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A mixed methods programme of research examining why older care home residents need treatment in hospital more often in some parts of England and how NHS England can best provide care for older residents in their care home.
The Challenge
The Challenge
Older people who live in care homes are at risk of harms during Emergency Department (ED) attendances and inpatient admissions. These harms can include reduced mobility, infection and delirium.
Around 40% of emergency admissions from care homes may be avoidable with better healthcare in care homes.
In some areas of England, residents are six times more likely to be treated in hospital.
'They come out worse than they went it.'
-PPIE contributor on older care home residents being transferred to hospital.
The NHS Enhanced Health in Care Homes (EHCH) Framework has recommended a broad range of enhanced services to support treatment of residents in their care homes and reduce hospital admissions. This enhanced care may mean residents are seen more often by a doctor or have their medications checked more often. It may also mean they are seen by someone with experience of looking after older people when they are acutely unwell.
Enhanced care should mean older residents do not need to be treated in hospital as often. There are differences in how enhanced services have been implemented across England. This may contribute to variation in ED attendances and admissions.
In this study, we want to know why older care home residents need treatment in hospital more often in some parts of England and how the NHS can best provide care for older residents in their care home.
Research Aims
Research Aims
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Measure variation in hospital attendances and admissions of care home residents across England.
Identify differences in implementation of the Enhanced Health in Care Homes Framework which contribute to variation.
Identify replicable safe and effective models of enhanced care which can help develop the Enhanced Health in Care Homes Framework.
Develop statistical tools to help monitor and plan services for care homes.
In achieving these aims, there are 3 work packages:
Study Timeline
Study Timeline
Contributions of Patients and the Public on the Study
Contributions of Patients and the Public on the Study
Patients, family members and care home professionals helped develop the proposal and funding application for the UVAC programme of research.
A plain English summary was provided to the Sheffield Emergency Care Forum (SECF), Health Data Research (HDR) UK North, the NICHE- Leeds Family and Friends panel and a Patient and Public Involvement and Engagement (PPIE) group from an NIHR-funded review of interventions for reducing hospital admissions from care homes. Online and in-person meetings with ten family members were held to discuss the study design. Four additional PPIE members provided written feedback. An ethnically and socio-economically diverse range of perspectives was included across the participants in these PPI groups. The study team also discussed a study outline at the Margaret Butterworth Care Home Forum and the NICHE-Leeds care support forum, which includes registered nurses, nurse associates and senior carers.
The involvement of the range of PPIE groups has altered the study design in the following ways:
When discussing the impact of emergency transfers to hospital, participants expressed how distressing they could be and the risk of loss of function and increased confusion. Particularly distressing were transfers occurring shortly before residents died, potentially preventing a more peaceful death.
One family member felt their relative was not transferred appropriately to hospital for sepsis treatment and this may have contributed to their death. Due to this discussion, place of death is included as an outcome and admissions/attendances will be interpreted alongside other study findings to assess whether low rates of attendances/admissions reflect appropriate care.
Other outcomes indicating quality/safety of care were discussed. Based on a participant’s experience of a family member deteriorating due to receiving too many sedatives, it was agreed prescription of sedative drugs would be included as an outcome and pharmacists should be interviewed.
Participants highlighted differences between transfers during the day and night due to availability of care home professionals/health care services. A plan to interview care home night staff is included.
Ethical issues and potential benefits of observing routine care within care homes were discussed. As transfers to hospital are an infrequent occurrence, observation of routine care was not thought useful to include as part of this study.
Study Advisory Group and Patient and Public Involvement and Engagement (PPIE) Study Groups
To date our Study Advisory Group and PPIE Study Groups have supported the design in a variety of ways. This has included informing our quantitative analysis variables (WP1), our recruitment strategy (WP2) and in making sure all of our public-facing documents are clear and understandable (WP2).
Stakeholder Work with care homes residents, their family and friends, and care home professionals
Recent stakeholder work undertaken by McVey and colleagues explored the understandings of care home professionals, residents and family members on 'avoidable transfers' of care home residents to hospital. In their work, McVey and colleagues found that stakeholders wished to reduce transfers, as they can be distressing for all those involved. However, they indicated that transfers should only be reduced where it is appropriate to do so, as there are many instances in which residents do require transferring to emergency care. The work also identified research priorities that align with EHCH care elements, including the need to explore improved joined up care, additional training for care home professionals (particularly around escalating to emergency care) and better access to primary care in care homes so that residents can get treatment where they live and not become avoidably unwell.
This work has informed this study in the following ways:
Appropriateness has been adopted as a more suitable concept than safe when considering the reduction of admissions to hospital from care homes.
We will recruit older care home residents with an experience of becoming so unwell they may have needed treatment in hospital in the last twelve months.
To learn more about this work and to access the full report, follow the link below:
Study Funder & Sponsor
Study Funder & Sponsor
This research is funded by the National Institute for Health and Care Research (NIHR) Academy, as a part of the Chief Investigator's Advanced Fellowship.
The University of Sheffield is the sponsor of the research.
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