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Engaging with the care home culture

When GPs in Yorkshire set out to manage residents in two care homes they saved nearly £50,000 on admission and prescribing costs – and also gained useful insight into the culture of care homes. Jane Robinson explains

There is a body of research that suggests care home residents have a better prognosis when treated in care homes rather than in hospitals, and that if hospitalisation could be reduced, mortality rates would also come down.

Our project focused on two care homes in the Goole, Howdenshire and West Wolds area – one with 24 residents and another with 30.

A session a week of GP time was dedicated to seeing care home residents with the aim of proactively managing their care, hoping to improve the quality of that care and, as a subsidiary aim, to reduce unnecessary medication and admissions – hence reducing costs.

This pilot scheme was led by Dr Clive Henderson, a local GP, and salaried GP Dr Marie Cohen and was funded out of a PCT development fund for each of the five localities in NHS East Riding.

The GPs aimed to increase the frequency of medication reviews and prevent inappropriate prescribing, to review residents who were becoming unwell at an earlier stage, to review residents after hospital discharge and to identify residents with end-of-life care needs.

A number of outcome measures were used to assess the project – first, hospital admissions. A reduction in hospital admissions is likely to be beneficial both in terms of quality of care for residents and also in economic terms.

Results after one year (2008/09 figures compared with 2009/10 figures) showed that admission costs were reduced by £53,462. Medication costs were reduced by £5,611.17. The cost of the scheme was £10,000, so the total saving worked out at £49,073.11.

Finding our feet

Extracting data from the computer system regarding changes in medication proved rather challenging.

Ultimately, residents' notes were individually reviewed, looking for medication changes by a dispenser.

Most of the reviews focused on reducing inappropriate prescribing, including antipsychotics, preventive therapies such as antihypertensives and statins, for patients who were either experiencing side-effects or coming to the end of their life, and anti-dementia drugs for patients who were no longer benefiting from them.

There is now only one patient who has received an antipsychotic in the last 90 days out of 54 residents, which compares with a national average of 20.9% of care home residents. As well as the benefits to patient care, the saving annually was estimated at £5,611.17.

The initial aim had been to focus on advanced care planning for patients, but this proved difficult as many patients had significant cognitive impairment and lacked capacity to make these decisions.

Gathering family members for discussion about what their relative might have wanted and what might be in their best interests proved to be very challenging.

In the future, we may look to encourage care homes to integrate some discussions about advance care preferences into admission procedures. As time passed the pilot also created an opportunity to give training and information to care home staff.

A training session on blood glucose monitoring was provided after a resident had to be admitted with hypoglycaemia that should have been spotted earlier. The care home staff continue to use this skill.

Admissions up, costs down

While admission costs reduced, the actual number of hospital admissions remained static at one care home and doubled at the other. To understand why, each admission was reviewed individually. Twelve of the admissions were found to be via 999 ambulance without any recourse to GP advice (both in and out of hours).

Most problems resulted in very short stays and perhaps could have been avoided – examples included constipation syncope and overflow diarrhoea.

Non-medically-trained care home staff are regularly faced with acute illness, and may find it difficult to assess the best course of action.

It is understandable that staff may call for an emergency ambulance when faced with acutely ill residents, but perhaps this is an area where increased training, nurse or GP support could reduce avoidable emergency admissions.

We saw a partial success in reducing admissions, in that the total number of days spent in hospital was decreased for each home and the overall cost of admissions was also reduced. This also goes against the trend across the PCT, which showed a small increase in admission costs over the two years being studied. There was no increase in deaths when the two years were compared.

The results appear to demonstrate that this type of service can reduce the total number of days in hospital and hence the costs of hospitalisation, but not the number of admissions.

One hypothesis is that more intensive GP input can successfully reduce the requirement for residents to have lengthy and complex hospital admissions, perhaps by better managing long-term health conditions and reducing admissions caused by problems with medications.

Palliative care

The impact on end-of-life care was also assessed by reviewing the notes of all residents who had died within the two years studied.

More intensive GP input appears to have increased the number of residents who were recognised as terminally ill and hence received palliative care.

Probably because of this, fewer patients died in hospital and this may also have contributed to the reduction in time spent in hospital and admission costs.

This is also beneficial to residents as the majority of people prefer to die at home and this is a key aim of the Gold Standards Framework. In the one case where the patient's preferred place of care was hospital, this was also achieved.

Further problems arose as staff struggled with the concept that a patient might be reaching the end of their life and that it might be inappropriate to admit them if they expressed a desire to remain at home.

They found it much easier to accept this for patients with a diagnosis of malignant disease, but very hard where patients had end-stage non-malignant disease.

The ambulance service is also key to managing admissions appropriately. The recent pilot of electronic information sharing with the ambulance services and out-of-hours GPs via Adastra is likely to support our efforts to prevent unnecessary hospital admissions.

The publication Dying for Change highlights the need to improve the delivery of palliative care. Introducing a proactive GP into a care home setting has gone some way towards achieving this, but much more needs to be done.

Cultural influences

The results of this project highlight there are differences between care homes, particularly in terms of thresholds for arranging emergency admissions. This may reflect the experiences of individual staff and managers, and increased training may be the best way to tackle this.

One key learning point was the need to influence the culture of the care home. The results showed the value of intensive GP input, but also demonstrate that this is not the only resource needed.

Evidently more staff training in health-related issues and day-to-day support is needed, and it is likely that a multidisciplinary team will be most effective at enhancing care delivered to care home residents.

The voluntary sector may also make an increasingly valuable contribution.

Care home staff and residents also expressed their satisfaction with the project and felt supported by the increased GP input.

The project has paved the way for trying different approaches in other parts of the East Riding. A GP from the Bartholomew Medical Group is piloting a multidisciplinary approach involving GPs, nurses and allied healthcare professionals such as pharmacists, occupational therapists and physiotherapists.

The message so far is that it is important to engage with the culture in care homes.

We propose that in the future, having evaluated all the different models we are piloting, the most effective one will be taken up more widely.

Jane Robinson is assistant director of localities at NHS East Riding


60-second summary

Initiative: Pilot with two care homes to see if one session a week of proactive GP care could enhance care and reduce admissions

Set-up costs: £10,000 for one year funded by the PCT

Results: While the number of admissions actually increased (doubling at one home), length of stay was significantly reduced as a result of GP intervention, creating a saving of almost £50,000. Pilot also highlighted training needs for care home staff in palliative care and need for future initiatives to be based on a multidisciplinary model