A systematic review of integrated working between care homes and health care services

Close collaboration between different health care professionals and care home staff e.g for the benefit of individual patients.

Organisational or clinical structures and processes designed to enable teams and/or organisations to work collaboratively towards common goals (e.g. integrated health and social care teams).

Integration of structures and processes that link organisations and support shared strategic planning and development for example, when health care services jointly fund initiatives in care homes [24, 25].

To understand the evidence for the benefits of different approaches to health care services supporting older people in care homes, we conducted a systematic review to identify studies using integrated working between primary health care professionals and care homes for older people; evaluated their impact on the health and well being of older people in care homes, and identified barriers and facilitators to integrated working.

We included interventions designed to develop, promote or facilitate integrated working between care home or nursing home staff and health care practitioners. Interventions that involved staff going in to provide education or training to care home/nursing home staff were included as long as there was some description of joint working or collaboration. We excluded studies where staff were employed specifically for the purpose of the research without consideration of how the findings might be integrated into ongoing practice (i.e. project staff introduced for a limited time to deliver a specific intervention). For a study to be included there had to be evidence of at least one of the following:

Clear evidence of joint working

Joint goals or care planning

Joint arrangements covering operational and strategic issues

Shared or single management arrangements

Joint commissioning at macro and micro levels

Studies also had to report at least one of the following outcomes:

Health and well being of older people (e.g. changes in health status, quality of life)

Service use (e.g. number of GP visits, hospital admissions)

Cost such as savings due to avoided hospitalisations

Process related outcomes (such as changes in quality of care, increased staff knowledge, uptake of training and education and professional satisfaction)

As the literature in this area is limited we included all studies that involved an element of evaluation. This included controlled and uncontrolled studies. However, because they are more susceptible to bias, studies without a control were used to describe and catalogue interventions rather than evaluate effectiveness. Process evaluations and qualitative studies including those using action research methodologies were included in order to identify facilitators and barriers to integrated working.

The electronic search strategy was conducted in February 2009. We searched the following electronic databases: Medline (PubMed), CINAHL, BNI, EMBASE, PsycInfo, DH Data, Kings Fund, Web of Science (WoS incl. SCI, SSCI, HCI) and the Cochrane Library incl. DARE. In addition, we contacted care home related interest groups and used lateral search techniques, such as checking reference lists of relevant papers, and using the 'Cited by' option on WoS, Google Scholar and Scopus, and the 'Related articles' option on PubMed and WoS. We applied no restrictions by date or country but included English language papers only. Details of the search terms used can be seen in Table 1.

Electronic search results were downloaded into EndNote bibliographic software. Two reviewers independently (SD, FB) screened all titles and abstracts of citations identified by the electronic search, applied the selection criteria to potentially relevant papers, and extracted data from included studies using a standardised form. Any disagreements concerning studies to be included were resolved by consensus or by discussion with a third reviewer (CG).

Due to substantial heterogeneity in study design, interventions, participants and outcomes we did not pool studies in a meta-analysis. Instead a narrative summary of findings is presented and where possible we have reported dichotomous outcomes as relative risks (RR) and continuous data as mean differences (MD) (with 95% confidence intervals). Data in the evidence tables is presented with an indication of whether the intervention had a positive effect (+), a negative effect (-), or no statistically significant effect (0). The qualitative studies were used to generate a list of potential barriers and facilitators to integrated working. Each paper was systematically read by two researchers (SD, CV) to highlight any factors that may have impacted on the process, both those that were explicitly referred to by the authors and those identified by the reviewers within the papers' narratives.

The quality of the included studies was assessed using design assessment checklists informed by the Cochrane Collaboration risk of bias tool [26] and Spencer et al's quality assessment checklist for qualitative studies [27]. The core quality-assessment domains are summarised in Table 2. As other non controlled studies were used to inform contextual understanding rather than evaluate effectiveness they were not formally quality assessed.

Data were extracted from each study on methodology, type of intervention, outcomes, participants, and location. In addition, an interpretive approach based on Kodner and Spreeuwenberg's (2002) work on integrated working, was used to compare and contrast the nature and level of integration across the studies using the principles of framework analysis [28]. Each study was categorised in terms of the degree of integration and the complexity classified as micro, meso and or macro. In addition, based on the assumption that care homes with a higher level of integration would show evidence of correspondingly greater levels of support and contact with health care professionals, each study was analysed to identify the amount of contact, support and training given by the health professionals involved in the study.

Ten studies were quantitative, (four of which were RCTs), one used mixed methods, two were process evaluations, three were qualitative and one was action research (see Table 3).

Nine were conducted in the UK, five in Australia, two in the USA and one in Sweden. Eleven (65%) studies were conducted in nursing homes, five in residential homes and one in a combination of both. Study participants included residents, relatives, care home staff both residential and nursing, and health professionals including general practitioners, district nurses, nurse specialists, pharmacists, psychiatrists and psychologists.

Seven studies were focused on individual care, for example, specific health care needs such as end of life [29‐33] or wound care [34] and dementia [35]. Six studies focused on residents' needs as a group, such as detection and treatment of depression [36], bowel related problems (Goodman, C. et al: Can clinical benchmarking improve bowel care in care homes for older people? Final report submitted to the DoH Nursing Quality Research Initiative PRP, Centre for Research in Primary and Community Care, University of Hertfordshire, 2007.) and or supporting the care home staff interactions with residents through training [37] and improved prescribing [38‐40]. A further four papers were service evaluations such as an in-reach team for care homes [41], a care home support team [42], and nurse practitioners [43, 44]. End of life care accounted for five papers [29‐33], three of which focused on care pathways [30‐32].

There were seven controlled studies of which four were RCTs. Although the RCTs could be expected to be less susceptible to bias than the non randomised studies the potential for bias in both groups of studies appeared to be high (see Tables 4 and 5).

A number of the studies appeared underpowered and for many follow up was short. The qualitative studies employed a range of methodologies including action research, interviews, focus groups and questionnaires. As with the quantitative studies, the quality was low, only two out of four [30, 33] had a clearly defined purpose and design. With one exception [33] descriptions of the study sample, data collection and analysis were inadequate and evidence of their credibility and transferability was limited (see Table 6).

The heterogeneity of outcomes and, in particular, the interventions meant that making comparisons between studies was problematic. Three studies looked at the effect on prescribing [38‐40], three included mortality as an outcome [39, 40, 44] and two looked at disruptive behaviour [35, 39]. The remaining outcomes, only included in single studies, were depression [36], hospital admissions [40], functional status [40], wound healing [34], and bowel related problems (Goodman, C et al: Can clinical benchmarking improve bowel care in care homes for older people? Final report submitted to the DoH Nursing Quality Research Initiative PRP, Centre for Research in Primary and Community Care, University of Hertfordshire, 2007). Full details of the results can be seen in Table 7. Although there were some improvements in outcomes, the majority of studies showed that the intervention had either mixed effects (that is improvement in one outcome but no effect or negative effect in another outcome), or no effect when compared with the control group. Insufficient information was available to evaluate the cost of integrated working between care homes and primary health care professionals.

There was a great deal of variation in how health care services and care homes worked together and the frequency of contact. For example, whilst some studies involved weekly multidisciplinary team meetings [43], monthly meetings were more common (Goodman, C et al: Can clinical benchmarking improve bowel care in care homes for older people? Final report submitted to the DoH Nursing Quality Research Initiative PRP, Centre for Research in Primary and Community Care, University of Hertfordshire, 2007)[30]. All the studies potentially increased care home staff access to health care professional's support and advice, with 15 out of 17 involving care home staff in multidisciplinary interventions or joint working. Care home staff were involved in multidisciplinary meetings and in some studies their opinions were sought [40], but they were led by health care professionals, with health care orientated and defined goals. Staff training was an integral part of all studies bar three; only a few studies consulted with care home staff on their perceived training needs [29, 33]. The range of training input varied from as little as three hours [31] to seven seminars [37] or continuous training and support [43, 44].

The level of integration for all studies and the degree of support and training provided by NHS staff for care home is reported in Table 8. The majority of studies showed micro integration at the clinical level involving close collaboration between care home staff and health care professionals to achieve specific outcomes (12 out of the 17) e.g. wound care techniques and wound healing. The remaining five studies were integrated at the clinical level but also showed greater complexity of integration in terms of funding and organisation or strategy, one at the meso level [42] and four at the macro level [31, 41, 43, 44]. In service delivery, four studies used dedicated multidisciplinary teams to support staff and residents in care homes [42], three of which achieved their remit of avoiding unnecessary hospitalisation [41, 43, 44]. Two UK studies also had health service funded beds within care homes, one for use by a specialist health care nursing team [41] the other to provide end of life care [31]. A distinguishing feature of four out of the five studies classified at higher levels of integration was that care home staff received support and or training which was ongoing, as opposed to being offered at discrete time periods during the intervention. For example, nursing home staff were facilitated to recognise and manage acute conditions [43], to improve residents' overall care [44].

A number of cross cutting themes that influenced the achievement of integrated working were identified (See Tables 9 and 10). These included, care home access to services and the different working cultures of care home staff and health care professionals that acted as barriers and facilitators. Care home staff identified a lack of support from health care professionals and a failure to recognise their knowledge and skills [29, 33, 42]. There were negative perceptions on both sides with care home staff feeling that health care professionals were sometimes acting in a 'policing' rather than an advisory capacity [29, 42] and health care professionals perceiving care home staff as lacking in knowledge and expertise, and unwilling to change their practice [30].

Whilst input and training from health care staff was valued, for care home staff to access it, dedicated time and finance from care home managers was necessary. Holding sessions within the care home and setting up a learning contract with the staff could facilitate training [32]. Examples of positive interactions included one care home support team described as acting as a link to 'the outside world' by the care home, and supporting clinical decision making across the multi disciplinary team [42]. Difficulty in maintaining levels of staff skills and knowledge were exacerbated by the high staff turnover experienced by care homes [29, 32, 33]. However, one study found a higher rate of staff turnover amongst the health care professionals involved in the intervention than the senior staff in the care homes (Goodman, C et al: Can clinical benchmarking improve bowel care in care homes for older people? Final report submitted to the DoH Nursing Quality Research Initiative PRP, Centre for Research in Primary and Community Care, University of Hertfordshire, 2007). Consistency of care home managers was identified as an important factor in building collaborative working with health care professionals [32].

Given the limited number of studies in the review, their heterogeneity, poor quality, small size, and low level of detail, the scope for discussion of integrated working between care homes and primary health care professionals is limited and firm conclusions cannot be reached. Only five studies were conducted in residential care homes which reinforced previous findings that the majority of research is carried out in nursing homes, even though this is not where most older people in long term care live [14]. The absence of older people's views and resident centred outcomes from the studies was notable.

Moreover the majority of studies were only integrated at the micro level that is, close collaboration between care home staff and professionals, so little information was available on the impact of integration at meso and macro levels. There was wide variation amongst the studies in terms of their level of care home staff support and training, and the involvement of older people. Care home staff training and support ranged between those studies where it was ongoing and those where it was provided only on one occasion. Where there was support and training of care home staff it was not clear if the ultimate aim was to train staff to a level of expertise so that health services could withdraw.

There is a need for more research that addresses how integrated working can best be achieved and that evaluates the effect of integrated working on the health and wellbeing of older people, service use and cost. Research with care homes should reflect the context and constraints of working across public and independent services, and involve care homes in the planning and design of interventions. Moreover as this population is known to have multiple co-morbidities that are often compounded by cognitive impairment there is a need for more studies to look at improving the quality of care for the care home population as a whole. Future evaluations should be large enough to detect a difference and outcomes need to be meaningful to care home staff and residents.

We used systematic and rigorous methods to synthesise the current evidence on integrated working between care homes and health care services and highlight areas for further research. There are, however, a number of methodological issues that could have a bearing on the validity of the results. Owing to a lack of evidence in this area we included all studies types including uncontrolled studies. Only four of our included studies were randomised controlled trials. Whilst uncontrolled studies might be more likely to be biased these broad inclusion criteria enabled us to investigate integrated working more widely and identify barriers and facilitators.

Although the studies reviewed were judged to have involved integrated working, it was not their main focus; only two studies referred to partnership working between care homes and health care services (Goodman, C et al: Can clinical benchmarking improve bowel care in care homes for older people? Final report submitted to the DoH Nursing Quality Research Initiative PRP, Centre for Research in Primary and Community Care, University of Hertfordshire, 2007.)[44]. The information on integrated working was based on how the intervention was described, who was involved and at what level. It is possible that how this was reported in the studies reviewed did not capture the extent of the integration achieved.