Work Package 2

Qualitative case study work examining differences in the implementation of enhanced care in care homes in six areas of England.

Work Package Aims & Objectives

Aims of this work package:

Identify any differences in implementation of the Enhanced Health in Care Homes Framework which may contribute to variation in hospitalisations of older care home residents.
Identify potentially replicable, appropriate and effective models of enhanced care which can help develop the Enhanced Health in Care Homes Framework to improve enhanced services for care home residents.

This will be achieve through the five following objectives:

To undertake comparative, in-depth qualitative case study research with ICSs, Community Trusts, GP practices, care homes and available enhanced services of six purposively sampled postcode districts containing one or more care home embedded within three different integrated care systems.

To characterise how EHCH Framework care elements are implemented and used to deepen the existing classification of care elements.

To identify the differences in elements of enhanced care which may cause variation in ED attendances and hospital admissions between postcode districts containing one or more care homes and ICSs through interviews with commissioners, GPs and care home staff.

To characterise the appropriateness and effectiveness of enhanced care services through interviews with care home professionals.

To characterise the appropriateness and effectiveness of enhanced services through interviews with older care home residents and their family and friends about the care they received when they were very unwell and may have needed treatment in hospital.

Planned Investigation

This qualitative research will use a comparative, in-depth case study design to explore what differences exist in the implementation of EHCH Framework care elements and how these differences may contribute to variation in rates of ED attendance and inpatient admissions for older care home residents.

The cases in this study will be postcode districts in England containing one or more care homes. There will be two cases embedded within three different regional ICSs, for a total of six cases.

We will select the cases based on the quantitative analysis from WP1. The figure to the left shows an example of how the cases will be embedded within three ICSs.

Data collection

We will conduct semi-structured interviews with a variety of participants in each case, including professionals who are responsible for overseeing the performance and/or commissioning of enhanced services in care homes in an ICS context, community trust professionals with responsibilities for care homes, GP practices, health and social care professionals who deliver enhanced care in care homes, care home professionals and older care home residents with an experience of being so unwell that they may have needed treatment in hospital in the last twelve months and their family and friends.

There will be four sequential stages to our data collection. This will help us build our understanding of enhanced care in each area as the study progresses.

Stage 1

The first stage of data collection in our case studies will focus on understanding what enhanced care services are commissioned in each regional ICS. We will also ask participants about the strengths and weaknesses of these services.

Stage 2

In the second stage of data collection we will interview the health and social care practitioners who deliver the enhanced care in care homes. It is likely that the practitioners interviewed in this stage will include multi-disciplinary team members who deliver specialist assessments, medication reviews and ‘home rounds’. The interviews will focus on further characterising the enhanced care services, as well as enhanced service practitioners’ perspectives on the strengths and weaknesses of the delivery of different care elements, and barriers and facilitators of their use.

Stage 3

In the third stage of data collection we will explore the experiences and perspectives of professionals working in care homes. This broadly includes managers, shift leaders, nursing staff and carers. The PPIE feedback in the design of this study indicated a need to work with both day and night shift staff as the available services and escalation of urgent and emergency care in care homes often differ between these contexts. Care home professionals will be interviewed to explore their experiences of decision-making around escalating care home residents to emergency care. We will also explore care home professionals’ perspectives on the appropriateness of the care provided enhanced care elements, specifically in terms patients receiving treatment in hospital when needed.

Stage 4

In the final stage of data collection in each case we will interview older care home residents who have had an experience of becoming so unwell that they may have needed treatment in hospital in the previous twelve months, and their family and friends who support them. These interviews will focus on participants’ experiences of becoming so unwell that they may have needed treatment in hospital and any enhanced care elements experienced as a part of their treatment.

Care home residents in our PPIE study group advised us that they would be happy to share their experiences with researchers. One resident told us of a recent difficult experience she when she needed emergency treatment and went to hospital and shared that she would have appreciated the chance to tell someone about it and, ‘hopefully make things better for others’.

Data Analysis

We are taking a framework approach to the analysis of the interview data in this work package. We will be working collaboratively with PPIE members to code parts of the interview transcripts and in interpreting the themes.

Anticipated Outputs & Impact

The findings will be disseminated to, and refined by, key stakeholders including ICS care home leads, care home managers, clinical practitioners and PPIE members through a series of workshops. The workshops will help inform WP3 and develop recommendations for implementing the Enhanced Health in Care Homes Framework.

We also plan to present the findings at academic and health services conferences, and publish them as a peer reviewed paper.

Approvals

This study has Social Care Research Ethics and Health Research Authority Approval: 25/IEC08/0014

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