Dr Eileen Burns is a past President of the BGS, NHS England National specialty adviser for older people and integrated person-centred care, and was a geriatrician in Leeds for twenty-two years. She was also the clinical director for a large teaching hospital department in the first part of the 1990s. She tweets @EileenBurns13
How can we best support care home residents to remain in their homes and avoid the exposure to unintended harms of a hospital admission?
Every year winter is viewed with increasing disquiet by those of us caring for older people within our overstretched and under-resourced health care system. As our population ages and our NHS services fail to change fast enough to meet the needs of our patients, we find each winter increasingly challenging.
The risks to an older patient living with frailty from healthcare associated harms (infections, falls, delirium, poor nutrition, deconditioning to mention but a few) are all too well documented, and most older people regard a hospital admission as something to be avoided wherever possible. Of course, sometimes an admission is appropriate and in line with a patient’s wishes; our role then is to minimise those harms whilst providing the needed inpatient care.
So, anything we can do to reduce demands on acute hospital beds whilst providing appropriate care for our patients must be grasped with both hands. In that spirit I’ve described a number of interventions focussed on the needs of care home residents, with the aim of increasing their chances of remaining well, and when they experience a crisis, of receiving care within their care home.
Some of these are within our own control; others require local commissioners or partners to act. Hopefully this list will prompt us to act or push others to do so. I’m very aware that time to get services in place is tight – so act now!
- Ensure that your local Enhanced Health in Care Homes service is delivering regular resident “ward rounds”, and that medication reviews and early assessment of deterioration are addressed. All residents and (where appropriate) their families should be given an opportunity for advance care planning which isn’t simply a “DNAR” order but includes wishes regarding future hospitalisation in the form of an escalation plan. And do ensure this plan is clearly communicated to all those who need to access it.
- Some areas have developed a “Community of Practice” for staff providing enhanced health in care homes, with some input from geriatricians. This provides an opportunity for sharing good practice, seeking peer input and providing training sessions. Is this a way of supporting staff which might work in your area?
- Ensure that all care home residents have been offered flu and Covid vaccinations, ideally co-administered. Consent can sometimes be a decelerant to delivery of vaccines for those residents unable to consent themselves (where families are contacted to be asked to assent) so it’s never too early to start the process.
- Ensure that care home staff and healthcare staff are offered and supported to be vaccinated for both flu and Covid – to reduce the risk of passing on infection and also to reduce sickness absence – as well as avoiding the unpleasant personal consequences of flu or Covid!
- If your area has a hospital at home (H@H)/virtual ward (VW) service, ensure that all care homes are fully aware of the service and how it is accessed. Some areas allow direct referral from care homes; if yours doesn’t, could it? If not, then at least if care homes staff are aware of the service they can advocate for their residents if the assessing clinician isn’t aware. Even if your H@H/VW service is in development, every area in England now has an urgent community response service (UCR) which can attend in a timely way for many urgent care needs. Could the operating hours of your local H@H service be extended? If you don’t have a H@H/VW could an embryonic service be developed even if just with a care homes focus initially?
- Arrange access to advice from a senior clinician for your ambulance service - “Call before you convey”. Several areas have reported the benefit to care home residents of a service whereby the paramedic attending a resident calls and discusses the case with a consultant geriatrician; rates of conveyance of residents have been reduced without unwanted effects. This is called Silver Triage in some areas. If you currently don’t offer this, could you? Yes, it’s an extra phone call but if it saves an admission and does the right thing for the patient, it’s worth it!
