Primary and Community Care

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: Resilient ageing is conceptualised as strive towards achieving satisfactory quality of life (QoL) at old age by embracing positive adaptation and coping mechanisms against adversities regardless of health conditions. Preventive Home Visit (PHV) including various types of home-care interventions were introduced to delay health deterioration and improved QoL. However, research related to resilience as an outcome measured for PHV is scarce. Therefore, this systematic review aims to evaluate the effectiveness of PHV in improving resilience among community dwelling older adults and the association with health and other QoL related outcomes.

Method: Database search was conducted by using five databases (PubMed, PsycINFO, CINAHL, Web of Science and Scopus) up to 31 March 2022 involving community dwelling older adults who received PHV. Three authors reviewed the articles for inclusion and performed methodological quality assessment.

Results: Out of 1,568 records, 14 articles involving 7,254 participants met the inclusion criteria with age range between 79 to 85 years old. Quality assessment by using Joanna Briggs Institute (JBI) Critical Appraisal Tools indicated that all articles were assessed as moderate to high quality and were included in the review. More than two third of the studies focused on health or combination of health and QoL and only three studies revealed positive effect of PHV. The remainder were either produced mixed results or had no effect following the intervention. There was only one study examined resilience. However, no significant effect of PHV was reported based on this study.

Conclusion: Based on this current review, there were mixed results of PHV effectiveness. Due to the paucity of research in this area, there is no conclusive evidence of the effectiveness of PHV in enhancing resilience in older adults. Since there has not been any research on PHV and resilience done in Low-middle Income Countries (LMICs), it is necessary to fulfil this gap. Future research should concentrate on developing more robust and holistic PHV interventions that involve resilience in addition to QoL and multi-domain health-related outcomes.

Introduction:

Major trauma including Traumatic Brain Injury (TBI) is an increasingly common cause of hospitalisation in older adults. We studied post-discharge recovery from TBI using a remote healthcare monitoring system that captures data on activity and sleep. We aim to assess the feasibility and acceptability of this technology to monitor recovery at home following a significant acute clinical event in Older adults.

Methods:

We installed Minder, a remote healthcare monitoring system, in recently discharged patients >60 years with moderate-severe TBI. We present descriptive analyses of post-discharge recovery for two males, corroborating data from Minder against verified activities and events. We recorded semi-structured interviews assessing acceptability.

Results:

We present 6 months of sleep and activity data from Minder and feedback from interviews. Data observed from Participant 1 revealed habitual patterns of activity and sleep. These remained stable, despite discrete clinical events. Conversely, Participant 2's data revealed irregular sleep patterns that became increasingly fragmented. Activity was detected in multiple rooms throughout the house at night, consistent with carer reports of night-time wandering. Increased overnight activity coincided with multiple falls, prompting increased care provision. Initial feedback from interviews was the technology helped participants and those involved in their care feel supported.

Conclusions:

As pressure on services mounts, novel approaches to post-discharge care are of increasing importance. Remote healthcare monitoring can provide high temporal resolution data offering ‘real world’ insights into the effects of significant health events in Older adults. Our provisional results support our hypothesis that use of this technology is feasible and acceptable for frail, multi-morbid participants and highlights the substantial potential of this technology to help clinicians improve community-based care and more effectively monitor interventions and chronic conditions.

Introduction

Covid has had a devastating effect on the Elderly, resulting in deconditioning, increased falls and loneliness. Tailored exercises can reduce falls in people aged over 65 by 54% and participation in physical activity reduces the risk of hip fractures by 50%, currently costing the NHS £1.7 billion per year in England. This 8 week intervention delivered by trained volunteers in patient’s homes, aims to reduce deconditioning, loneliness and the risk, incidence and fear of falling (FOF) amongst frail patients post-discharge from hospital.

Method

A gap in service was identified in Frail patients discharged from hospital, at risk of falling and awaiting community physiotherapy. A steering group was set up including acute and community therapists, volunteers and carers to design a collaborative intervention to bridge the gap. At risk patients were identified and referred by ward therapists supported by the hospital volunteering team. Volunteers were trained to deliver an 8 weeks programme of progressive exercises in patients’ homes with additional signposting to appropriate statutory and voluntary services. Qualitative and quantitative outcome measures were taken at week 1 and week 8 of the intervention

Results

• 91.5% total health outcomes improved or maintained by average
• FOF reduced by 22.5%
• 180 degree turn improved by 43%
• 60 sec Sit to Stand improved by 14.75%
• Timed Up And Go improved by 15.5%
• Confidence to cope at home improved by 15% 
• Pain / discomfort (self-reported) improved by 18.75% 
• Overall health (self-reported) improved by 8.5%

Conclusion(s).

Targeted exercise at home with skilled volunteers can improve functional fitness and health outcomes in a frail elderly population at risk of falls when discharged home from hospital. The programme increases patients’ connectivity to local voluntary and community sector services. Volunteers’ mental health improves by engaging in meaningful service.

Introduction

Heart failure (HF) is a common problem managed in our West Lothian multi-disciplinary hospital at home (HaH) service, however significant variation in practice was noted with considerable resource implications. We aimed to standardise and improve this by developing a dedicated protocol.

Methods

We developed a protocol to guide the assessment and management of HF within HaH. We collected baseline (n=25) and follow-up data (n=10) after protocol introduction from patients referred to HaH with heart failure. Outcomes reviewed included anticipatory care planning (ACP) decisions, length of stay (LOS) and treatment strategy. We held staff education sessions and surveyed staff confidence regarding HF management.


Results

ACP discussion rates improved after protocol introduction, with decision rates improving for both escalation of care (28% to 80%) and resuscitation (44% to 60%). LOS reduced after protocol introduction (mean 6.3 days to 5.9 days). Titration of oral diuretics alone (71%) was associated with a shorter LOS (mean 5.4 days) compared to IV (29%, mean 8.1 days), with no difference in 28 day outcome. In those with HF with reduced ejection fraction, the rates of beta-blocker prescription increased (57% to 80%) however ACE-inhibitor prescription decreased (29% to 20%). Use of add-on therapy (e.g. thiazide diuretics) increased (12% to 30%) with a decrease in complication rates (12% to 0%). All staff found the protocol helpful with an improvement in confidence levels.


Conclusions

Through introducing a standardised protocol, we observed an improvement in anticipatory care discussion rates and a trend towards shorter LOS. Oral diuretic titration was less resource intensive without an adverse impact on outcome. Future plans include ongoing education and data collection, trialling a joint multi-disciplinary meeting with cardiology for discussion of complex patients and embedding a treatment strategy of oral diuretic titration with a ‘discharge with planned review' approach in appropriate patients.