Background
Objectives
Methods
Stage 1: Defining the scope of the review - concept mining and theory development
Stage 2: Theory refinement and testing
Health care for older people resident in care homes achieves optimal outcomes if | How expressed in service delivery models/intervention research |
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System based quality improvement approaches incentivise health care staff (GPs and care home staff) regularly to visit and review residents’ health status then care home staff will prioritise the aspects of care activities that are being monitored, review of patient care and avoid inappropriate and avoidable use of urgent and emergency services | Interventions that use financial payments, sanctions and audit to improve particular health care outcomes and adherence to protocols and guidance |
Age-appropriate care can be accessed by older people resident in long term care. Then residents will not have to wait to have symptoms treated and then they will experience fewer episodes of avoidable ill health | Interventions that focus on assessment maintenance and improvement of function, management of diseases and symptoms associated with old age through education, training of care home staff and access to visiting clinical experts and care home specialist teams |
Interventions are predicated on establishing relational approaches that promote integrated working between visiting health care and care home staff. Staff will become less risk averse, trust each other’s opinions and be willing to engage with activities that promote residents’ health and support them to stay in the care home. | Emphasis on strategies that support co-design and joint priority setting to achieve improved outcomes for residents, e.g. shared education and training, continuity of contact with particular clinical experts, shared learning, feedback on achievements between health and care home staff |
Research focus of papers reviewed with one or more outcomes of interest (medication use; use of out-of-hours services; hospital admissions including emergency department attendances; length of hospital stay; and user satisfaction) | References |
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Medication management | |
End of life care | |
Resident health promotion (e.g. nutrition, flu prevention, tissue viability, oral health, functional improvement, dementia care, falls prevention) | |
Management of depression and related interventions | |
Pay for performance/audit | |
Interventions to promote health service use, integration of health and social care services in care homes including specialist roles and reduce use of secondary care |
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Studies which considered residents in a care home with specific health needs/problems and focused on one or more of the outcomes of interest
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Studies of any intervention designed to improve the health status of care home residents that involved visiting health care professionals and offered opportunities for transferable learning to a UK setting
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Studies that provided context relevant evidence on the implementation and uptake of interventions in care homes generally (not confined to health care), that also helped build our programme theories and logic.
Stage 3: Analysis and synthesis processes
Results
System based quality improvement mechanisms to improve health care outcomes: the use of incentives, sanctions and targets
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Context: Care home staff have intermittent contact with the residents’ GP; encounters with primary care are usually unplanned and in response to an urgent need and this affects the proactive identification of residents’ health care needs, access to and quality of care and frequency of acute episodes of ill health.
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Resources/Intervention: GPs are provided with a range of incentives and sanctions to visit regularly and undertake resident assessments in key areas of care for example medication review, and provide the care home with support and advice in addition to individual patient visits.
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Mechanisms: GPs are motivated to engage with the care home staff because of the incentives and sanctions that prompt them to complete regular reviews of care home residents and work with care home staff to plan care and identify residents in need of additional support and care.
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Outcomes: Care home staff are more confident working with GPs around particular areas of care, specifically medication management and reduced use of OOH and emergency services.
“Incentive schemes can only work if the organisations and clinicians whose behaviour they are trying to change understand what is required ( our emphasis ) . Too often, the incentives are blurred or inconsistent. In part, this is a result of the complexity of the current system” p14
They (incentives) work best when all the ducks are lined up in a row: financial, organisational, and professional incentives, then the incentives are providing encouragement (our emphasis) to do the things that doctors believe they should be doing anyway (Martin Roland When incentives go wrong http://www.cchsr.iph.cam.ac.uk/2107).
Age appropriate care can be accessed by older people resident in long term care
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Context: Care homes have unpredictable access to health care services, the majority of staff are not clinically qualified, residents are frail and in the last years of life with complex health and social care needs.
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Resources/Intervention: Experts in care of older people visit care homes regularly to compensate for known deficits in knowledge and skills.
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Mechanisms: Care homes staff feel supported and trained in how to provide care to frail older people. They are motivated to learn new skills because of the facilitation and ongoing expert support they receive.
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Outcomes: Care home staff are more confident and skilled in looking after care home residents and specific areas of care. Residents' function is improved or maintained and staff have higher levels of job satisfaction and the care homes are less likely to use emergency and out of hours services,
Relational approaches to promote integrated working between visiting health care and care home staff that emphasise interpersonal skills and shared decision making
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Context: The expertise of care home staff in providing care for older people with frailty and/or dementia is seldom recognised by visiting health care professionals. Health care interventions, emphasising physical health, do not fit well with care home priorities of providing a homely setting and working practices that seek to balance positive risk taking with patient safety. Working patterns to facilitate in reach from numerous health professionals are difficult to accommodate by care home staff with limited resources who want to achieve a more personalised environment for residents.
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Resources/Intervention: Models of care that introduce opportunities for joint priority setting and processes that support ongoing discussion and review of residents’ health care needs between care home and visiting health care professionals.
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Mechanisms: Identification of key personnel in the care home to work with visiting health care professionals trigger a response where staff are motivated to develop shared priorities for care and a sense of common purpose because their views are valued, they develop approaches that fit with the care home working patterns, incorporate care home staff knowledge and priorities are jointly agreed, enacted and reviewed.
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Outcomes: Care home staff and visiting health care professionals are motivated to work together and improve care for residents in agreed areas of practice. Residents’ function is improved or maintained; staff have higher levels of job satisfaction; and the care homes are less likely to use emergency and out of hours services.
Shared priority that fitted with care home workflow
At times it was difficult to explain our remit to staff. We had little time to change attitudes of some staff to issues of mobility; making it hard to facilitate a change in practice Underwood et al. [47] (p 2013)
Fit with the care home workplace
“We think this success (reduction in hospital deaths, improvement in quality of life for residents with dementia) is related to the training addressing staff fears and problems (our emphasis) as well as increasing knowledge” Livingston, et al. 2013 (p1587)
It proved difficult to build collective understanding of and commitment to the study resulting in inconsistent implementation…Managers’ commitment to the nutrition guidelines did not extend to using scarce resources to facilitate implementation (p10)