Care Home Medicine

Introduction: Functional decline and restricted mobility are common issues among nursing home residents with dementia, resulting in frequent use of physiotherapy services. While these residents can typically articulate their therapy needs and preferences, these have not been investigated properly regarding physiotherapy and exercise, which may compromise therapy adherence. This study aims to explore the needs and preferences of nursing home residents with mild to moderate dementia in relation to physiotherapy and exercise interventions.

Methods: Semi-structured individual interviews were conducted with 15 nursing home residents diagnosed with mild to moderate dementia, who could understand and speak Dutch and were capable of providing informed consent. Thematic analysis was used to analyze interview data.

Results: A total of 82 unique codes were identified from the interviews, leading to four major themes: preferences regarding physiotherapy sessions; defining physiotherapy and exercise; exercise without physiotherapist supervision; communication. Generally, residents preferred physiotherapy that included exercise and advice aimed at maintaining independent physical functioning. Participants perceived physiotherapy as more intense compared to gymnastics classes, and it was not seen as applicable to all individuals. If safety and quality were ensured, exercises could be performed without physiotherapist supervision. While residents wanted their family caregivers to stay informed about their therapy, they mostly preferred to exercise with someone else.

Conclusions: Residents in our study expressed preferences regarding physiotherapy sessions, communication, and family caregiver involvement, which when implemented may enhance therapy adherence and effectiveness. Furthermore, a shift toward a more supervisory role for the physiotherapist, rather than the conventional "hands-on" approach, emerged as a possibility.

Introduction

As a response to the increased demand for nursing home services for older adults, there are new initiatives include building larger nursing homes to accommodate greater numbers of residents. This initiative can be detrimental to those older residents who required to be relocated from their current nursing home to a new one. However, there is limited understanding about how older residents adapt to this relocation, particularly on how they tackle the various issues after relocation. Thereby hindering healthcare personnel to identify appropriate strategies to support older residents during the process of relocation. The aim of this poster is to present the experiences of older residents in the immediate period after relocating to a new nursing home.

Method

A descriptive qualitative approach was adopted. Purposive sampling was used to recruit twenty-four older residents, who were relocated from existing nursing home to a new nursing home, upon ethical approval was sought. Semi-structured interviews were conducted based on the “process of adjustment” framework after consent was obtained. Each interview lasted for around thirty minutes and audio-recorded. Data were analysed using thematic analysis.

Results

Four themes were identified namely: adaptation to the new environment, interaction with other residents, interaction with healthcare personnel, and changes to their daily life. In particular, participants highlighted changes to their daily routines and interactions with others, but most of them expressed positivity about their relocation to the new nursing home.

Conclusion

The results illuminate the initial experiences of older residents required to relocate from their nursing ‘home’ to another with no choice. These findings will inform further interviews over time to help inform person-centred care for residents, the role of carers and service providers, and the care environment.

Introduction

End-of-life (EOL) care in care homes includes patients experiencing "ordinary dying" from dementia or frailty, alongside those with chronic diseases and cancer. Recognizing non-specific decline is complex. The One Weston Care Home Hub (CHH) implements comprehensive EOL care, achieving 95% of deaths in the preferred place and prioritising a "good death". Whilst "Just in Case" (JIC) injectable medications are commonly prescribed, a broader understanding of prescribing patterns is useful for learning about medicines waste and recognition of dying. This study investigates the prevalence of common prescriptions and explores the need to re-evaluate anticipatory medications for care home residents.

Method

A qualitative audit evaluated EOL care prescribing practices in 100 care home deaths by examining medication management in patient notes. Data were collected retrospectively on parameters including the completion of palliative drug charts, issuing JIC medications, and the timeline from prescribing JIC medications to death. Information on medications administered within the last two weeks of life and the cause of death was also recorded.

Results

34% received no additional medications. Antibiotics were the most commonly issued medications; 31% patients received them, half in liquid form. Other prescriptions included oral or topical analgesia (21%), laxatives (9%), benzodiazepines (8%), and oral steroids (5%). Liquid preparations comprised half of the issued medications. 74% of patients had JIC medications issued a median of 23 days before death (range: 1-1244 days).

Discussion

The use of antibiotics in this cohort is complex: are they prescribed for successful treatment, or could braver decisions be made not to prescribe when recovery chances are limited? Injectable JIC medications are a timely proxy for recognizing the terminal phase, but 26% of patients who died did not have these in place. Further study is required to determine if they were indeed not needed and how many of those prescribed were used.

Introduction

The Action Falls programme has demonstrated effectiveness in reducing falls amongst care home residents in a trial but has not been implemented widely (Logan et al, BMJ, 2021, 375, e066991). Co-production of implementation has been identified as a mechanism for achieving buy-in. This study aimed to co-produce an implementation model.

Methods

Systemic action research with an appreciative approach framed co-production workshops in three stakeholder groups: residents and relatives, care home staff and representatives from health and social care organisations. Topics explored were stakeholder priorities, design of the implementation model and evaluation outcomes. Data collection and analysis occurred concurrently to identify key themes. Participating stakeholders were invited to a celebration event to discuss key themes, share ideas and finalise the model.

Results

One action research cycle was completed. Eighteen workshops were undertaken with 16 stakeholders (7 care staff, 7 health and social care representatives, 1 resident and 1 relative). Falls training was reported as an area requiring improvement. The main priority identified was the need for a shared approach to learning about falls. Other themes were: tailoring training to individual and care home learning needs, involving key people in falls learning, safe spaces to share experiences and build relationships, providing regular learning opportunities, confidence in falls management as an appropriate measure of implementation success, and the need for a mixed methods approach to evaluate the model. A shared learning model was developed at the celebration event. The model included three components: accessible information for residents and relatives, bespoke training for each care home, and provision of ongoing support.

Conclusions

A shared learning model was co-produced as part of the Action Falls implementation strategy. This now needs evaluation.

Introduction

Respiratory viral illnesses (RVI) pose a serious threat to LTC residents. Those with frailty often experience non-specific presentations causing delayed diagnosis and treatment of infection. To facilitate early RVI detection, a screening protocol was developed to evaluate changes in cognitive and functional status of LTC residents using

the Single Question in Delirium (SQiD) with new Single Question in Functioning (SQiF) and Single Question in Reduced Mobility (SQiRM). This study aims to address: (i) If  novel (SQiD/SQiF/SQiRM) screening was superior to public health in detecting COVID-19 in LTC, and; (ii) Did combining the novel and public health screening improve detection of COVID-19?

Methods

The novel screening protocol was integrated into daily screening for RVI at three LTC homes in Nova Scotia, Canada. Daily assessments were recorded in consenting residents. If any of the novel protocol was positive, the 4As Test (4AT) and Hierarchal Assessment of Balance and Mobility (HABAM) were evaluated and a positive 4AT and/or HABAM triggered an RVI swab for COVID-19. Area under the curve (AUC,) sensitivity and specificity analysis using PCR tests as the reference criterion was utilized.

Results

Between October 2021 to February 2024, 378 LTC residents consented to participate, resulting in 142 positive COVID-19 PCR tests. Preliminary results show public health screening had a sensitivity of 68.3%, specificity of 52.1% and AUC of 0.60. Novel protocol exhibited sensitivity of 12.0%, specificity of 85.2% and AUC of 0.49. Combining public health and novel screening yielded a sensitivity of 80.3%, specificity of 32.3% with a AUC of 0.59.

Conclusions

Preliminary results suggest that incorporating public health and novel protocol screening for daily RVI assessments in LTC is advantageous. Predictive accuracy is slightly less with combined  screening, but sensitivity of the combined screening protocols remains high.

Other information

Ethical approval obtained from Nova Scotia Health Research Ethics Board #1026558.

Introduction:

Many UK care home (CH) residents live with multiple long-term conditions, leading to high levels of healthcare utilisation. Previous studies have used routine data to describe their health and social care characteristics separately. Accurately identifying when an individual is admitted to a CH from routine data is challenging. This study aims to provide a combined health and social care profile of a cohort of long-stay CH residents, at the point of admission, using linked primary, secondary and social care data.

Methods:

Individuals aged 65 and over registered to a GP practice contributing to the ‘Connected Bradford’ dataset who were admitted to a CH between January 2016 and December 2019 were included. Start and end dates for social care packages (nursing and residential) were identified from local authority social care data. Respite and reablement packages were excluded. Complete self-funders were not identified with this method. Linked secondary and primary care data were used to describe health characteristics. CH residents identified using primary care records and local authority data will be compared.

Results:

2,801 individuals were admitted to a CH during the study period of whom 1998 (71%) were long-stay residents (>6 weeks). Only 72% of participants identified using local authority data, had a primary care code indicating CH residency in their primary care records. Median length of stay was 272 days (IQR 63 to 480). Mean age at admission was 85 years (SD 8), median Index of Multiple Deprivation decile five. 59% of residents required nursing care from admission. 79% of individuals were taking 5 or more medications.

Conclusions:

Using local authority data offers a novel way to identify and characterise CH residents. Linkage of primary care records to local authority data improves identification of CH residents using routine data. Additional linkage with address history would further improve accuracy.

Introduction

Institutional care for older people is a relatively new social phenomenon in Egypt that is associated with societal stigma. Traditionally dependent older people are looked after by family members at home. There are currently 145 care homes in Egypt, mostly based in Cairo serving 2% of the older population. The aim of this study was to understand the perspectives of paid caregivers on the strengths, weaknesses, opportunities, and threats (SWOT) associated with their professional roles. This knowledge is crucial to deliver a culturally sensitive training program for caregivers, and enhance their job satisfaction, ultimately leading to person-centred high-quality care.

Method

Two focus group meetings, 90 minutes each, were conducted with 39 caregivers in a private care home in Cairo. Each group was further divided into four working sub-groups using a SWOT approach to guide the discussion. Generic themes were identified, analysed, and agreed on by the group participants.

Results

Thirty-nine caregivers (31 % males), age range 18-50 years, were interviewed including undergraduate and qualified nurses and social workers. Five themes were identified: administration, team values, training, place and equipment, and residents and families. SWOT findings related to each theme are summarised below: Theme Strength Weakness Opportunities Threats Administration Support and flexibility Poor incentives Access to healthcare services Lack of rest facilities Team values Peer support Mixed qualities in different leaders Outdoor recreational activities Lone working Training Mentoring program Unfulfilled training needs Regular updates on comprehensive geriatrics assessment No medical cover Place & equipment Resident accommodation Not always fit for purpose Health and safety compliance Cost of accommodation Residents & families Sharing knowledge Discriminatory attitudes towards staff Documentation of residents’ priorities Unfounded complaints

Conclusion

Reflecting on the views of paid caregivers provided valuable insight that could enhance the quality of institutional care for older people in Cairo.

Introduction:

Care home residents are increasingly presenting to hospitals. In October 2022, a frailty team was formed in our district general hospital, consisting of two SHOs, one SpR and one consultant, with support from pre-existing care home ANP and community resource team (CRT). Focusing on patients presenting to the Emergency Department, their aims were early identification of care home residents in order to optimise their care by facilitating discharge, tackling polypharmacy and seizing opportunities for advanced care planning.

Method:

Care home residents were highlighted on the ED clinical system, using a unique icon, and reviewed by the frailty team. Anonymised patient statistics were logged into a bespoke e-database. This generated a dashboard of graphs showing trends in outcomes. The statistics from the first 8 months (3/10/22 to 5/6/23) were utilised to show patient demographics, number of reviews and rates of discharge.

Results:

297 care home residents were reviewed. 83.8% of these patients had a Rockwood Clinical Frailty Score of ≥ 7. Delirium was present in 91 (30.6%) patients. 121 (40.7%) had at least 1 medication stopped. 165 (55.6%) were discharged after frailty review. Do not resuscitate forms were completed for 208 (70.0%) patients. Advanced Care Planning was discussed with 138 (46.5%) patients and 6 (2.0%) patients were not for re-admission. End of life care was commenced for 17 (5.7%) patients.

Conclusion:

It is clear that patients attending the Emergency Department would benefit from an early comprehensive geriatric assessment. The benefits this has provided in one North Wales DGH are significant and have made strides in reducing unnecessary admissions, reducing polypharmacy and providing holistic, interdisciplinary and patient centred care including advanced care planning. Whilst the Emergency Department is not an ideal environment for this, the team have demonstrated the benefits to this model.

Introduction: Meaningful involvement of experts by experience in the design of health and care research is now well-established as good practice (Staniszewska, 2018). For example, it is essential that the voices of residents and staff are properly heard in care homes research, since they provide important perspectives not necessarily shared by the wider multidisciplinary team (Shepherd et al. 2017). Nevertheless, there are concerns that involvement can be tokenistic, or vulnerable to power imbalances (Baines & de Bere, 2017; Jennings et al., 2018).

Methods: A care home in north east England is working with researchers to pioneer a new approach to involvement, with residents and staff at the centre. The care home has helped to shape a number of research projects, for example a feasibility study of mealtime care training. In this study, an advisory group was set up initially within the care home itself, comprising residents, staff and family carers. Subsequently the group was joined by people from other care homes in the area, with support from the local authority. In parallel to this, health and social care professionals have contributed to the advisory group through one-to-one meetings with the researcher.

Results: Advisory group meetings in the care home have provided an inclusive and equitable platform for residents and staff to share their views on the research topic and design. Other stakeholders have been able to input into the project, but separately and in a way that has left room for key voices to be properly heard. Contributors have felt valued and are keen to continue in the process.

Conclusions: This study offers an alternative and authentic model for the involvement of experts by experience in social care research, inverting the more typical approach so that residents and staff are at the centre not the periphery.

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. .