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 fecal 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 cardio respiratory 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 personalized 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.