have seen the resident before.”

  • Consistency of clinical practice. Another geriatrician spoke of the need to have clear protocols that care home staff can follow’. “Systematic approaches to the management of common conditions. Systems of management for behavioural problems, bowel care, communication, PEG feeding and (the) need to assume ownership of these systems so that people know what to do. CPR forms and advanced wishes forms. And you need information for relatives as well.”

  • Standardised assessment. A GP recommended: “Proper assessment forms. Evaluated and standardised with a score…It needs to be a mixture of bringing the individual needs and desires to the forefront but also to be a way of us getting information about that person’s health problems and recording that in a standard way [that allows for] easy data entry. The score system is hugely advantageous because it would help us support staffing levels and make arguments.”

Staff feedback. One GP described a method which he had found effective in helping staff to understand how they interacted with patients. “The idea came out of a cancer professional development review in Scotland Cancer Network, a small group I headed up called RAPPORT. This is to do with trying to care for people better and the need to have therapeutic relationships with the people we serve. Getting people to think about how they like to be treated or not treated in a non-clinical sense. And then thinking about something they have done well and an interaction that has led to a successful encounter with a patient, a time they have felt fulfilled.

6. Learning from the evidence

Academic interest in care homes and their residents has grown considerably in the last few years. The graph below illustrates the growth of publications available through online searches with a focus on care homes healthcare over the last 30 years or so.

As part of the research for this paper, the BGS commissioned Professor Julienne Meyer of City University and her My Home Life project team working with the Universities of Hertfordshire (Professor Claire Goodman) and Nottingham (Professor John Gladman) to review the available evidence. The key points of this evidence are set out below. (More detail on the findings of the literature review is available in the Evidence Review on the BGS website.)

a) Models of care to support healthcare for residents of care homes

No definitive evidence emerges from the literature reviews to favour one model of primary care over another. There is little information available to evaluate whether different configurations of specialists and/or healthcare teams can replace or augment usual primary care. The relative merits of primary care organisation-based, cluster-based or GP-based nurse practitioners, compared to care home specialist teams are not known. One viable approach could be to increase investment in the GP services that have a specialist interest and formal responsibility for care homes and/or developing care home specialist case managers (nurse practitioner community matron, therapist) linked to General Practice. Another approach could be multi-disciplinary in-reach teams as an add-on to existing primary care. Care home-specific practices for areas with a high density of care homes could have the time, expertise and organisation to deliver the interventions referred to in this paper. No evidence exists to indicate if this is so in practice, nor of what the economic effect may be.
It would appear from the reviews however that, regardless of the model developed, service commissioners and planners might start by addressing the following:

  • Prompt transfer of clinical information to the care home to enable healthcare staff to build on the wealth of assessment that will have been conducted prior to the transfer of care. The exact format of this varies in the UK, but there is plenty of evidence that detailed multi-disciplinary assessments prior to an individual moving into a care home can identify remedial problems and ongoing healthcare priorities. This will facilitate continuity of care where a change of GP or other healthcare professional occurs.

  • Discussion and planning of future care for older people in care homes (including the use of advance directives) to reduce unplanned admission to hospital care services and inappropriate interventions at the end of life.

  • Nurses working as case managers could compensate for deficiencies in the scope of usual primary care. This could supplement general medical services and serve as a clinical and communication bridge to specialists and other community health services, thus improving resident outcomes and resource use.

  • Involvement of community pharmacy services to support medication reviews and improve prescribing practices.

  • Close links with community mental health teams to improve assessment and care of residents with behavioural and mental health problems.

  • Close links with community rehabilitation services, such as links with skilled therapists to support day-to-day care which can prevent or minimise complications with disabling conditions such as spasticity, contractures and pain.

  • The use of support tools and care frameworks that encourage a shared and systematic approach to joint working between care homes, community nursing and other health professionals. Used in partnership, these tools can provide a basis for continuity and consistency of approach (even where there is rapid turnover in the workforce).

It should be recognised that it is not possible to be prescriptive about exact models of care in an increasingly diverse care market, where the need for care home provision is projected to increase and the organisation of primary care is about to change,. We consider it more important to agree key principles (see Recommendation 1, section b) that can ensure health care interventions are appropriate. We would argue that any service model commissioned or delivered in the UK should be judged on the basis of how well it can implement a proactive and structured approach to care that enables some or all of the above.

b) Innovations and Examples of Good Practice in NHS service provision

Initiatives which have developed at a local level to support medication review (for example, by a primary care trust in England) increase the uptake of flu immunisation, improve end of life care, result in more screens for malnutrition or reduce falls. All these reflect recognition that more should be achieved for this population than is currently done.
The driver for many of these schemes has been concern that the care home residents are being admitted “inappropriately” to hospital. As a result, the schemes may depend on temporary central funding earmarked for this purpose. Sustainability is therefore threatened by this short-term funding, by being focused only on selected and sometimes “failing” homes, and by the schemes not having been integrated into a comprehensive model.
More recently, nurse case managers working as nurse practitioners or community matrons (drawing on US models of working with care homes) have been supported to liaise with GPs and hospital specialists to coordinate and manage the care that residents receive.123 These roles are developed locally, sometimes by individual general practices and sometimes by localities, often in response to particular service concerns.

c) Learning from others

Emerging evidence from across the UK suggests that commissioning health related inputs for care homes can improve the quality of care, reduce hospital admissions and save money. Below are six examples:

  1. In Sheffield, a locally enhanced service (LES) evaluation of the Sheffield PCT scheme demonstrated that the overall care planning process is carried out well and there is widespread evidence of good relationships developing between practices and homes. Feedback from the pilot showed that, of care home residents, 94% agreed that the GP service gave them the help they wanted and needed, and 84% agreed that they felt they received better care with the new GP service. For care home staff, 97% agreed that their relationship with GPs had improved and 86% agreed that the new service helped them understand more about residents’ health. Finally, for family members, 97% agreed that the person they care for received better care.

Although the pilot in Sheffield has only been running for a short time, evidence of the benefits of the scheme is beginning to emerge. In year one of the scheme, there was a reverse in the trend of rising emergency visits from care homes in the area, with a reduction in emergency admissions by six per 100 care home beds (approximately 9%) compared with the previous year. This translated into a gross savings of £145,000 in a single year for the 500 care home beds taking part in this small-scale pilot. The number of A&E attendances fell by three per 100 care home beds (approximately 10%) at a time when A&E attendances were rising in other areas. The use of emergency care practitioners (ECP) following 999 calls also fell by approximately one third.124

  1. A recent pilot in Leicester trialed shared management of patients in residential homes between GP practices and community geriatricians. The pilot offered GP practices access to comprehensive geriatric assessments, care planning, rapid written feedback and a telephone advisory service. After six months, out-of-hours consultations fell by 16% and requests for visits by 37%. Hospital admissions were also reduced by more than half. The total cost of hospital admissions fell by 60%.125

  1. A recent review of a locally enhanced service (LES) in a London borough found it saved money and improved service continuity and good working relationships126. The LES had also ensured that preventative measures took place through regular monitoring and ‘check up’ of care home residents127, and improving service efficiency.128 Care home residents and their family members were also very satisfied with the GP service.129

  1. A study in care homes in Peterborough PCT conducting nutritional screening with ‘Malnutrition Universal Screening Tool’ showed a 31% reduction in the number of hospital admissions (27% reduction in emergency admissions) and a significant reduction (58%) in the length of hospital stays.130

  1. A care home specialising in the rehabilitation of severely impaired adults provided evidence of one primary care practice model working proactively. It was agreed that all residents be registered with a designated GP practice where there was one male and one female practitioner who performed a round of the home on most weekdays. Over a six-year period they have documented a ten fold reduction in acute hospital admissions (Roberts 2011 personal communication).

  1. A study by the Joseph Rowntree Foundation in Bath and north east Somerset looked at a joint NHS and local authority initiative providing a dedicated nursing and physiotherapy team to three residential care homes. The initiative aimed to meet the nursing needs of residents where they live and to train care home staff in basic nursing. The results included reduction in hospital admissions and prevention of nursing home transfers. Cost savings were estimated, ranging from a ‘worst case’ scenario of £2.70 extra per resident to the more likely scenario of £36.90 savings per week. Savings were mainly through reduced use of NHS services, while the PCT and social services both funded the intervention.131

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