How should healthcare services to care homes be configured – results from the Optimal Study

Adam Gordon is Clinical Associate Professor in Medicine of Older People at the University of Nottingham. He tweets @adamgordon1978 Claire Goodman is Professor of Health Care Research at the University of Hertfordshire.  She tweets @HDEMCOP Here they describe findings from the Optimal Study, funded by the National Institute of Health Research and delivered by a collaboration of researchers from the Universities of Hertfordshire, Nottingham, Surrey, City University London, University College London, Kings College London and Brunel University.

The UK care home sector, with 425,000 beds, is just over three times the size of the acute hospital sector.  It is home to some of the oldest and most vulnerable members of UK society.  The average resident is over 85, has multiple health conditions, cognitive impairment and physical dependency.  Providing care to such older adults is recognised to be complex and challenging.

When we started the National Institute of Health Research-funded Optimal study, a number of constituencies – including relatives and residents’ groups, health and social care policy makers, healthcare providers and the care home sector – had recognised a need to change how healthcare was delivered to care homes. Despite wide-ranging agreement that change was needed, there was, however, no consensus over how healthcare to care homes should be configured.

There has been a long-history of attempts to deliver healthcare in innovative ways to care homes and their residents – with the number and variety of approaches increasing in recent years as interest has piqued.  These range from the establishment of care home-specific practitioner roles, through providing payment incentives to general practitioners to modify how they support care homes, to establishing networks for collaborative working between NHS and care home staff.

With the Optimal Study, the second phase of which is published in this month’s Age and Ageing, we set out to learn what we could, from existing models of healthcare provision to UK care homes, about the best way to structure care to meet residents’ needs.

We started with a realist review which considered the findings of published literature on healthcare models to care homes.  We then set out to test and refine these theories in case studies across three geographically-distinct UK health and social care economies.  We followed 239 residents from 12 care homes for 12 months and quantified and costed their use of healthcare services.  We also conducted detailed interviews and focus groups from 181 participants – including care home residents, their relatives, and care home and NHS staff – to understand how the various approaches to healthcare operated, who they improved outcomes for, and under what circumstances they improved outcomes.

The Optimal Study identified approaches to healthcare that represented a continuum ranging from multiple NHS services which “wrapped around” the care home in a specified and organised way, to much less co-ordinated approaches where individual NHS services and staff-members established their own professional relationships with care home residents, sometimes without connection to care home staff.

We identified that healthcare services for care homes achieved better outcomes when NHS staff were given time and space to develop relationships with care home staff and when the part of their work which they undertook with care homes was legitimized through role specification or job description. NHS staff were better able to work in a relational way to establish good healthcare where they had specific expertise in care of older people, particularly in the management of dementia. An enabling feature was services which were commissioned so that multiple disciplines could interact with each other and directly with care home staff, such that care could “wrap around” care homes. An important finding of Optimal was that appropriately configured services could take over some aspects of daily healthcare from GPs. Where this took place, GPs were less likely to feel overwhelmed by their work with care homes or to discuss it in negative terms. Nevertheless interactions with GPs were identified as being integral to how residents interpreted the quality of their healthcare – this was, in part, because of the role that GPs were recognised to play in medication management, diagnosis and prognosis.

A video summarising these findings can be accessed here.

These areas provide very clear foci for those who set health and social care policy, and who design and provide healthcare services.  It is reassuring to note that many of the features described are now core components of the NHS England Framework for Enhanced Health in Care Homes. Perhaps, now, stakeholders in the delivery of healthcare to care homes are closer to a consensus than when we started our work.

Optimal was funded by NIHR Health Service Delivery and Organisation (HSDR 11/021/02). The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the NIHR or the Department of Health.

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