Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes

Chadborn, Neil; Devi, Reena; Hinsliff-Smith, Kathryn; Banerjee, Jay; Gordon, Adam L

doi:10.1007/s41999-020-00389-w

Cited by 17 publications

(23 citation statements)

References 98 publications

(192 reference statements)

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“…It is possible that the intervention succeeded because of its comprehensiveness and as a result of the recognition it gave to the pivotal role played by care home staff in designing, implementing, and delivering the GtACH programme in this setting. 33 Clinicians and policy makers should, when working to prevent falls in care homes, implement interventions that are similarly comprehensive in scope and that include each of the components included in GtACH. There are always caveats associated with extrapolating such findings to care homes that might differ structurally, culturally, or organisationally from those included in the study, but we do not believe that these issues of generalisability can be addressed by further trials.…”

Section: Discussionmentioning

confidence: 99%

Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation

Logan

Horne

Gladman

et al. 2021

BMJ

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Objectives To determine the clinical and cost effectiveness of a multifactorial fall prevention programme compared with usual care in long term care homes. Design Multicentre, parallel, cluster randomised controlled trial. Setting Long term care homes in the UK, registered to care for older people or those with dementia. Participants 1657 consenting residents and 84 care homes. 39 were randomised to the intervention group and 45 were randomised to usual care. Interventions Guide to Action for Care Homes (GtACH): a multifactorial fall prevention programme or usual care. Main outcome measures Primary outcome measure was fall rate at 91-180 days after randomisation. The economic evaluation measured health related quality of life using quality adjusted life years (QALYs) derived from the five domain five level version of the EuroQoL index (EQ-5D-5L) or proxy version (EQ-5D-5L-P) and the Dementia Quality of Life utility measure (DEMQOL-U), which were self-completed by competent residents and by a care home staff member proxy (DEMQOL-P-U) for all residents (in case the ability to complete changed during the study) until 12 months after randomisation. Secondary outcome measures were falls at 1-90, 181-270, and 271-360 days after randomisation, Barthel index score, and the Physical Activity Measure-Residential Care Homes (PAM-RC) score at 91, 180, 270, and 360 days after randomisation. Results Mean age of residents was 85 years. 32% were men. GtACH training was delivered to 1051/1480 staff (71%). Primary outcome data were available for 630 participants in the GtACH group and 712 in the usual care group. The unadjusted incidence rate ratio for falls between 91 and 180 days was 0.57 (95% confidence interval 0.45 to 0.71, P<0.001) in favour of the GtACH programme (GtACH: six falls/1000 residents v usual care: 10 falls/1000). Barthel activities of daily living indices and PAM-RC scores were similar between groups at all time points. The incremental cost was £108 (95% confidence interval −£271.06 to 487.58), incremental QALYs gained for EQ-5D-5L-P was 0.024 (95% confidence interval 0.004 to 0.044) and for DEMQOL-P-U was 0.005 (−0.019 to 0.03). The incremental costs per EQ-5D-5L-P and DEMQOL-P-U based QALY were £4544 and £20 889, respectively. Conclusions The GtACH programme was associated with a reduction in fall rate and cost effectiveness, without a decrease in activity or increase in dependency. Trial registration ISRCTN34353836 .

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Section: Discussionmentioning

confidence: 99%

Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation

Logan

Horne

Gladman

et al. 2021

BMJ

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“…The lack of a nationally-agreed minimum dataset for UK care homes is a recognised limitation for social care research. The COVID-19 pandemic strongly highlighted the need for more reliable identification of the care home population within national routine datasets as well, and there are studies underway to address this [ 49 , 50 ]. The availability of such datasets would increase the scope and potential robustness of evaluative studies that could be carried out to assess the potential effectiveness of future QI programmes, perhaps using step-wedge or other randomised designs in which the effects of an intervention could be compared with contemporaneous matched controls.…”

Section: Discussionmentioning

confidence: 99%

The Effect of Providing Staff Training and Enhanced Support to Care Homes on Care Processes, Safety Climate and Avoidable Harms: Evaluation of a Care Home Quality Improvement Programme in England

Damery

Flanagan

Jones

et al. 2021

IJERPH

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Older people living in care homes are at risk from avoidable harms, which may require hospital attendance or admission. This paper describes a mixed methods evaluation of a large quality improvement (QI) programme that provides skills training and facilitated support to staff in 29 care homes across two localities in the West Midlands, UK. The Safety Attitudes Questionnaire (SAQ) is used to assess changes to care home safety climate between baseline and programme end at 24 months. We use routinely collected data to assess pre- and post-programme avoidable harms and hospital attendance/admission rates. Semi-structured interviews with programme managers (n = 18), and staff (n = 49) in four case study homes are also used to assess perspectives on programme implementation. Our results show that safety climate scores increase by 1.4 points. There are significant reductions in falls (p = 0.0006), severe pressure ulcers (p = 0.014), UTIs (p = 0.001) and ‘any’ events (p = 0.0003). Emergency hospital attendances reduced, but admissions increased. Interview participants report improvements to teamwork, working practices, information sharing, knowledge and skills. Upskilling care home staff can improve working practices and attitudes towards resident safety and care quality, which may be associated with significant reductions in avoidable harms rates. Care staff turnover rates are high, which may impact the potential for longer-term sustainability of the changes observed.

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“…Health Information and Quality Authority standard number 15) was a major driver behind this high level of compliance. 46 Two recent reviews 47,48 give a broad perspective on the topic of improving health care in care homes.…”

Section: Patterns Of General Practitioner Working With Care Homesmentioning

confidence: 99%

“…The second review was a scoping review of QI in care homes 48 with broad inclusion criteria selected 65 international studies. A striking finding was the absence of evidence or discussion about how GPs were involved, although a few studies referenced the involvement of specialists in gerontology/ geriatric medicine.…”

Section: Patterns Of General Practitioner Working With Care Homesmentioning

confidence: 99%

“…105,106 GPs' input is acknowledged as part of this, but, to the best of our knowledge, how they co-ordinate or integrate with care homes has not been explained or discussed in detail. 48 The fact that GPs have not featured significantly in descriptions of care home improvement work to date could mean that their role has been taken for granted as core, but not described. Alternatively, it could be that the need for QI is a reflection of the absence of GP involvement in particular aspects of care delivery in care homes.…”

Section: General Practitioner Specialising In Care Homesmentioning

confidence: 99%

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GPs’ involvement to improve care quality in care homes in the UK: a realist review

Chadborn

Devi

Williams

et al. 2021

Health Serv Deliv Res

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Background Organising health-care services for residents living in care homes is an important area of development in the UK and elsewhere. Medical care is provided by general practitioners in the UK, and the unique arrangement of the NHS means that general practitioners are also gatekeepers to other health services. Despite recent focus on improving health care for residents, there is a lack of knowledge about the role of general practitioners. Objectives First, to review reports of research and quality improvement (or similar change management) in care homes to explore how general practitioners have been involved. Second, to develop programme theories explaining the role of general practitioners in improvement initiatives and outcomes. Design A realist review was selected to address the complexity of integration of general practice and care homes. Setting Care homes for older people in the UK, including residential and nursing homes. Participants The focus of the literature review was the general practitioner, along with care home staff and other members of multidisciplinary teams. Alongside the literature, we interviewed general practitioners and held consultations with a Context Expert Group, including a care home representative. Interventions The primary search did not specify interventions, but captured the range of interventions reported. Secondary searches focused on medication review and end-of-life care because these interventions have described general practitioner involvement. Outcomes We sought to capture processes or indicators of good-quality care. Data sources Sources were academic databases [including MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Cumulative Index to Nursing and Allied Health Literature, PsycInfo® (American Psychological Association, Washington, DC, USA), Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA) and Cochrane Collaboration] and grey literature using Google Scholar (Google Inc., Mountain View, CA, USA). Methods Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines were followed, comprising literature scoping, interviews with general practitioners, iterative searches of academic databases and grey literature, and synthesis and development of overarching programme theories. Results Scoping indicated the distinctiveness of the health and care system in UK and, because quality improvement is context dependent, we decided to focus on UK studies because of potential problems in synthesising across diverse systems. Searches identified 73 articles, of which 43 were excluded. To summarise analysis, programme theory 1 was ‘negotiated working with general practitioners’ where other members of the multidisciplinary team led initiatives and general practitioners provided support with the parts of improvement where their skills as primary care doctors were specifically required. Negotiation enabled matching of the diverse ways of working of general practitioners with diverse care home organisations. We found evidence that this could result in improvements in prescribing and end-of-life care for residents. Programme theory 2 included national or regional programmes that included clearly specified roles for general practitioners. This provided clarity of expectation, but the role that general practitioners actually played in delivery was not clear. Limitations One reviewer screened all search results, but two reviewers conducted selection and data extraction steps. Conclusions If local quality improvement initiatives were flexible, then they could be used to negotiate to build a trusting relationship with general practitioners, with evidence from specific examples, and this could improve prescribing and end-of-life care for residents. Larger improvement programmes aimed to define working patterns and build suitable capacity in care homes, but there was little evidence about the extent of local general practitioner involvement. Future work Future work should describe the specific role, capacity and expertise of general practitioners, as well as the diversity of relationships between general practitioners and care homes. Study registration This study is registered as PROSPERO CRD42019137090. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 20. See the NIHR Journals Library website for further project information.

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Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes

Cited by 17 publications

References 98 publications

Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation

Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation

The Effect of Providing Staff Training and Enhanced Support to Care Homes on Care Processes, Safety Climate and Avoidable Harms: Evaluation of a Care Home Quality Improvement Programme in England

GPs’ involvement to improve care quality in care homes in the UK: a realist review

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