Multidisciplinary residential home intervention to improve outcomes for frail residents

Approximately 420,000 older people live in care homes in England [1]. “Care homes” is a generic term; within the UK there are “care homes with nursing” and “residential homes” (RHs) providing accommodation and support with activities of daily living, but without on-site nurses. Resident needs in both nursing and RHs are complex, with a combination of physical frailty and mental health conditions [2].

Care home residents have 40–50% more emergency admissions and fewer outpatient appointments than the general population of the same age [3]. Many avoidable admissions are driven by unsatisfactory provision of healthcare services [4, 5] with medication errors occurring in approximately 70% of residents [6]. The majority of care home residents are in their last years of life [3] but may not receive adequate end-of-life care or advance care planning (ACP) [7]. This is especially challenging for the 80% of the care home population with dementia [8].

Enhanced Health in Care Homes (EHCH) is a cornerstone of the NHS Long Term Plan [9]. Integrated care between primary, secondary and community providers, is effective and can lower rates of emergency bed use [3, 10]. Multi-disciplinary teams (MDTs) linking community and hospital-based services increase functioning, reduce hospital costs and lengths of stay [11]. Key Recommendations from The British Geriatrics Society (BGS) Quest for Quality report include ensuring fair access to NHS services, providing a comprehensive geriatric assessment (CGA), promoting autonomy and care plans towards the end-of-life [5]. Despite many “top down” policy drivers, implementing change in practice is challenging and a more “bottom-up” context-specific approach such as local quality improvement may deliver more pragmatic and sustainable change [11]. The strength of a quality improvement approach includes linking useful interventions with improvement results and why they worked, which may be able to inform improvement elsewhere [12].. The process of healthcare improvement is about bridging gaps within the six domains of healthcare quality as set out by the Institute of Medicine: safety, effectiveness, patient-centred, timely, efficiency and equity [13].

RHs have higher ambulance call and emergency admission rates [3, 14] and fewer General Practitioner (GP) visits [15] compared to care homes with nursing thus our focus on RHs for this project.

We aimed to address a range of important clinical issues to improve multi-disciplinary care in RHs focusing on key elements derived from current policy; CGA, medication optimisation, end-of-life care planning and education to reduce hospital admissions [16].

We conducted a multi-disciplinary RH quality improvement project in two cycles. The first cycle was a pilot, subsequently rolled out to another location. Cycle one was conducted between 20/09/2017–14/02/2018 and cycle two between 21/03/2018–12/08/2018.

The RHs ranged between 21 and 73 beds (Table 1). Tables 1 and 2 show resident demographics and outcomes.

Our objective was to improve multidisciplinary care in RHs, specifically focussing on CGA, medication burden, end-of-life care planning and team education. Our detailed MDT assessment of 34 residents from three RHs reduced prescribed medications and acute hospital admissions and thus NHS costs. We increased the completion of DNACPR forms and our educational sessions received positive feedback.

CGA improves outcomes for older people in the community, hospital setting and long-term facilities [22‐24] but is not routinely conducted in RHs [25].

We implemented our model specifically in RHs to deliver CGA with input from GP, geriatricians, psychiatrist, pharmacist, RH staff/ managers and family members when available. We did not have direct access to therapists, social workers and voluntary staff but the GP liaised with these services when needed. Psychiatric input was essential; over 75% of residents had dementia and a high proportion experienced BPSD. Other initiatives have also found psychiatric support vital. In Camden and Islington the MDT has actively focused on mental wellbeing with psychology resources and activity coordinators, increasing knowledge, skills and staff support resulting in fewer hospital admissions and shorter lengths of stay [26]. Our project reflects similar ongoing work in the UK such as the Proactive Healthcare of Older People in Care Homes (PEACH) protocol which uses a quality improvement collaborative (QIC) intervention to improve the delivery of CGA in care homes. The PEACH intervention team comprises a GP, social care staff, nursing staff, therapists, geriatricians, voluntary staff, pharmacists, dementia specialists, care home workers/mangers and members of the public [27]. Relational working between the care home and external services is key to successful healthcare delivery in this setting [28].

Our MDT approach resulted in fewer emergency admissions and reduced medication burden. Staff reported feeling more supported and were more proactive in bringing issues to our attention. The educational sessions were open to all staff. Our intervention may have had wider impact across the RH as there was a reduction in hospital admission costs across the whole home.

There is little literature on addressing polypharmacy in RHs where residents are particularly vulnerable to inappropriate prescribing [29]. One systematic review showed that MDT meetings, educational interventions, particularly face-to-face education improved prescribing quality [30]. Our intervention facilitated MDT discussions and educational sessions around polypharmacy. Specialist pharmaceutical input also helped to reduce medications prescribed, potentially reducing costs.

Care homes (including RHs) will become the commonest place of death over the next 20 years [31]. Education, particularly peer-training and inter-professional collaboration are potentially effective mechanisms for improving end-of-life care, although education for care home staff with a high turn-over would need to be ongoing to have a sustainable impact [32]. We dedicated 3 of 16 education sessions to end-of-life care. We had multiple discussions as an MDT around end-of-life for residents enabling the development of patient-centred care plans and improved group knowledge and experience [33]. As a result of the project one GP practice to set up an ‘ACP clinic’. Within both cycles, most residents had a DNACPR form completed. In cycle 2, we used an online electronic system (Coordinate My Care) to share care plans with GPs, secondary care and the Ambulance Service.

There are limitations to the model developed. Ideally MDT participants should not change however this is inevitable when using specialist trainees who regularly rotate. The presence of the same GP lead, pharmacist and RH staff facilitated continuity. It is important when delivering CGA as part of an MDT that there is strategic collaboration between organisations providing team members, to ensure effective MDT functioning [22]. For sustainability, trainees require protected time away from regular duties. With multiple RHs, more trainees would be required, drawing resources away from secondary care. Standardised proformas to facilitate CGA would have reduced variability and improved outcome monitoring. In addition, the MDT did not include therapists or social workers who could add considerable value. Systematic processes for screening residents in need of review such as medication burden or hospital admissions, may be more effective. Reducing acute admissions shifts the burden of care onto the RH, i.e. people who die there may have previously gone to hospital, nursing home or hospice creating increased emotional burden on staff.

We only saw a proportion of residents and would need more sessions to review all. Few family members could attend, which could have led to under-representation of patients’ values and preferences. With more organisation, families could be invited earlier saving GPs time in following up with them. Data gathered regarding patient reviews and staff feedback differed between cycles as the project developed, making it harder to compare outcomes. We took a pragmatic approach to data collection but there are some limitations to this for example we only counted medications but did not look at groups and types of medications. This quality improvement project was set across three care homes so may not be generalisable to other settings.

Whilst this project was running there were widespread changes in policy, for example the primary care networks (PCN) UK national rollout in 2020 which ensured that every care home is now supported by an MDT by their PCN. Our project aligns with this change in policy as we have shown the benefits of the MDT working within the care home. As well as policy changes there are other emerging studies in this field such as the GRAPE study which will be looking at how GPs are involved in initiatives to improve services and care within the care home setting [34].

The EHCH framework highlights variable access for care home residents to NHS services [16] but does not specifically mention mental health. Our project supports the Royal College of Psychiatrists report on delivering the Long-Term Plan advocating mental health input as central to care home services [35]. The BGS policy calls for access to CGA, personalised care plans and follow-up for all older people with frailty, dementia, complex and long-term conditions. Our intervention provides a mechanism to deliver on these policies, creating an opportunity for shared learning and enabling residents to receive more specialist care.

This was an effective multi-disciplinary project which facilitated CGA within the RH setting whilst focussing on reducing polypharmacy and improving end-of-life care. This had a perceived impact on both physical and mental health of residents. The MDT were able to benefit from the shared learning opportunities and improved inter-professional relationships. This project demonstrates a sustainable model which could be applied to other RHs.