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How to… set up care home reviews

Dr Niti Pall explains how her PBC group set up a scheme to review the needs of residents in nursing homes and improve their quality of care

Dr Niti Pall explains how her PBC group set up a scheme to review the needs of residents in nursing homes and improve their quality of care

Meeting the needs of care home residents with multiple diagnoses and long-term conditions requires a programme of co-ordinated support. But often care is fragmented, as local authorities, social care, GPs and the acute sector are all involved in supporting residents. This can result in a lack of individual care, unnecessary acute admissions and prescribing of multiple medications, sometimes inappropriately.

41230842Smethwick and Oldbury Alliance PBC group (SOCA), which covers 17 practices serving a population of around 89,000 people, wanted to focus on residents' individual needs. Now the group's multidisciplinary review team – a consultant geriatrician, a senior elderly care pharmacist and a nurse – is visiting care homes in the area with the aim of improving residents' standard of support.

The team spends four hours per week at each care home with nursing care. The target is to conduct a holistic multidisciplinary assessment on some 120 residents in the PBC cluster within 12 months.

Inspiration

Stuart Hutchinson, a consultant geriatrician for the Sandwell and West Birmingham Hospital Trust, inspired our PBC group to take action. While working for the neighbouring Heart of Birmingham Teaching PCT in 2005, he had the idea for a multidisciplinary review team that would visit nursing homes to assess residents' needs.

Dr Hutchinson had noticed some inappropriate acute admissions and thought that by conducting an in-depth medication review there was potential to avoid admissions to acute hospitals and scope to make substantial savings through simplifying residents' medication regimes. The Heart of Birmingham Teaching (HOB) PCT financed his idea and for the next three-and-a-half years Dr Hutchinson, along with a nurse and an elderly care pharmacist, reviewed nursing homes in the area.

Results were impressive. The most recent showed that the team had seen 97 residents, made 351 interventions and saved £32,000 in prescribing costs alone.

For six years Dr Hutchinson has run a weekly multidisciplinary elderly care clinic, along with a GP specialist in elderly care, at my practice, Smethwick Medical Centre. Naturally, he wanted to share information with the practice and SOCA about the scheme and his findings. With feedback from the cluster clinical advisory group (CAG, a PBC cluster subcommittee) and other clinicians in the area, we knew there was potential to improve care in Sandwell nursing homes.

Into action

SOCA was impressed by the work and decided to look into conducting its own review. PBC has been progressing slowly in Sandwell despite fantastic encouragement from the PCT, which has made sure the three PBC groups in the area, which together cover 325,000 patients, receive indicative budgets and management support. As well as hoping to benefit residents, we felt the scheme would make people take notice of PBC's potential.



To help get the project off the ground, last year we invited Dr Hutchinson to talk to the CAG. The group meets monthly to bounce around ideas and discuss how to improve care in our community. Having decided that care home residents in the area could benefit from such a scheme, the group fed back information from that meeting to the cluster manager who looked at funding.

He suggested some of the money from the primary care initiative fund and the cluster's prescribing incentive scheme – both given by the PCT to each PBC group to help them redesign services – could help finance the project. All the practices within our group agreed to pool some of that money, around £20,000, to fund a multidisciplinary team to perform reviews in care homes.

The group presented to the CAG and the PBC board a specification for the service we wanted to commission. To keep things simple while getting the key benefits of the service across, our specification fitted one side of A4 paper. We sought to improve quality of care and patient/carer satisfaction, ensure value for money, avoid unnecessary hospital admissions and reduce inappropriate prescribing.

The board saw the benefits, ratified it and agreed a 12-month pilot scheme.

Costs

Using money from the primary care initiative fund, SOCA employed Dr Hutchinson for one session a week, at £15,000 annually.

A pharmacist at the PCT focused on care homes, so the PCT seconded her to the PBC for one session a week to use her skills in the care home review project. SOCA commissions free nursing home care advisers (FNCAs) operating within Sandwell PCT's community services, who are associated with certain care homes with nursing to do reviews one session a week. FNCAs were created by the Department of Health in 2001 to provide free nursing care in nursing homes, and do away with the anomaly of people having to pay for nursing in the care homes when it is free in other settings.

The cost of a band 7 nurse for one session a week is £5,500 a year. The only start-up cost was a £400 laptop with WiFi, paid for by the PBC group, which the review team uses to record its findings while in the care home.

Putting it out there

With a tried and tested pathway, funding and a review team in place it was all systems go. Marketing before the start of the project was important so we wrote to the seven nursing homes in the area to gain their consent to conduct reviews. This marketing continues to ensure the profile of the scheme is maintained and that savings are realised within the cluster.
41230843
We also wrote and spoke to all the GP practices in our cluster to make them aware of the scheme. Here we came across our biggest obstacle. GPs were concerned that by reviewing residents, recommending or stopping medications, or proposing further investigations, we would increase their workload. To reassure GPs, we showed them some of the data from the prototype scheme, including its potential to make huge prescribing savings and reduce referrals. But the real tickbox for GPs was that the review could enhance patient care. We tend to forget this, but improving care is often the real driver to motivate clinicians to change their way of working.

The final scheme

The pilot project began in February this year. The team is allocated four hours on-site per week at each care home that has nursing care, with the aim of carrying out a holistic multidisciplinary assessment on around 120 residents within the PBC cluster in one year. Carers and families of residents are informed about the health assessment and must consent to it. Assessments are divided between team members. The consultant might do a physical examination, the nurse assesses the resident's care plan with a risk assessment, while the pharmacist looks at prescribing issues.

While on-site, findings are input on to a template on a laptop. That same day a summary report is emailed or faxed to the nursing home and associated GP practice. It is vital results of assessments are passed on quickly, so any changes to a resident's care can be made promptly. If the findings of the review need to be urgently dealt with, one of the team contacts the care home and GP practice to make sure they are aware of review recommendations and in agreement about the next steps. Dr Hutchinson has a pad of FP10s, which allows him to issue a new prescription for the resident.

Responsibility for implementation of recommendations is then passed to the care home's nursing management team, with the support of the GP and the FNCAs. An evaluation with cost savings is made at the end of each care home with nursing review, and presented to SOCA and the PCT.

Outcomes

The team has identified several areas where care can be enhanced. For example, residents have been receiving unnecessary multiple medications, or are on liquid feeds as a staple rather than a supplementary diet. Recommendations are given in a supportive way with team members reassuring staff they are trying to improve residents' care and are there to help, not criticise.

This project has made substantial savings in prescribing and by talking to clinicians we know acute referrals and emergency call-outs have decreased. In its first six weeks, the team saw 15 nursing home residents in Smethwick and Oldbury, resulting in 39 interventions and £13,600 in projected annual prescribing savings in those patients.

Nursing home staff say they appreciate advice on residents' care. GPs are enthused by the way the scheme is trying to improve care for older people and say it has made their lives easier. Residents seem to be comfortable with the assessments and like the attention they receive.

If the scheme is approved by the PBC group after the pilot, the plan is to review residents on an annual rolling basis. Initial results are promising and we are starting to see the benefits of the work we've been doing. It's a small service, but it might make a huge difference to the lives of care home residents.

Dr Niti Pall is chair of the stakeholder group for Smethwick and Oldbury Practice Based Commissioning Alliance PBC group (SOCA) and a senior partner at the Smethwick Medical Centre

Dr Niti Pall: Care is often fragmented for patients in homes which can result in unnecessary admissions and high prescribing Dr Niti Pall 60-second summary Thinking of doing the same?

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