Hospital admissions from care homes

Radcliffe Lisk is consultant geriatrician and specialty lead for care of the elderly at Ashford and St Peter’s Hospital Foundation Trust. Here he tells us about how to reduce hospital admissions from nursing homes.

There are an estimated 400,000 older people resident in care homes across the UK, many of whom experience a high level of unmet need and unacceptable levels of variation in the quality of care they receive¹. Residents of care homes have complex healthcare needs, reflecting multiple long-term conditions, significant disability and advanced frailty. Care provided to this complex cohort of people is often fragmented. Day to day care services are delivered to a variable standard often with high staff turnover and limited support from the wider health system.

NHS England guidance states that ‘Healthcare for care home residents should be an actively commissioned service, with clear specifications linked to quality outcomes and contractual obligations’². The British Geriatrics Society¹ also recommends a multi-disciplinary approach to such commissioned services, including consistent access to specialist community nursing and a range of allied health professionals.

Quality Watch³ (a major research programme providing independent scrutiny) published “Focus On: Hospital Admissions From Care Homes” in January 2015. This report, which routinely collected information on hospitalisations from care homes, could be used to enhance the understanding of hospital use by care home residents and thus target areas for shared learning and improvements.

The report³ used Hospital Episode Statistics (HES) covering the period April 2011 to March 2012, looking at hospital admission rates from 17,459 care homes compared with the over 75s in the general population.

Key findings noted from the analysis were:

• Care home patients were much older (86.3 compared to 82.1) and were 40-50% more likely to have emergency admissions. There were also significantly fewer elective admissions and outpatient appointments compared to the general population aged 75 and over.
• Care home patients admitted to hospital tend to be towards the end of their lives. Around 40% of care home residents admitted as an emergency died within 6 months of admission, this was double that of the over 75s.  Interestingly, care home helps prevent emergency admissions in the last 2 months of life.
• The health problems recorded on admission to hospital were different for patients who were living in a care home. Pneumonia, dementia and epilepsy being 3 times more common compared to the general population aged 75 or over. Other more common reasons for admission from care home residents include sepsis, head injuries and hip fracture.
• In areas containing care homes where hospital admissions were high, there was a greater proportion of instances where patients had 3 or more admissions in a year (as opposed to the higher rates being because more patients had single admissions). There was also significant variation in admission rates between areas containing care homes, with an average of 0.45 admissions per bed for care homes offering nursing services and 0.59 admissions per bed for residential homes.

Ashford & St. Peter’s NHS Trust started a care home project ⁴ in April 2010 with 3 nursing homes that had the highest number of multiple admissions (≥4). This was expanded to 12 nursing homes from April 2011 – Oct 2012 using 4 interventions which led to a 35% reduction in hospital admissions. The interventions included geriatrician review and telephone advice, end of life care and intravenous therapy. This incorporates some of the findings noted in the Quality Watch report.

The report mentioned a great proportion of instances where patients had multiple admissions (a patient was admitted 31 times in a year). A Sussex model⁶ identified high risk groups and with community matrons using telehealth, they reduced admissions by 75%.

Another successful model is the Airdale⁷ project whereby the hospital used experienced nurses to provide a 24hr teleconsultation for residents in care homes, using shared electronic health records. This led to a 45% reduction in hospital admissions.

It is widely accepted that good quality preventive care in the general population can reduce the frequency of health crises that require hospital admission⁸. There is no reason why that idea does not apply to people in care homes. Innovative care home models should look at community based chronic disease management, especially for the small number of individuals having multiple admissions (using telehealth where applicable). End of life care, provision of comprehensive geriatric assessment on admission with personalised care plans, regular medication review, falls risk assessment and regular access to geriatricians should also be considered.

References

1. British Geriatrics Society (2011) Quest for Quality
2. NHS England (2014)  Safe, compassionate care for frail older people using an integrated care pathway.
3. Quality Watch (2015) Focus on: Hospital admissions from care homes.
4. R Lisk, K Yeong, A Nasim, B Mandal, R Nari, Z Dhakam: (2012) Geriatrician input into nursing homes reduces emergency hospital admissions; Archives of Gerontology and Geriatrics Nov 2011 Arch Gerontol Geriatr 55(2):331-7
5. R. Lisk, R. Nari, K. Yeong, (2014) Geriatrician input into 12 care homes reduced emergency hospital admissions which was maintained with education & training of GPs and care home staff. Age Ageing 43 (suppl 1):
6. Admission Avoidance – Sussex Community NHS Trust (2014)  
7. Teleconsultation – Airedale NHS Foundation Trust (2011) 
8. D. Oliver, C. Foot, R. Humpheries; Making our health and care systems fit for an aging population