Piloting an anticipatory care intervention for people living in a residential care home

Unlike nursing homes, which have a qualified nurse on duty 24 hours, residential homes offer a social care model and are managed by a senior care assistant. This may increase the risk of admission to the emergency department (ED). The 45 bedded residential care home and associated GP medical practice in this pilot reported poorly communicated, inappropriate, and duplicate referrals to the practice, with nearly half of admissions to the emergency department occurring without professional assessment of any kind. The pilot aimed to enable care home staff to improve identification of residents at risk of deterioration and to make appropriate referrals to GP and other services. Method Intervention: A nursing team from the Northern Health and Social Care Trust – the Responsive Support, Education, and Anticipatory Care with Care Homes (REACH Team) – delivered an educational programme to home staff focused on early detection of decline. This included: • Recording of vital signs. • Recognition of ‘soft signs’ of decline (such as change in diet, reduced mobility, and agitation) using the ‘RESTORE2 Mini’ tool. • Using the SBARD structured communication tool when referring residents to the GP or other services. Results Over a three-month period: • 14 of 28 staff (50%) took part in the training. • 43 of 45 residents (96%) assessed for frailty and referred to a pharmacist for medication review. • Anticipatory care plans were completed with 38 of 50 residents. • When residents were referred to their GP using SBARD, about 60 % were managed within the home. • 63% of admissions to the emergency department (ED) occurred after professional assessment, although overall attendance rate was not affected in the first 6 months. Conclusions A short, nurse-led, educational intervention enables residential staff to effectively identify residents at risk of of deterioration, improve communication, and make referrals to appropriate health services. .