'ProactivE heAlthcare for older people living in Care Homes' – PEACH Study

Key points: • Quality Improvement Collaboratives bring staff from different organisations together to improve healthcare in care homes. • Healthcare improvement should align with existing work priorities and be led by staff with experience of collaboration. 2 • Care home staff can lead healthcare improvement if approaches and structures are adopted which enable them to do so. • GPs were keen to be involved in care home improvement collaboratives but did not have capacity to lead. • Comprehensive Geriatric Assessment is unfamiliar to many community staff working in improvement and may cause confusion. Abstract Background Quality Improvement Collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood.

Introduction: This protocol describes a study of a quality improvement collaborative (QIC) to support implementation and delivery of comprehensive geriatric assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching and assistance with project evaluation. Methods and analysis: The QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in four local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as context-mechanism-outcome configurations describing what needs to be in place to use QICs to implement service improvements in care homes. Ethics and dissemination: The study protocol was reviewed by the National Health Service Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham (reference: LT07092016) ethics committees. Both determined that the Proactive HEAlthcare of Older People in Care Homes study was a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphical illustration and a dissemination video.

Objectives Comprehensive Geriatric Assessment (CGA) may be a way to deliver optimal care for care home residents. We used realist review to develop a theory-driven account of how CGA works in care homes. Design Realist review Setting Care homes Methods The review had three stages: first, interviews with expert stakeholders and scoping of the literature to develop programme theories for CGA ; second, iterative searches with structured retrieval and extraction of the literature; third, synthesis to refine the programme theory of how CGA works in care homes. We used the following databases: Medline, CINAHL, Scopus, PsychInfo, Pubmed, Google Scholar, Greylit, Cochrane Library, and Joanna Briggs Institute. Results 130 articles informed a programme theory which suggested CGA had three main components: structured comprehensive assessment, developing a care plan, and working towards patient-centred goals. Each of these required engagement of a multi-disciplinary team (MDT). Most evidence was available around assessment, with tension between structured assessment led by a single professional and less structured assessment involving multiple members of an MDT. Care planning needed to accommodate visiting clinicians and there was evidence that a core MDT often used care-planning as a mechanism to seek external specialist support. Goal-setting processes were not always sufficiently patient-centred and did not always accommodate the views of care home staff. Studies reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare resource use and objective measures of quality of care. Conclusion The programme theory described here provides a framework for understanding how CGA could be effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care homes. All three components are required to make CGA work – this may explain why attempts to implement CGA by interventions focussed solely on assessment or care planning have failed in some long-term care settings. Registration details PROSPERO (PROSPERO 2017:CRD42017062601). https://bmjopen.bmj.com/content/9/4/e026921

Introduction care home residents are often unable to complete health-related quality of life questionnaires for themselves because of prevalent cognitive impairment. This study compared care home resident and staff proxy responses for two measures, the EQ-5D-5L and HowRU. Methods a prospective cohort study recruited residents ≥60 years across 24 care homes who were not receiving short stay, respite or terminal care. Resident and staff proxy EQ-5D-5L and HowRu responses were collected monthly for 3 months. Weighted kappa statistics and intra-class correlation coefficients (ICCs) adjusted for clustering at the care home level were used to measure agreement between resident and proxies for each time point. The effect of staff and resident baseline variables on agreement was considered using a multilevel mixed effect regression model. Results 117, 109 and 104 matched pairs completed the questionnaires at 1, 2 and 3 months, respectively. When clustering was controlled for, agreement between resident and staff proxy EQ-5D-5L responses was fair for mobility (ICC: 0.29) and slight for all other domains (ICC ≤ 0.20). EQ-5D Index and Quality-Adjusted Life Year scores (proxy scores higher than residents) showed better agreement than EQ-5D-VAS (residents scores higher than proxy). HowRU showed only slight agreement (ICC ≤ 0.20) between residents and proxies. Staff and resident characteristics did not influence level of agreement for either index. Discussion the levels of agreement for EQ-5D-5L and HowRU raise questions about their validity in this population.

This paper outlines the statistical analysis plan for the PEACH study, describing how these challenges have been addressed. It acts as reference point for further publications from the PEACH study. https://www.nottingham.ac.uk/emran/documents/issue-22-emran-sep-2018.pdf

Integrated care in care homes, nursing homes, long term care facilities and residential care facilities for older people.

• Introduction Residents of care homes are likely to have frailty and complex needs and be high users of healthcare resources. Comprehensive Geriatric Assessment (CGA) may benefit residents and improve healthcare delivery. Evidence shows CGA can improve outcomes for older people in hospital and at home but the literature has not been reviewed to consider how it might work in care homes. • Methods A realist review was used to identify and characterise programme theory that underpins CGA in care homes. The outcomes of interest were health-related quality of life and satisfaction with services among residents and staff. We also considered NHS service use by care home residents. The review had three stages 1) identify candidate programme theories through interviews with key stakeholders; systematic search of the published evidence, 2) refine programme theory through iterative literature search, lateral searches and enquiries to study authors, and 3) synthesis of evidence and testing programme theories. • Results To inform our programme theory development and search strategy we interviewed 8 practitioners; including physicians, an occupational therapist, and a care home manager. Searching peer-reviewed and grey literature retrieved 81 documents. CGA in care homes is a multi-component programme comprising assessment, multi-disciplinary team meeting and care planning. A nested pattern of configurations of ‘Context, Mechanism and Outcomes’ has been developed describing the interactions between different team members (residents, practitioners and care home staff). Key mechanisms relate to; respect for knowledge from different disciplinary expertise, reaching a shared understanding of priorities and shared purpose for the care plan, and delegation to a case manager to deliver the care plan. These programme components are supported by learning, training and computer-based data-sharing. • Conclusion There is limited evidence for CGA in care home settings. We have synthesised the important programme theories from this body of evidence. Funded by Dunhill Medical Trust

Introduction Care home residents are relatively high users of healthcare resources and may have complex needs. Comprehensive geriatric assessment (CGA) may benefit care home residents and improve efficiency of care delivery. This is an approach to care in which there is a thorough multidisciplinary assessment (physical and mental health, functioning and physical and social environments) and a care plan based on this assessment, usually delivered by a multidisciplinary team. The CGA process is known to improve outcomes for community-dwelling older people and those in receipt of hospital care, but less is known about its efficacy in care home residents. Methods and analysis Realist review was selected as the most appropriate method to explore the complex nature of the care home setting and multidisciplinary delivery of care. The aim of the realist review is to identify and characterise a programme theory that underpins the CGA intervention. The realist review will extract data from research articles which describe the causal mechanisms through which the practice of CGA generates outcomes. The focus of the intervention is care homes, and the outcomes of interest are health-related quality of life and satisfaction with services; for both residents and staff. Further outcomes may include appropriate use of National Health Service services and resources of older care home residents. The review will proceed through three stages: (1) identifying the candidate programme theories that underpin CGA through interviews with key stakeholders, systematic search of the peer-reviewed and non-peer-reviewed evidence, (2) identifying the evidence relevant to CGA in UK care homes and refining the programme theories through refining and iterating the systematic search, lateral searches and seeking further information from study authors and (3) analysis and synthesis of evidence, involving the testing of the programme theories. Ethics and dissemination The PEACH project was identified as service development following submission to the UK Health Research Authority and subsequent review by the University of Nottingham Research Ethics Committee. The study protocols have been reviewed as part of good governance by the Nottinghamshire Healthcare Foundation Trust. We aim to publish this realist review in a peer-reviewed journal with international readership. We will disseminate findings to public and stakeholders using knowledge mobilisation techniques. Stakeholders will include the Quality Improvement Collaboratives within PEACH study. National networks, such as British Society of Gerontology and National Care Association will be approached for wider dissemination. Trial registration number The realist review has been registered on International Prospective Register of Systematic Reviews (PROSPERO 2017: CRD42017062601).

BGS Blog on the challenges of conducting research in the care home setting, reminding us how difficult it can be for researchers to adapt their protocols to work in care homes, whilst addressing why research in residents extremely important: