Context matters: the contrasting effect of enhancing support in residential and nursing homes

10 April 2019

The NHS Long Term Plan commits to improving NHS support to all care home residents over the next five years. This includes stronger links with primary care networks to help keep care home residents healthy and out of hospital wherever possible.

Previous work by the Improvement Analytics Unit shows that providing additional support in care homes has the potential to improve outcomes for care home residents.  The Principia enhanced support in Rushcliffe included aligning care homes with general practices, regular visits from a named GP and improved support from community nurses including training of care home staff. Our analysis found that care home residents who received enhanced support attended A&E 29% less frequently than similar care home residents elsewhere, and were admitted to hospital as an emergency 23% less often. This matters because hospital admissions can expose residents to stress, loss of independence and risk of infection, and care home residents often prefer to be treated at home or avoid the need to seek urgent treatment in the first place.

Although the initiative was associated with fewer hospital admissions overall, it is possible that the effect of the enhanced support differed between different settings. This is important to know, so that scarce NHS resources can be targeted or adapted in order to produce the greatest gains for patients. 

Large impacts in residential care homes

In further analysis just published in BMJ Quality and Safety, we’ve found that residents moving to residential care homes, which provide personal care but not 24-hour access to nurses, and who received enhanced support had lower emergency hospital use than those in residential care homes not receiving enhanced support. These residents had on average 40% fewer emergency admissions and 43% fewer A&E attendances than the comparison group. They also had 50% fewer ‘potentially avoidable’ admissions – ie admissions for conditions that were potentially manageable, treatable or preventable outside of a hospital setting, or that could be caused by poor care or neglect.

In contrast, in nursing homes, we found no evidence that people moving to nursing homes with enhanced support used more or less emergency hospital services than the comparison group. So why the disparity?

Residential care home staff may need more clinical support 

One possible explanation of our findings is that staff in residential homes may have less access to clinical expertise than nursing home staff, including less access to GPs. Without access to clinical input, residential home staff might not be able to make decisions regarding their residents’ health, therefore having to rely more on A&E and emergency services.  It’s also possible that health problems are not detected and addressed as early as they could be, or not managed as well. The enhanced support may be addressing these issues by providing more regular access to health care, for example through regular visits with a GP.

Interestingly, we found that in the other areas of England that we compared against – where there wasn’t enhanced support – people in residential care homes had more A&E attendances and emergency admissions than those living in nursing homes. This is not what we expected, given that people in residential care homes tend to be less severely ill than nursing home residents.  This finding might suggest that there is more scope to reduce A&E attendances and emergency admissions in residential homes than nursing homes.

As residential care home residents tend to be less severely ill than nursing home residents and fewer are nearing their end of life, it is also possible that it is easier to avoid admissions in residential care homes than nursing homes through these kinds of interventions.

There were also differences in how the programme of enhanced support was implemented in Rushcliffe between residential and nursing homes, with community nurses providing more training to health care assistants in residential homes. As well as the difference in services, this might have led to stronger relationships developing between care home staff and NHS teams in residential care homes and more engagement and buy-in from staff.

What does this mean for the implementation of the NHS Long Term Plan?

Although it’s difficult to generalise from just one evaluation of one local care home intervention, these results suggest that improved NHS support for care homes, as outlined in the NHS Long Term Plan, might have more potential to reduce emergency hospital use among residents in residential care homes than nursing homes.

This does not mean that there is not scope for improvements in nursing homes too. Maybe a more targeted approach will be required, for example through regular reviews of residents’ hospital admissions to help identify and track reasons for unnecessary A&E attendances and emergency admissions or identify residents of particular concern. It may also be that a greater focus on engaging nursing home staff in the initiative is needed.

Of course, emergency hospital use is not the only measure of care quality – there may be other benefits from enhanced support to consider. Further evaluations, including qualitative studies, of similar initiatives comparing outcomes in residential and nursing homes would be useful to better understand how these differences affect the implementation of care home interventions and resident outcomes. The Improvement Analytics Unit will soon publish two more evaluations of care home initiatives, providing a good opportunity to review the results across several similar interventions and see what we can deduce.

This article was originally published in the HSJ on 8 April 2019.

Therese Lloyd (@ThereseTHF) is a Senior Statistician within the Improvement Analytics Unit at the Health Foundation

Further reading

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The impact of providing enhanced support for care home residents in Rushcliffe

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