Dr Adam Gordon is Clinical Associate Professor in Medicine of Older People at the University of Nottingham. He works as a community geriatrician and conducts research into models of care delivery in care homes. From 2013 to 2015, he was Honorary Secretary of the British Geriatrics Society.
Care home residents have complex care needs. Between 75 and 80% of residents have memory problems, 57% are affected by urinary incontinence, 42% have faecal incontinence and some 61% require assistance with mobility. The average number of medications per resident is 8 and the average number of medical diagnoses is 6.
Much of the health and social care provided in care homes is excellent, but it is not surprising that things break down from time to time given the complexity of the care problems seen. When things do break down, it is often the failing of multiple parts of the system at the same time. Recent scandals around hydration in care homes have seen residents cut down on their fluid intake because they were worried about accessing enough of the right continence supplies, whilst both health and social care staff failed to recognise the problem until the resident’s health had deteriorated to a critical state.
These types of problems are caused not by one professional, or one care provider, but by multiple failings at multiple points. It may be impossible to get things right all of the time, but we ought to do what we can to make things as good as they can possibly be.
We know from research into caring for older people in hospitals and in their own homes that people stay healthier for longer and face fewer medical complications when their care is “integrated”. There are lots of different ways of defining this, but specialists in medicine for older people recognise three main components:
- Assessments should be comprehensive and take account of not just medical but also psychological, social and environmental issues, as well as a person’s performance in day-to-day tasks. This might be considered a holistic approach. In a care home we believe these assessments should be conducted on admission and at least 6 monthly thereafter.
- Multiple professionals should be on hand to support both the detailed assessment of residents and also their day-to-day care delivery. The core team would include (but not be limited to) care assistants, nurses, a doctor, a physiotherapist, an occupational therapist and social worker. Different professionals would be required at different times, but all need to be available and accessible.
- A single professional needs to be in overall charge of a resident’s care. They need to recognise that they are in charge, and others need to know that they are in charge. This means that all important decisions are logged and communicated and nothing is missed. This is sometimes called case management. The professional who should most logically provide case management will vary from case to case. For many care home residents the care home manager would be a very logical person to fulfil this role but, in order for them to do this, they have to be recognised as doing so by all professionals involved, including those from the National Health Service and Social Work departments.
In the modern era of care, one might add a fourth component to this, which is the importance of patient, or resident, centred care. Residents need a voice in their own care decisions, which have to reflect their personal priorities. Decisions should be made in a shared way by residents and their care team where possible. Many care home residents can do this. Some are less able to, particularly those with the most advanced memory problems. It is also important to realise that many residents have families or significant others outside of the care home, who can help with decisions and whom it is all too easy to exclude if care teams are task focussed. The broader concept of relationship-centred care is sometimes used to ensure that these relatives and significant others are included.
These models of care seem logical. Yet there are many care home residents around the country that cannot yet access care that follows these principles. The NHS has started to recognise this. The Five Year Forward View, which is NHS England’s plan for the next half-decade, has singled out care homes as a particular area of interest. There are six care home vanguard sites that are working to implement models of care which are as integrated as possible, and which hope to prove that things can be done to a consistently high standard. This can only be achieved through partnership with the care home sector, and a number of high profile national and regional providers have stepped forward to support the process.
Meanwhile, the question is: what can individual providers do? The first answer is to recognise that care homes and NHS providers share a common challenge, which is providing care to residents whose physical and mental health is often complex and challenging. The next is to realise that it is only through collaboration and team-work that the best care will be realised. Further, to consider the practical ways in which care can be constructed to be integrated. Who will do the initial assessment? How will action plans from the assessment be case managed? Who will conduct the regular reviews?
The British Geriatrics Society has produced two pieces of guidance that can help health and care home teams to structure and plan their care. They are called Quest for Quality and the Care Homes Commissioning Guidance, and are available online at http://www.bgs.org.uk