Care Home Medicine

Background: The serious outcomes of outbreaks of COVID-19 in care homes have been described internationally. The experiences of professionals working through outbreaks has received less attention, missing opportunities to acknowledge and learn lessons. Our aim was to explore the experiences of care home staff in Scotland of managing COVID-19 within their homes to help inform understanding and future practice.

Methods: From April to August 2022, 34 individual semi-structured interviews were conducted with care home staff working in homes which experienced an outbreak(s) of COVID-19. Reflexive thematic methods were used to analyse verbatim deidentified transcripts.

Findings: There was no singular experience of COVID-19 outbreaks within care homes. We identified four broad groupings of homes with outbreaks (significant outbreaks, managed outbreaks, outbreaks in remote/rural homes & outbreaks in homes supporting younger adults), with overlaps in timing and severity and variation in the support received and impact. The national response to the COVID-19 pandemic resulted in fundamental change to care home relationships. Staff responded by adaptation in uncertainty. However, they were challenged by emerging inequalities influencing residents’ care. There were tensions between staff experience and evolving external approaches to regulation and oversight. All this change resulted in psychological impacts on staff. However, there was also widespread evidence of compassionate leadership and teamwork in their responses. Effective sources of support were underpinned by respectful relationships and continuity, tailored to individual contexts.

Conclusions: The lived experiences of care home staff during the COVID-19 pandemic provide valuable insights applicable beyond the pandemic context. This includes: recognition of the specialism, complexity and diversity of care home practice; the value afforded by embedding genuine representation and involvement in planning, policy-making and research; the need for individualising to people in their contexts and the value of fostering respectful relationships across professional groups to support residents.

Introduction:

A scoping exercise in a residential dementia care home identified high numbers of falls occurring in residents’ bedrooms at night. Assessment and reduction of risk was often difficult since many falls were unwitnessed, and residents had poor recall. Collaborative working between Lewisham Community Falls Service (CFS); and Lewisham Linkline Service; involved the use of the ‘Just Checking’ monitoring system to enhance multifactorial falls assessment.

Method:

The Occupational Therapist (OT) in the CFS completed an initial multifactorial falls assessment. This helped to determine if data on night-time activity would be beneficial. This was discussed with care home staff and patient’s family prior to installation by the Telecare Specialist. The system was left insitu for four weeks with regular analysis of data by the OT and Telecare Specialist.

Results:

Resident A was a new admission with a recent dementia diagnosis and an injurious fall at home. 'Just Checking' was installed to monitor night time orientation and if he used his walking aid. He was refusing to keep a light on and was resistant to staff entering his room for checks. 'Just Checking' data guided intervention which included installation of motion centred lights. The resident started to use his walking aid at night without staff involvement. Resident B who had moderate to severe dementia, had demonstrated some challenging behaviours at night which increased his falls risk. 'Just Checking' data showed that he was restless throughout the night. This lack of quality sleep was identified as a key falls risk factor. Further exploration of his life story found that he had been a night worker for many years. Care home staff changed his day/sleep patterns. He experienced no further falls.

Conclusion:

Used as an adjunct to multifactorial falls assessment; ‘Just Checking’ can provide valuable data to understand falls risk and improve resident safety.

Background

Person-centred structured medication review (SMR) is associated with reduced polypharmacy, adverse drug reactions (ADRs), admission to hospital and mortality. Our service development aimed to explore the cost-efficacy of a multi-disciplinary team (MDT) providing SMR as part of a comprehensive geriatric assessment for care home (CH) residents.

Method

We established an MDT consisting of a consultant geriatrician, specialist clinical pharmacist, two general practitioners, clinical fellow, physician associate and frailty paramedic practitioner. Training on SMR was given by the pharmacist to other team members, with further support offered through the pilot.

Results

A total of 785 residents were reviewed across 20 CH sites during the initial 6-month pilot. Overall, polypharmacy was reduced by an average of 1.33 medicines per resident (8.32 to 6.99). The drug classes most commonly deprescribed were laxatives, antidepressants, lipid lowering drugs, opioids, and nutritional supplements. Medicines altered included three classes known to cause 40% of avoidable hospital admissions due to ADRs(1): diuretics (stopped/changed for 42 residents), antiplatelets (stopped for 34 residents) and anticoagulants (stopped/changed for 26 residents). Annual projected medication savings totalled £131,462(net), with an average saving of £169 per resident (range £63- £367). Drug classes with the largest cost impact were nutritional supplements (40% total savings), laxatives (12%), opioids (12%) and anticoagulants (11%). Carbon footprint savings from the 12 inhalers stopped during this phase totalled 1,323,098 gCO2e per annum: equivalent to 4562 car miles.

Conclusion(s)

A multi-disciplinary approach to medication review was shown to reduce inappropriate polypharmacy in care home residents. This intervention was associated with significant projected cost savings. Future work should aim to target SMR to patients with the highest rates of inappropriate polypharmacy.

References: 1. Howard, R. L. et al. Which drugs cause preventable admissions to hospital? A systematic review. British Journal of Clinical Pharmacology vol. 63 Preprint at https://doi.org/10.1111/j.1365-2125.2006.02698.x (2007).

Introduction:

The Enhanced Health in Care Homes Framework recognises personalised advance care planning (ACP) as a key component of optimal healthcare for care home residents. We established a multi-disciplinary care home team providing comprehensive geriatric assessment (CGA), structured medication review (SMR) and advance care planning (ACP) to a pilot cohort of frail residents in 17 care homes. We aimed to explore the acceptability and perceptions of proactive ACP alongside CGA from the perspective of resident’s next-of-kin (NOK), primary care staff and care home managers (CHMs).

Methods:

Data was collected using standardised questionnaires between February-September 2022. Data were analysed using qualitative content analysis. This was undertaken independently by two lead authors, after which codes and categories were identified through a collaborative approach and triangulation.

Results:

Four categories emerged from NOK data: 1) Perceived benefit of frailty specialist review, 2) Perceived improved knowledge of the individual through holistic assessment, 3) Sensitive conversations were perceived to have been handled well, but this was sometimes challenging over the phone, 4) Families felt empowered in shared decision making. Six categories emerged from primary care feedback: 1) Perceived benefit of holistic reviews, 2) Improved information sharing using same clinical system, 3) Specialist frailty involvement supporting GP learning, 4) Challenges with set-up, 5) Perceived avoidance of admissions following reviews, 6) Time and financial savings for NHS Four categories emerged from CHM feedback: 1) Perception that medical reviews were overdue, 2) Reduced care home staff workload through saving of time, 3) Specialist review and 4) Empowering staff to avoid admissions.

Conclusions:

This evaluation identified key feedback themes in relation to the perceived value and acceptability of a dedicated care home team performing CGA based ACP. Stakeholders expressed positive views about the service, suggesting benefits for individual residents, primary and community healthcare staff, and the wider healthcare system.

Introduction: The Enhanced Health in Care Homes Framework recognises personalised advance care planning (ACP) as a key component of optimal healthcare for care home residents ​(1)​. Documented ACP discussions guide decision-making in acute situations and may facilitate avoidance of inappropriate hospital admissions. Methods: We established a multidisciplinary care home service which aimed to provide comprehensive geriatric assessment (CGA) based ACP to all residents within three pilot care homes. We evaluated the effect of proactive, systematic CGA and ACP. Ambulance call-out and conveyance data for the pilot care homes were compared for three months before and after our intervention. Results: 122 residents were reviewed during the pilot period and 61 new ACPs were completed. Amongst the 61 new ACPs, 41 new decisions were made during the pilot to avoid future hospital admission and to prioritise comfort in the community. Total ambulance callouts to the 3 pilot care homes were observed to fall from 55 to 33 in the 3 months following our intervention: a reduction of 40%. Additionally, when an ambulance attended the scene, conveyance to an acute hospital was observed to fall by 50% (pre-n =40 vs post-n=19), in favour of discharging into the community. Conclusion: The provision of systematic CGA-based advance care planning in care homes may be associated with a lower frequency of ambulance call-outs and lower rates of conveyance of care home residents to hospital. Proactive advance care planning may influence GP, care home, and paramedic decision-making.

​​1. NHS England and NHS Improvement. The Framework for Enhanced Health in Care Homes. 2020 Mar.

Introduction

Across inpatient HSC settings ward based medicines management pharmacy technicians support ward based multi-disciplinary teams.  The aim of this study was to explore the potential role and impact of a medicines management pharmacy technician and ‘stock solution’ in a Care Home facility.

Method

A 30 bedded private Care Home was identified for the pilot.  A medicines management pharmacy technician liaised with senior nursing staff to review and understand the monthly medication ordering process.  The technician audited the Care Home’s medication destruction records for 4 months and reviewed all the medication documentation i.e. T-MARs, kardexes and MAR charts.  A ‘PRN medication stock solution’ with standard operating procedure (SOP) for use was devised and trialled for 2 months. 

Results

The monthly medication ordering process took a minimum of 12 hours, if no discrepancies/queries.  This process could be completed by a medicines management pharmacy technician. 

From destruction records the combined wastage of medications, controlled drugs and topical medications extrapolated to £11163.66 per year. 

An average of 2.33 discrepancies per resident were identified between kardex and MAR.  87.7% were classed as Eadon grade 4 i.e. intervention is significant and results in an improvement in the standard of care.  The remainder were Eadon graded 3.  An average of 0.2 discrepancies per resident were found between the T-MAR and MAR/Kardex.  These discrepancies were classed as Eadon grade 3 - Intervention is significant but does not lead to an improvement in patient care.

Following stock solution trial nursing staff completed questionnaires.   Questionnaire response rate was 71%.   The majority of responses were positive about the trial.

Conclusion

Use of a Medicine Management pharmacy technician, together with a ‘PRN medication stock solution’, similar to medicines management in a hospital ward would lead to a reduction of waste, cost savings and an improved standard of care.

Introduction

Older people living in care homes sometimes experience episodes of acute functional decline. These represent a diagnostic challenge to healthcare professionals and can result in antibiotic prescriptions or hospital admissions, though this may not always the most appropriate management strategy. We aimed to understand how episodes of acute functional decline are recognised, managed and escalated by care home staff in the UK.

Method

This was a qualitative interview study with UK care home staff, including managers, nurses and carers. Participants were recruited through advertisements circulated via email, social media and word of mouth. Semi-structured interviews were conducted over the phone between January 2021 and April 2022. Thematic analysis was facilitated by NVivo software. 

Results

25 care home staff were interviewed. Participants described feeling confident in recognising when residents were less well than usual, especially if they knew them well. However, they sometimes felt it was difficult to differentiate between an ‘off day’ and something more significant. Most participants talked about clear early communication amongst the team to flag a resident of concern. Initial management steps in the care home included checking clinical observations and doing a urine dipstick. Many participants talked about considering the underlying cause for deterioration. Some participants felt comfortable monitoring residents for a few days themselves or trying a simple intervention. Others preferred escalating directly to outside clinical support.  Triggers for escalation included perceived severity of illness, gut feeling or failure to respond to initial supportive management.

Conclusions

These results highlight the skill base of care home staff. However, it has also helped to identify areas for additional support and training including the use and interpretation of the urine dipstick. The findings of this study are being used to inform the design of a feasibility prospective cohort study of UK care home residents.

Background: People living with dementia are more likely to move into care homes. The true prevalence of dementia among care home residents in Scotland is not known. People living with dementia often interact with multiple social and healthcare services, thus routine data may offer a way to enhance understanding.

Aim: To compare national health and social care data sources recording dementia status for Scottish care home residents.

Methods: A retrospective cohort study of adult (≥ 18 years) care home residents in Scotland during financial years 2012/13 and 2013/14. An indexing process linked data from the Scottish Care Home Census (SCHC) to Community Health Index numbers to allow linkage to healthcare datasets. Anonymised individual data was accessed in a secure environment, within the National Safe Haven. A linked dataset with acute/general and psychiatric hospitalisations (SMR01, SMR04), prescriptions (Prescribing Information System), Scottish Patients at Risk of Admission and Readmission (SPARRA) data, and National Records of Scotland (NRS) mortality records was analysed. Dementia recording was studied across these datasets.

Results: In 2012/13 and 2013/14, 31,589 and 31,504 care home residents were included for analysis. In 2012/13, 17,548 (55.5%) had dementia according to SCHC. PIS and SMR01 confirm 4,701 (26.8%) and 4,254 (24.3%) SCHC dementia records, respectively. SMR04 and SPARRA confirm 1,830 (10.4%) and 964 (5.5%). Among 2012/13 residents, 19,593 (62.0%) have at least one dementia record across datasets. Of these, 10,445 (53.3%) have one record – 83.9% SCHC records, 7.3% SMR01 records, and 5.0% PIS records. Of 15,781 residents who die within 5 years from 2012/13, 6,984 (44.3%) have death records confirming dementia. Results for 2013/14 are similar.

Conclusion: Routine data enhances dementia ascertainment amongst care home residents, with most confirmation from general hospitalisations and prescriptions. Primary care data and analysis of more financial years would enable further exploration of dementia recording patterns.

Introduction: According to the Health Education England (HEE) Framework for Enhanced Health in Care Homes 2020, 33% of people over 65 and 50% of people over 80 have one or more fall a year, figures which significantly increase in care home residents. Prevention of falls promotes the quality of life of elderly patients and could significantly reduce the burden on primary and secondary care stemming from fall induced fractures, loss of mobility and community follow up. The Comprehensive Geriatric Assessment (CGA) for falls includes a full falls assessment questionnaire, medication review, lying/standing blood pressure and frailty index. The HEE set out a requirement that all care home patients should have a CGA assessment within 7 days of readmission to a care home following a hospital episode because of a fall. This audit examined the compliance of Four Counties primary care network (PCN) to the 7-day CGA HEE guideline for falls. Methods: Retrospective analysis of 68 eligible patients from Four Counties PCN between 31st March 2021 and 1st March 2022. Analysis indicated a poor compliance to the HEE CGA guidelines (15%). After presenting to the MDT, we formulated a system-wide plan to improve reporting of care home falls to OTs, creating protected time for pharmacists to conduct care home medication reviews and promoting in-person weekly care-coordinator meetings. The PCN was audited for a second time after 3 months. Results: A significant improvement (15% to 57%) in adherence to the HEE CGA framework was noted after implementation of above changes. Medication review in 7 days improved from 42% to 80% and falls assessment questionnaire in 7 days compliance improved from 23% to 70%. Conclusion: Creating clear protocols for reporting falls and clarifying MDT roles in the CGA are essential to identifying and preventing falls in at-risk care home residents.

Introduction: 

Primary care-based frailty identification and proactive comprehensive geriatric assessment (CGA) remains challenging. Our Devon-based Primary Care Network has developed and introduced an innovative, community-based IT-assisted CGA (i-CGA) process, which includes advance care planning (ACP). We wished to see if this process could improve effectiveness of ACP in residential care home (CH) residents.

Methods/Intervention:

1) GPs clinically assessed all CH residents for frailty.

2) Proactive i-CGAs completed using our IT-assisted CGA tool, which prompts to review/consider/address:

• Previous i-CGA-related entries
• Traditional CGA-domains/risks
• High-risk drugs/deprescribing
• ACP discussions (hospitalisation/resuscitation/place of death preferences)

3) ACPs shared with relevant healthcare services/Out-Of-Hours.

Interim analysis focused on adherence to ACP-documentation in severely frail residents, comparing groups:

• i-CGA (1-year post-i-CGA completion)
• Control (1-year post-frailty diagnosis, no i-CGA, usual care)

Results:

i-CGA group: 196 residents(16 mild, 69 moderate,111 severe frailty)

Control group: 100(13 mild,31 moderate,56 severefrailty ).

No significant baseline differences.

Advance care planning:

• i-CGA: 100% residents had documented resuscitation decisions. 97% (191/196) preferred to "allow a natural death. Patients with severe frailty: 85%(94/111) preferred not to be hospitalised. 55%(52/94) died, 90%(47/52) in their CH.
• Control:  72%(72/100) had documented resuscitation decisions or which 97% in this group (70/72) preferred to "allow a natural death". Patients with severe frailty: 29%(16/56) had no hospitalisation preferences documented and in this group 25%(4/16) died in hospital.

Hospitalisation in residents with severe frailty:

• i-CGA: compared to the preceding year, unplanned hospitalisation rates fell:0.86 to 0.68/person years alive.
• Control: Unplanned hospitalisations increased:0.87 to 2.05/person years alive.

Survival: significant group mortality difference was seen at one year: 55%(62/111) severely frail i-CGA residents died compared to 77%(43/56) controls, p=0.0013.

Conclusions:

Proactive primary care-led i-CGA in severely frail CH residents promotes up-to-date discussions regarding preferred place of care and death. Most prefer not to be hospitalised, despite traditionally high rates of unplanned admissions. Our i-CGA/ACP process improves adherence to preferences, reduces unplanned hospitalisations and mortality rates. Progressive i-CGA completion and annual/opportunistic reviews should confer progressive benefits.