Adam Gordon is Clinical Associate Professor in Medicine of Older People at the University of Nottingham. He is currently principal investigator for the Dunhill Medical Trust funded PEACH study which considers using quality improvement collaboratives to implement Comprehensive Geriatric Assessment in care homes. His twitter handle is @adamgordon1978. You can follow the PEACH study @PEACHstudy. He will be speaking at the upcoming BGS Autumn Meeting in London.
Care home residents in the UK receive their healthcare predominantly through the National Health Service. Their social care – primarily focussing on enablement to support activities of daily living and supporting participation in society – is provided by staff in their care home.
Or at least that’s how it looks on paper. In reality, the boundary between health and social care is less well defined. Providing care to the older people who live in care homes, many of whom have multiple conditions and are approaching the end of their life, requires frequent give and take between healthcare and care home staff.
Comprehensive geriatric assessment (CGA) – a term which encompasses comprehensive multidomain assessment by multidisciplinary teams to guide individualised care and management plans – has been shown to be a useful conceptual model to guide the organisation of care of older adults in hospital and community settings. Organising care in a similar way in care homes means co-ordinating the efforts of staff from multiple organisations so that they can work together. Working across organisational boundaries has implications for information governance, policies, protocols and statutory roles and responsibilities.
No two care homes are the same and the market forces which shape care delivery in care homes differ from region to region. If CGA is going to succeed in care homes, therefore, the services delivering it will need to be developed at a local level to take account of the variability within the sector.
The Proactive Healthcare for Older People in Care Homes (PEACH) study was funded by the Dunhill Medical Trust in 2015. We set out to develop quality improvement collaboratives (QICs) across four Clinical Commissioning Groups in South Nottinghamshire with the primary focus of implementing CGA in care homes. Each of these groups included lay representatives, care home staff, frontline healthcare staff and commissioning managers. Careful attention was given to establishing working relationships between QIC participants that were non-hierarchical, respectful and gave everybody the opportunity to participate. The PEACH team facilitated QIC meetings, bringing together all four working groups so that they could share their challenges and the progress they had made. We did this five times. Between meetings we provided support to individual QIC teams from each of the CCGs – including signposting them to experts in measurement science, in quality improvement and information technology where required.
The result was four quite different initiatives in each of the CCG areas. Two were immediately recognisable as CGA – with multidisciplinary assessment followed by care co-ordination. Two were much more focussed initiatives. One of these implemented pharmacist-led medication assessment, the other implemented dietician-led nutritional assessment. We found, though, that over time these more focussed initiatives changed and developed to include elements of multidisciplinary assessment and team working that resembled comprehensive geriatric assessment. It is possible that, by allowing these teams to start with the doable – what could be achieved within available resource – they made more progress towards an implementation of CGA than if we had been much stricter about how they were required to proceed.
Throughout the progress of the collaborative we used focus groups, interviews and direct observation to develop an understanding of how the collaboratives worked. We also visited teams to learn what really happened in care homes as they tried to change care. We are still working to understand our findings but some early insights include that:
- Care home staff were an important source of momentum. They kept the collaboratives moving forward and valued the interaction and shared working with NHS staff. They considered the early work around flattening hierarchies and empowering care home staff to have been important in giving them a voice.
- The term CGA was frequently confusing for participants in the collaboratives. They found it difficult to implement a concept that they didn’t understand. Generic terms including “co-ordinated care” and “multidisciplinary assessment” were often better understood and allowed teams to confidently get on with improvement work.
- The lack of readily accessible, high quality, data about how care home residents interact with NHS services made it difficult for teams to measure change as part of their improvement studies. They didn’t have time, in addition to their day-jobs and the improvement projects, to focus on data collection and analysis.
- General practitioners held considerable power within the collaboratives. They were able to legitimise, or delegitimise, improvement plans by virtue of their engagement.
We are still working to understand our data – but we know there is much more to learn from the efforts of our enthusiastic improvement teams.
Our project completes in September 2018. We hope you’ll be able to join us at the Autumn Meeting of the British Geriatrics Society to hear more.