Meeting Needs in Care Homes
People who live in Care Homes have increasingly complex needs and need continuity. Staff working in Care Homes are in the lowest 10% of the pay scale, are often on zero hours contracts, and there is a high turnover of staff (Roy Lilley, Gimme Strength 15th January 2020). It’s tough working in care homes, and even tougher if you are trying to navigate the different requirements and care plans of practices where the residents are registered. We know aligning care homes to practices improves the quality of care for people who live there (see below ‘What Works’) – and they spend less time in hospital. As described in the blog on acuity – having continuity makes a real difference as does valuing and supporting people who care for these folk. So given this is known, why isn’t primary care doing this everywhere? My experience is that many Practices have found ways of working with their CCG and Local Council to solve the problem. But there are examples where this is not happening – often a mix of a lack of imagination about funding and Practices being intransigent. It requires learning from those who have worked it out, and for a collaborative approach to funding. Proactive management improves people’s lives, reduces overall costs and reduces demands on general practice overall, but it does need the CCGs to find ways to fund it. My sense is that PCNs can solve this one with ICS colleagues– and should.
Here are a couple of amazing examples:
“For several years we have a LES for GP care home rounds and one care home per Practice. It works, our practice does weekly rounds and we have the lowest rate of unplanned admissions for dementia patients in the county.”
“We have GP weekly ward round. GPs are supported by community nurse practitioners from community services. We were one of the care home vanguards. Secondary care geriatricians support weekly MDT. We have case management and pharmacist support. We have developed fantastic relationships with care home staff we support & help each other. It reduces overall demand for GPs.”
What Works
As commissioners are challenged to secure reduced demand on A&E there is one area where there is real evidence that, if put into practice across the UK, will make a significant difference. It’s the Care Home Sector. Here we set out the best practice in care homes, both to reduce demand on secondary care, but more importantly so that our elderly citizens have a good life in their final years. Put simply there is no excuse now not to register one care home with one practice, and for GPs to proactively manage care in these homes.
The Published Evidence
Looking at the published evidence of the impact of care homes, which have achieved circa 20% reduction in A&E attendance, they have the following common elements:
The Care home residents are all registered with one GP practice.
There is proper care planning between the practice and the care home staff, with a named GP taking a lead in each practice for their care home, undertaking proactive visits.
There is nursing support (supervision & coordination) of care home staff and training for care home staff.
This is the difference it makes:
The Rushcliffe Evaluation showed 29% less care home visits than the control homes.
At Robin Lane Practice in Leeds they have achieved 25% reduction in A&E visits (CQC report)
The Wakefield Care Home programme has delivered 25% reduction in ambulance calls, 30% reduction in A&E attendance, 27% reduction in admissions.
The Sutton Care Homes support for care home forum; ‘red bag’ / collaborative; and assessments/ training to support frail elderly, has lead to a decrease in length of stay when residents are admitted to hospital (circa £185,000 cost reduction). Their medication review project has lead to an actual cost saving based on reducing medicines prescribed of £56,062 (part year effect). Projected as a full year effect, this would be a saving of £94,943 which equates to an average saving of £184 per review.
Gateshead Care Homes project achieved 19.6% reduction in admissions to hospital.
Sheffield has had one practice to care home since 2008. Here the care homes are part of the system. If you are on a medical ward and not ready to go home you go to the care home of your GP until you are ready.
When asked how to reduce A&E attendance this has to be one of the top priorities for GPs and Commissioners. Not only that but it means frail elderly people can stay in familiar surroundings getting good care outside hospital. It has to be the right thing to do.
Visiting the 80 Outstanding Care Homes
So what makes a good Care Home experience? Lance Gardner and a colleague visited 80 outstanding care homes. I interviewed him to find out what it was that made these care homes outstanding.
Small Business. They tend to be owned by individuals or families who own a small number of home (no more than 15 in total). The outstanding care homes are not owned by the big 4 (Barchester, HC1 4 seasons and BUPA), except where HC1 has just bought out a family business care home that was outstanding. The lesson is that you can’t do this at industrial scale
Whole pathway. These outstanding homes offer more than one element of care – the most successful ones offer domiciliary care, residential, nursing, Elderly Mentally Ill, and are also ordinary homes to well older people. They are offering the whole pathway of care.
End of Life Care. The culture is the same as a hospice. The reason that’s important is because in nursing homes in the UK the average length of stay is 9 months, so of course its palliative. In residential care its 18 months. You need to think about care homes like you do a hospice, where nothing it too much trouble. Lance asked one home when did it last sack a member of staff, and they said when a resident asked for poached eggs on toast at 9.30pm but the staff member said the kitchen was closed. The staff member hadn’t understood the nature of the service they are offering. In your own home the kitchen is never closed. The orientation is not hotel services, but home services.
A community. These homes mix their care needs carefully, so you don’t have segregated sections. In the poorer quality homes you find the bottom floor is residential, the next floor is nursing, the top floor is dementia. The good homes are becoming communities. In normal life people tend to live with people of similar age, so if you take a normal cul de sac of people in their 80s some will have dementia, or nurses visiting. These care homes are re-creating a more normal mix, with elderly people across the spectrum of need living together.
They treat their staff really well. They view their staff as crucial assets to the business. They tend to pay more, paying over the living wage, and providing additional benefits e.g. one care home has a holiday home for staff, and tickets to the local FC. Staff in these homes are free to innovate and change without seeking permission, so they can offer bespoke care.
One GP Practice. They tend to have one GP practice per care home. They keep people there rather than send them to hospital.
Carers find these outstanding homes don’t smell, they are greeted warmly, and they find that either the residents are not around because they are out, or the residents are undertaking constructive activity e.g. baking cakes and bread. In these homes people have jobs/roles within the care home community, for example a lady with profound dementia who appears not to know the date or time, will set all the tables for lunch at 11.30 every day. She doesn’t know what day it is, but she will set lunch independently and reliably, with a template that shows here where everything goes so she doesn’t have to remember where to put the plate and cutlery.
These care homes are creating additional income from having a cinema, a spa, a restaurant. They are diversifying, to supplement the income from residents.
Have a look at this video of the Belong Care Community which shows this community model and excellence in action.
This is the way forward for Care Homes, and the standard we should be expecting for our elderly citizens. It can start with how the Health System chooses to work with people.
Note: Lance Gardner was previously CEO of the Care Plus Group and is now the Care Architect at All About Care, designing care plans or care pathways for individuals and companies across the health and social care sector. You can reach him at @lanceAACltd or 07595385699