Jenni Burton is a Clinical Research Fellow in Geriatric Medicine funded by the Alzheimer Scotland Dementia Research Centre and the Centre for Cognitive Ageing and Cognitive Epidemiology at the University of Edinburgh. Here she discusses the results of two linked systematic reviews of predictors of care home admission from hospital. She tweets @JenniKBurton.
Care home admission from hospital has long been recognised as an area of significant variation in practice (Oliver D et al. 2014. Making our health and care systems fit for an ageing population) and one which remains a strategic target to reduce across the UK. However, more than half of care home admissions each year in Scotland come directly from hospital settings. It is therefore important to explore the predictors of this life-changing transition to help inform prognostication, communication with individuals and their families, service planning and the extent to which we can intervene to prevent or modify this outcome.
We therefore performed two linked systematic reviews and meta-analyses to determine which factors predicted new care home admission following hospital admission. The reviews included data from a total of 387, 124 individuals from 41 studies set in Europe, North America and East Asia.
We found that age, female sex, dementia and functional dependency all increased the likelihood of going into a care home from specialist geriatric and general hospital settings (Harrison et al. 2017 Age and Ageing ). After a stroke, age and stroke severity were the consistent predictors of the need for care (Burton et al. 2017 JAGS).
Although these factors are consistent with our experiences in clinical practice, they are neither specific enough to identify individuals in our care who are likely to require admission to care home at discharge nor do they capture the complexity of these decisions. Factors which feel significant in day-to-day work, such as patient and family preferences, finances, availability of social care or informal support were rarely measured in the included studies. Continence, loneliness and behavioural and psychological symptoms were overlooked by the majority of studies and modifiable risk factors were rarely considered.
None of the papers specifically considered the in-hospital model of care and detail was lacking around the level of care was provided within the care home settings. Rates of care home admission varied from 3-77% in the specialist geriatric and general hospital settings and 7-39% after stroke.
Encouragingly for practitioners and patients alike the most recent update of the Cochrane Review of Comprehensive Geriatric Assessment (Ellis et al. 2017) found high quality evidence that CGA reduces the likelihood of nursing home admission. We would advocate that future research studies should clearly describe the model of care provided and use a core set of validated measures to assess and report data on cognition and functional performance to facilitate comparisons and pooling.
Rates of care home admission from hospital are increasingly being used as performance measures to compare hospitals and trusts. However, these data represent many individual complex decisions and it is important they are further interrogated to help establish best practice. Alongside these efforts, more bespoke research is needed to explore the perspectives and experiences of those who are involved in these decisions. This will help us to understand how best to support individuals and their families and ensure we provide appropriate care to those who may require admission to a care home.