Maria Zubair

Effective health care for older people living and dying in care homes: A realist review

BackgroundCare home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes.MethodsWe conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group.ResultsStrategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change.ConclusionHow relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.

Families and caring amongst older people in South Asian communities in the UK: a pilot study

The increasing number of older people within Britains and, more generally, Europes ethnic minority communities raises the need for the development of health and social care services which are appropriate to the specific needs and expectations of these older members of the various ethnic minority communities. Within the UK, the Pakistani and Bangladeshi communities can be identified as being in greater need of care and support in older age. There is, however, comparatively little research that examines the family and caring relationships of these ethnic minority older people, particularly those who are not identified from contacts with statutory and/or voluntary agencies. Drawing on a small but diverse sample of 20 older Bangladeshi and Pakistani women and men aged 50 years and older, we explore our participants’ understandings and experiences of care and support within the context of their family lives and social networks. Our data from the 20 semi-structured pilot interviews suggest that, much like the trend within the general population, the family remains central in the provision of care and support for these ethnic minority older people. We conclude by considering the implications this has for social care policy and practice.

Relationships, expertise, incentives, and governance: Supporting care home residents' access to health care: An interview study from England

Objectives To explore what commissioners of care, regulators, providers, and care home residents in England identify as the key mechanisms or components of different service delivery models that support the provision of National Health Service (NHS) provision to independent care homes. Methods Qualitative, semistructured interviews with a purposive sample of people with direct experience of commissioning, providing, and regulating health care provision in care homes and care home residents. Data from interviews were augmented by a secondary analysis of previous interviews with care home residents on their personal experience of and priorities for access to health care. Analysis was framed by the assumptions of realist evaluation and drew on the constant comparative method to identify key themes about what is required to achieve quality health care provision to care homes and resident health. Results Participants identified 3 overlapping approaches to the provision of NHS that they believed supported access to health care for older people in care homes: (1) Investment in relational working that fostered continuity and shared learning between visiting NHS staff and care home staff, (2) the provision of age-appropriate clinical services, and (3) governance arrangements that used contractual and financial incentives to specify a minimum service that care homes should receive. Conclusion The 3 approaches, and how they were typified as working, provide a rich picture of the stakeholder perspectives and the underlying assumptions about how service delivery models should work with care homes. The findings inform how evidence on effective working in care homes will be interrogated to identify how different approaches, or specifically key elements of those approaches, achieve different health-related outcomes in different situations for residents and associated health and social care organizations.

Embodying Gender, Age, Ethnicity and Power in 'the Field': Reflections on Dress and the Presentation of the Self in Research with Older Pakistani Muslims

In recent years, there has been an increasing interest in researching people growing older in the South Asian ethnic minority communities in the UK. However, these populations have received comparatively little attention in wide-ranging discussions on culturally and socially appropriate research methodologies. In this paper, we draw on the experiences of a young female Pakistani Muslim researcher researching older Pakistani Muslim women and men, to explore the significance of gender, age and ethnicity to fieldwork processes and ‘field’ relationships. In particular, we highlight the significance of dress and specific presentations of the embodied self within the research process. We do so by focusing upon three key issues: (1) Insider/Outsider boundaries and how these boundaries are continuously and actively negotiated in the field through the use of dress and specific presentations of the embodied ‘self’; (2) The links between gender, age and space - more specifically, how the researchers use of traditional Pakistani dress, and her differing research relationships, are influenced by the older Pakistani Muslim participants’ gendered use of public and private space; and (3) The opportunities and vulnerabilities experienced by the researcher in the field, reinforced by her use (or otherwise) of the traditional and feminine Pakistani Muslim dress. Our research therefore highlights the role of different presentations of the embodied ‘self’ to fieldwork processes and relationships, and illustrates how age, gender and status intersect to produce fluctuating insider/outsider boundaries as well as different opportunities and experiences of power and vulnerability within research relationships.

The Optimal Study: Describing the Key Components of Optimal Health Care Delivery to UK Care Home Residents: A Research Protocol

Long-term institutional care in the United Kingdom is provided by care homes. Residents have prevalent cognitive impairment and disability, have multiple diagnoses, and are subject to polypharmacy. Prevailing models of health care provision (ad hoc, reactive, and coordinated by general practitioners) result in unacceptable variability of care. A number of innovative responses to improve health care for care homes have been commissioned. The organization of health and social care in the United Kingdom is such that it is unlikely that a single solution to the problem of providing quality health care for care homes will be identified that can be used nationwide. Realist evaluation is a methodology that uses both qualitative and quantitative data to establish an in-depth understanding of what works, for whom, and in what settings. In this article we describe a protocol for using realist evaluation to understand the context, mechanisms, and outcomes that shape effective health care delivery to care home residents in the United Kingdom. By describing this novel approach, we hope to inform international discourse about research methodologies in long-term care settings internationally.

Doing Pakistani Ethnicity the Female Way: Issues of Identity, Trust and Recruitment when Researching Older Pakistani Muslims in the UK

In this chapter we reflect upon our experiences of undertaking qualitative fieldwork with older Pakistani Muslim women and men living in the United Kingdom (UK). The significant increase that is expected within the next 20 years in the proportion of older people living in minority black and ethnic communities within the UK (Merrell et al., 2006) — particularly those living within the Bangladeshi and Pakistani communities (see Katbamna et al., 2002; Phillipson et al., 2003; Burholt & Wenger, 2003) — suggests a growing need for conducting research on this hitherto under-researched group of Bangladeshi and Pakistani older people (see Vincent et al., 2006; Victor et al., 2012). This is especially because of the particularly high levels of inequality and disadvantage experienced by members of these communities in the UK (Qureshi, 1998; Harding & Balarajan, 2001; Nazroo et al., 2004; Nazroo, 2006), and their higher levels of morbidity rates (Katbamna et al., 2002), which are likely to have important implications for how old age is experienced by members of these minority groups. However, as it is common with many other under-researched minority and migrant groups, doing qualitative research with older Bangladeshis and Pakistanis presents researchers with key challenges. These challenges stem not merely from the cultural and linguistic differences that may often exist between researchers (and also between the wider academic world) and these ethnic minority groups (see Boneham, 2002; Feldman et al., 2008; Hanna et al., 2008; Lloyd et al., 2008), but also relate to the particular social and cultural identities of the researchers vis-a-vis those they research.

Using comprehensive geriatric assessment for quality improvements in healthcare of older people in UK care homes: protocol for realist review within Proactive Healthcare of Older People in Care Homes (PEACH) study

Introduction Care home residents are relatively high users of healthcare resources and may have complex needs. Comprehensive geriatric assessment (CGA) may benefit care home residents and improve efficiency of care delivery. This is an approach to care in which there is a thorough multidisciplinary assessment (physical and mental health, functioning and physical and social environments) and a care plan based on this assessment, usually delivered by a multidisciplinary team. The CGA process is known to improve outcomes for community-dwelling older people and those in receipt of hospital care, but less is known about its efficacy in care home residents. Methods and analysis Realist review was selected as the most appropriate method to explore the complex nature of the care home setting and multidisciplinary delivery of care. The aim of the realist review is to identify and characterise a programme theory that underpins the CGA intervention. The realist review will extract data from research articles which describe the causal mechanisms through which the practice of CGA generates outcomes. The focus of the intervention is care homes, and the outcomes of interest are health-related quality of life and satisfaction with services; for both residents and staff. Further outcomes may include appropriate use of National Health Service services and resources of older care home residents. The review will proceed through three stages: (1) identifying the candidate programme theories that underpin CGA through interviews with key stakeholders, systematic search of the peer-reviewed and non-peer-reviewed evidence, (2) identifying the evidence relevant to CGA in UK care homes and refining the programme theories through refining and iterating the systematic search, lateral searches and seeking further information from study authors and (3) analysis and synthesis of evidence, involving the testing of the programme theories. Ethics and dissemination The PEACH project was identified as service development following submission to the UK Health Research Authority and subsequent review by the University of Nottingham Research Ethics Committee. The study protocols have been reviewed as part of good governance by the Nottinghamshire Healthcare Foundation Trust. We aim to publish this realist review in a peer-reviewed journal with international readership. We will disseminate findings to public and stakeholders using knowledge mobilisation techniques. Stakeholders will include the Quality Improvement Collaboratives within PEACH study. National networks, such as British Society of Gerontology and National Care Association will be approached for wider dissemination. Trial registration number The realist review has been registered on International Prospective Register of Systematic Reviews (PROSPERO 2017: CRD42017062601).

Optimal healthcare delivery to care homes in the UK: a realist evaluation of what supports effective working to improve healthcare outcomes

Abstract Introduction care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use. Methods a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners. Results context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which ‘wraps around’ care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites. Conclusion activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.