Melanie Handley

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.

Living in uncertain times: trajectories to death in residential care homes

Background Older people living in care homes often have limited life expectancy. Practitioners and policymakers are increasingly questioning the appropriateness of many acute hospital admissions and the quality of end-of-life care provided in care homes. Aim To describe care home residents’ trajectories to death and care provision in their final weeks of life. Design and setting Prospective study of residents in six residential care homes in three sociodemographically varied English localities: Hertfordshire, Essex, and Cambridgeshire. Method Case note reviews and interviews with residents, care home staff, and healthcare professionals. Results Twenty-three out of 121 recruited residents died during the study period. Four trajectories to death were identified: ‘anticipated dying’ with an identifiable end-of-life care period and death in the care home (n = 9); ‘unexpected dying’ with death in the care home that was not anticipated and often sudden (n = 3); ‘uncertain dying’ with a period of diagnostic uncertainty or difficult symptom management leading to hospital admission and inpatient death (n = 7); and ‘unpredictable dying’ with an unexpected event leading to hospital admission and inpatient death (n = 4). End-of-life care tools were rarely used. Most residents who had had one or more acute hospital admission were still alive at the end of the study. Conclusion For some care home residents there was an identifiable period when they were approaching the end-of-life and planned care was put in place. For others, death came unexpectedly or during a period of considerable uncertainty, with care largely unplanned and reactive to events.

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.

Promoting independence, health and well-being for older people: a feasibility study of computer-aided health and social risk appraisal system in primary care

BackgroundWith population ageing, research is needed into new low-cost, scalable methods of effective promotion of health and wellbeing for older people. We aimed to assess feasibility, reach and costs of implementing a new tailored computer-aided health and social risk appraisal system in primary care.MethodsDesign: Feasibility study.Setting: Five General Practices in London (Ealing) and Hertfordshire, United Kingdom (UK)Participants: Random sample of patients aged 65 + years.Intervention: The Multi-dimensional Risk Appraisal for Older people (MRA-O) system includes: 1) Postal questionnaire including health, lifestyle, social and environmental domains; 2) Software system generating a personalised feedback report with advice on health and wellbeing; 3) Follow-up of people with new concerning or complex needs by GPs or practice nurses.Evaluation: Feasibility of implementation; participant wellbeing, functional ability and quality of life; social needs, health risks, potential lifestyle changes; and costs of implementation.ResultsResponse rates to initial postal invitations were low (526/1550, 34%). Of these, 454/526 (86%) completed MRA-O assessments. Compared to local UK Census data on older people, participants were younger, more were owner-occupiers and fewer were from ethnic minority groups than expected. A range of problems was identified by participants, including pain in last week (269/438, 61.4%), low physical activity (173/453, 38.2%), sedentary lifestyle (174/447, 38.3%), falls (117/439, 26.7%), incontinence (111/441 25.2%), impaired vision 116/451 (25.7%), impaired hearing (145/431, 33.6%), depressed mood (71/451, 15.7%), impaired memory (44/444 9.9%), social isolation (46/449, 10.2%) and loneliness (31/442, 7.0%). Self-rated health was good/excellent in 312/437 (71.4%), and quality of life and well-being were slightly above age-specific population norms. Implementation costs were low. Practices reviewed medical records of 143/454 (31.5%) of participants as a consequence of their responses, and actively followed up 110/454 (24.2%) of their patients.ConclusionsA computer-aided risk appraisal system was feasible for General Practices to implement, yields useful information about health and social problems, and identifies individual needs. Participation rates were however low, particularly for the oldest old, the poorest, and ethnic minority groups, and this type of intervention may increase inequalities in access. Widespread implementation of this approach would require work to address potential inequalities.

Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review

Objectives To identify features of programmes and approaches to make healthcare delivery in secondary healthcare settings more dementia-friendly, providing a context-relevant understanding of how interventions achieve outcomes for people living with dementia. Design A realist review conducted in three phases: (1) stakeholder interviews and scoping of the literature to develop an initial programme theory for providing effective dementia care; (2) structured retrieval and extraction of evidence; and (3) analysis and synthesis to build and refine the programme theory. Data sources PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, NHS Evidence, Scopus and grey literature. Eligibility criteria Studies reporting interventions and approaches to make hospital environments more dementia-friendly. Studies not reporting patient outcomes or contributing to the programme theory were excluded. Results Phase 1 combined findings from 15 stakeholder interviews and 22 publications to develop candidate programme theories. Phases 2 and 3 identified and synthesised evidence from 28 publications. Prominent context–mechanism–outcome configurations were identified to explain what supported dementia-friendly healthcare in acute settings. Staff capacity to understand the behaviours of people living with dementia as communication of an unmet need, combined with a recognition and valuing of their role in their care, prompted changes to care practices. Endorsement from senior management gave staff confidence and permission to adapt working practices to provide good dementia care. Key contextual factors were the availability of staff and an alignment of ward priorities to value person-centred care approaches. A preoccupation with risk generated responses that werelikely to restrict patient choice and increase their distress. Conclusions This review suggests that strategies such as dementia awareness training alone will not improve dementia care or outcomes for patients with dementia. Instead, how staff are supported to implement learning and resources by senior team members with dementia expertise is a key component for improving care practices and patient outcomes. Trial registration number CRD42015017562.

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.

Promoting health and wellbeing for older people in primary care: a feasibility study

Abstract Background There is a need for research into effective approaches to promote health and wellbeing for older people in primary care, particularly using technologies. These interventions may, however, generate inequalities in access. We aimed to assess the implementation in UK primary care of the multidimensional risk appraisal in older people (MRAO). The objectives were to (1) assess feasibility and costs of embedding the MRAO system; (2) identify sociodemographic characteristics of older people who choose to take part in a health promotion intervention; (3) identify factors helping or hindering older people and professionals from using recommendations to promote health and wellbeing; and (4) assess the utility of the MRAO to promote working across health, local government, and voluntary sectors. Methods We completed a mixed-methods feasibility study in five general practices in London and Hertfordshire. A random sample of people aged at least 65 years were included. People living in nursing or care homes and those with severe dementia or terminal illness were excluded. The MRAO intervention was a software system that analysed responses to a multidimensional questionnaire covering health, lifestyle, and social and environmental domains and generated tailored advice about health services, behaviour change, and local resources. Participants and practices received copies of the report and followed up those with new or complex problems. Four locality cross-sector working groups considered commissioning and service recommendations from local profiles of needs generated. We undertook quantitative and qualitative assessments. Quantitative analyses consisted of feasibility (uptake, attrition, process), wellbeing, needs or health risks, lifestyle, quality of life, service use, and costs at baseline and 6 months of follow-up. Qualitative analyses consisted of thematic analysis of four cross-sector working group meetings and in-depth qualitative interviews with 22 working group participants and 30 older people. Ethics approval was granted by the London-East REC (11/LO/1814). Written informed consent was obtained before enrolment. Findings 527 of 1550 (34·0%) people responded and 454 of 527 (86·1%) returned completed questionnaires. There were differences across sites, with 283 of 770 (36·8%) returned in Hertfordshire and 171 of 780 (21·9%) in London. Median age of participants was 73·2 years (IQR 68·9–78·9), 240 (52·9%) were women, 378 (83·3%) were white British, 400 (88·1%) lived in owner-occupied accommodation, 271 (59·7%) had no post-16 education, and 122 (26·9%) received only the state pension. Compared with local UK Census 2011 data, participants were younger, more were owner occupiers, and fewer were from ethnic minority groups than expected. A range of needs were identified at baseline, including pain (300 of 454 [66·1%]), low physical activity levels (211 [46·5%]), deteriorating mobility (change in last 12 months in walking in 131 [28·9%] or climbing stairs in 170 [37·4%]), falls (117 [25·8%]), urinary incontinence (111 [24·4%]), vision (116 [25·6%]), hearing (106 [23·3%]), depression (71 [15·6%]), impaired memory (44 [9·7%]), social isolation (46 [10·1%]), and loneliness (31 [6·8%]). Recent life events were common (182 [40·1%]). Baseline self-rated health was good or excellent in 312 (68·7%) and wellbeing was slightly above median age-specific population norms (median score Warwick–Edinburgh mental wellbeing scale 55·0, IQR 49·0–61·0). Preliminary analysis of 52 in-depth interviews and four working groups suggests the process was feasible to implement and of value to practices in identifying previously unknown needs. Multidisciplinary working groups seemed to find it difficult to interpret and act on findings. We will present findings on costs, behaviour changes, health service utilisation, wellbeing and quality of life at follow-up, and qualitative data on context, mechanisms, and effect. Interpretation Baseline findings suggest the MRAO system is feasible to implement in primary care. Practices can use it to identify individual needs and inform commissioning. However, participation rates are low, particularly for older age (at least 85 years), lower socioeconomic status, and ethnic minority groups. Funding Medical Research Council LLHW G1001822/1.