Enhancing health care in care homes: integration in practice

Many care homes provide laudably caring environments for residents living with frailty, dementia and complex needs, often in the face of funding constraints and recruitment problems. Indeed, ‘enhanced care in care homes’, is one of the new care models set out in the NHS five year forward view, and six vanguard sites are currently taking work forward to offer older people better, more joined-up care and rehabilitation services. This is good news, as it is high time this issue was brought to the fore – for a number of reasons.

First, we are talking about large numbers: an estimated 380,000 people live in approximately 17,000 nursing or residential homes in England – 95 per cent of them over 65. There are around three times as many adults in care homes as in general hospital beds. For the foreseeable future people will continue to live in care homes, and they have the same rights to care as the rest of us.

Second, care home residents have complex needs, as the British Geriatrics Society set out in its paper, ‘Quest for quality’. For instance, approximately two-thirds of care home residents are immobile or need assistance with mobility, four-fifths have dementia or other mental impairment, and two-thirds live with urinary or faecal incontinence or both. The median number of prescribed medications is nine per resident. Stroke, movement disorders and other progressive neurological conditions are common, as is progressive cardiorespiratory disease. Most residents suffer recurrent falls.

Third, these health care needs are not consistently well-met. A joint report by the British Geriatrics Society and the Care Quality Commission, ‘Failing the frail’, revealed a patchy and chaotic approach to commissioning and providing health care services for care home residents. These missing services and care gaps included medication review, care planning, access to normal primary care services, rehabilitation after acute illness, and allied health professional input on speech therapy and specialist mental health support. Furthermore, too many residents are admitted to hospital, particularly near the end of their life, for want of advance care planning or access to palliative care. Recent studies have shown that proactive medical review and more responsive support for care home residents can reduce emergency hospital admissions in general and that repeated hospital admissions make little difference to residents’ outcomes.

Fourth, care home staff have major responsibilities for delivering personalised care and support for residents. Yet the Care Quality Commission State of care report in 2012/13 highlighted issues in many homes around risk, safety and safeguarding, medicines management and basic care, with staff recruitment and retention identified as key determinants.

Finally, if we are looking at the need for more integrated working to support older people across several sectors, care homes could play a critical role. There are thousands of facilities - from small private concerns, to those run by social enterprises, charities and large chains - all sitting at complex interfaces with primary, acute and community care, palliative care, mental health care, statutory home care services and housing. It’s a complex web.

On 2 July, The King’s Fund hopes to celebrate some solutions to these problems in its one-day conference on enhancing health care in care homes. It’s part of our wider programme of work on improving services for older people, including our report on making health and care systems fit for an ageing population, and a series of conferences and smaller workshops.

Highlights include an update from some of the Forward View vanguard sites, a focus on the use of telehealth for care home residents, and panel discussions on the role of inspection and regulation and where care homes might fit into new models of integrated care.

Beyond creating some needed heat and light in this key area, we hope the conference generates some real momentum and cross-agency collaboration, so that NHS England continues to prioritise it and the incoming government doesn’t forget it.

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#543808 George Coxon
Various inc care home owner & Devon kitemark Chair

Always pleased to read your blogs David and so glad to see what I perseve as ever supportive care home comments in a climate of much negative adverse media headlines of care home bashing. I'm fresh from an exceptional evening residents&guests meeting full of humour & positivity. We are in coproduction flow with out local GP Federation as well as another project with our NHS FT ( RDE) Our meeting tonight had 2 senior research academics join us prior to our first care home SIG tomorrow who've already tweeted about what a great time they had at our meeting where we talked about dementia awareness week, dying matters week, reflecting best practice regarding LGBT issues in care homes and culminated in an emotional singalong of Danny Botled by Harold one of our residents. We are a front foot care home modest but proud of the life we live and the energy and imagination we generate. We are part of the solution to a health& social care system in crisis But we need more & better engagement in the Vanguard programme. I'm working with NHS England seniors on this & connecting with the vanguard leads on how we benefit from innovation Our mtg tonight was very united in the KPOOH factor keeping people out of hospital this is where we must devote more attention both for cost and more critically care reasons.
Thanks again David. Sorry not to be joining the 2nd July event. Hope it inspires more determination for impact & engagement for us small providers

#543832 Jayne Muir
Home Manager
Caring Home Healthcare Group

As being very new to this - I was invited to talk with Julienne Meyer at the Kings Fund Event today - I am passionate about care of the elderly but am facing the ever increasing battle of the dreaded CQC!

#543883 Penny Davison
Commissioning Manager
NHS Sunderland CCG

I have had the great pleasure of working with people from the NHS, Social Care and Care Homes in Sunderland to deliver Enhanced Care in Care Homes. The programme is making a fantastic difference to the residents, families and staff! Just need to get on and deliver it to all the care homes in Sunderland, learning lessons from ourselves and elsewhere as we go!

I too was at the event with Jayne and was impressed by the passion and desire to work together to make a real difference!

Although Sunderland is not a Vanguard programme for care homes we are Vanguard programme for MSCP which does include enhanced care homes as part of our bid!

#543884 David Oliver
Visiting Fellow
King's Fund

Thanks Jayne for contributing to our workshop and thanks Penny for highlighting what is clearly an excellent example of cross sector working in Sunderland. I had a great email from the team in Walsall yesterday wanting to celebrate similar successes. I know of several groups around the four nations doing similar good work in or with long-term care. Not all can be formal "vanguards" but that doesn't diminish their importance. It would be good to pull together these examples in due course and give them some more publicity. For starters, if you wanted to write about the work in Sunderland for BGS blog I would be happy to ensure its published


#543886 Solveig Sansom
Head of Integration
South Devon & Torbay CCG

Thanks David, great blog and some really useful links as always. One of our challenges as a CCG is how we evidence the success of any services we commission, and this applies to services in care homes too. A key outcome we'd look to evidence is a reduction in unnecessary unplanned admissions but data restrictions mean we can no longer access that information. I can't make the conference but I'd be most interested to find out if any other CCGs have managed to find a way round this one?

#543887 david oliver
visiting fellow
Kings Fund

Dear Solveig

Always happy to help and to answer emails. Meantime if you haven't seen the Quality Watch Report on hospital admissions from care homes, BGS care Home Commissioning Guidance and Recent NHS Benchmarking audit on acute care for older people they may provide some answers. Also there are several examples from specific localities for instance Radcliffe Lisk from Ashford and St Peters (see BGS blog and BGS newsletter for write up) or Elizabeth Kendrick work in NE - other examples available


#544026 J R Hartley
Director - Nursing Home
Nursing Home

After a number of years with local PCT's and Local Authorities; engaged in a number of projects concerned with care homes, integration, non-elective admissions, partnership working and the plethora of concepts and trendy acronyms that form the new vocabulary of the day, I cannot help but feel we are once again looking for the problems to fit the latest DoH driven solutions. These days, the vast majority of Residents who are eligible for state funding or whose relatives are willing to part with precious inheritance cash/assets are extremely frail; living with many co-existing conditions and who need direct hands on care 24 hours a day (hard work, sweat and tears). They do not need or benefit from access to SALT, physio/OT/Telehealth. What they need (and I am sure in the main receive all across England) is kind , compassionate and sustained hands on direct/intimate care. To ensure this can be provided, what care homes really need is adequate funding (and dare I say a little less distraction thanks to a now over zealous and 'out to prove a point' regulator called the CQC). Whilst we continue to stay passive and non-nonchalant with regards to paying care homes the equivalent of Travellodge/Premier Inn rates for 24 hour, unlimited care, accommodation and all conceivable everyday living expenses, we are but pis*ing in the wind with this latest in a long, long line of pump priming, spearheading, pilot, vanguarding, projects streams and strands and stakeholder get togethers; which ALL deliver absolutely nothing but a few 2 year fixed term contracts for the project group members.

#544031 David Oliver
visiting fellow
The Kings Fund

Dear "JR Hartley" - you wont hear me or the King's fund disagreeing one iota about the need for adequate social care funding including the need for adequate funding of long term nursing and residential care. I and we have said so on the record on numerous occasions. However, that doesn't mean that adequate access to high quality healthcare isn't important - precisely because residents do have such complex healthcare needs. And they are entitled under the NHS constitution, the equality act and the GP contract to receive it. I make no apology for saying so but that doesn't mean adequate funding for the care itself isn't equally important


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