Reducing hospital admissions from care homes
A community service used education and support to boost the competence of care home staff to manage residents’ needs. This has cut avoidable hospital admissions
In this article…
- Developing the role of a community matron for care homes
- Why reducing inappropriate hospital admissions from care homes is important
- Improving patient outcomes through joined-up care and effective communication
Caroline Burns and Caroline Hurman are community matrons for care homes at First Community Health and Care CIC, Caterham, Surrey.
Burns C, Hurman C (2013) Reducing hospital admissions from care homes. Nursing Times; 109: 1/2, 23-25.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- Individual care homes, rather than individual residents, can be the frequent attendees to hospital
- Advice and support from a community matron can reduce inappropriate hospital admissions from care homes
- Empowering nurses to be competent and confident in the management of their residents is crucial
- Effective communication is vital in providing high-quality care
- Social enterprises offer the opportunity to address gaps in service provision
Admission to hospital can be a frightening experience for care home residents, and is often unnecessary. In east Surrey a number of care home residents were being transferred to the acute hospital inappropriately. To reduce avoidable attendance/admissions, a community matron for care homes role was developed.
The matrons used an advisory, supportive and facilitative approach to assist care home staff in developing their competence and confidence in managing their residents’ care. The service has significantly reduced avoidable attendance/ admissions and has improved care quality.
The National Service Framework for Older People emphasised the need to provide the right care in the right place at the right time. Hospital is not necessarily the best place for older people, unless they are in need of acute medical or surgical intervention (Department of Health, 2001).
Admissions are expensive (DH, 2004) and often a frightening experience for older people, particularly those who are frail and vulnerable (DH, 2010); people with advanced dementia are particularly vulnerable and are frequently admitted to hospital, often unnecessarily (National End of Life Care Programme, 2010).
More than 17,500 care homes provide nursing and/or personal care for older people in England. These are owned and managed by a range of public sector, private sector and not-for-profit organisations (Care Quality Commission, 2012).
Care homes have undergone generic name changes over the past decade, so for clarity throughout this article, homes offering nursing care for older people are referred to as “nursing homes”; homes providing personal care only for older people are referred to as “residential homes”. The term “care home” is used to encompass all homes for older people.
In the east locality of Surrey, it was noted that a significant number of users of the acute hospital were residents in care homes. As a result the community matron for care homes service was developed in 2008. We soon discovered that it was certain care homes, and rarely individual residents within those care homes, that were the high users of the acute hospital.
As a result we began to focus on working with the managers and staff in the care homes to reduce and avoid inappropriate hospital attendance/admissions of all their residents.
The aims of the service
The community matron for care homes service aims to:
- Cut avoidable hospital attendance/admissions from care homes;
- Reduce inappropriate 999 ambulance calls from care homes;
- Help care home staff to become competent and confident in managing their residents, referring to the Royal College of Nursing’s (2006) Facilitation Standards as guidance.
To achieve these aims the service:
- Develops and promotes appropriate alternative pathways to hospital admission;
- Provides advice and support to staff in managing their residents’ needs;
- Develops and facilitates training for care home staff;
- Monitors and reviews emergency ambulance calls from care homes;
- Targets support to the care homes that are high users of the ambulance service and acute hospital;
- Promotes use of advanced care planning within the care homes as part of improving end-of-life care;
- Encourages care homes to undertake the National Gold Standards Framework training or apply aspects from it (www.goldstandardsframework.org.uk);
- Uses a case management approach for individual residents referred to the service in the prevention of acute hospital admission;
- Provides the interface and closes the gap between care homes, the local community health provider, ambulance trust and the acute hospital;
- Identifies and supports vulnerable adults within a multi-agency safeguarding framework;
- Promotes greater dignity and respect for residents within care homes.
Addressing the issues
We identified several problems that were contributing to avoidable emergency hospital admissions of care home residents across the care home community:
- Nurses and carers in some of the homes lacked confidence and the necessary competencies to offer all the care their residents needed;
- The incidence of falls was high in some homes;
- There was a lack of partnership working between care homes and the acute hospital, and between care homes, so homes were often working in isolation;
- Many homes did not offer advanced care planning or recognise the end-of-life stage, particularly in residents with dementia;
- Communication within some of the care homes, and with outside agencies such as hospitals and GPs, was poor.
Working in partnership with the ambulance service and care homes to identify the highest ambulance service users, we established a local benchmark for the number of ambulance calls made compared with the size of the care home.
The community matron for care homes service then targeted the six nursing homes and five residential homes that had exceeded their benchmarks in the previous six months. This involved making additional visits to monitor and review emergency ambulance calls and encouraging and supporting the staff to reflect on alternative pathways.
We also provided routine visits to support, advise and facilitate training to all homes in the locality with the aim of avoiding unnecessary hospital admissions.
Competencies and confidence
We organised training sessions for nurses within the nursing homes to increase their skills and knowledge to better enable them to provide 24-hour care. These included procedures for which residents were often being taken to A&E, such as male and suprapubic catheterisation and administration of subcutaneous fluids.
Residential home care staff were given training packs for use in partnership with the district nursing teams. Teaching sessions delivered by the district nurses or the community matrons for care homes have included subjects such as the prevention of pressure damage and the importance of oral fluid intake to prevent dehydration .
When they are visiting care homes, the community matrons use an advisory and supportive approach, rather than hands-on, with the aim of enabling registered nurses and care staff to become more confident and competent in the management of residents’ care.
Reducing the incidence of falls
The community matron for care homes worked with the falls team, within First Community Health and Care, and care home staff to try to reduce the number of falls and consequent hospital admissions. Managers of some of the larger residential homes, where there was a high incidence of falls were encouraged to put in place an ongoing falls prevention training package for their staff.
Isolation and lack of partnership working
The community matrons for care homes set up and coordinate quarterly nursing home forum meetings so that nursing home staff can meet key professionals from the multidisciplinary team and acute hospital with the aim of working together to reduce hospital admissions. After receiving positive feedback from the nursing home forum and interest from the residential home managers, we also set up a forum for residential homes. This is developing closer links and working relationships within the acute hospital with discharge liaison sisters, ward managers, pharmacy and A&E to improve admission and discharge pathways.
Advanced care planning
Despite the fact that when asked about their preferred place to die most people would prefer not to die in hospital, national figures suggest most deaths (58%) occur in hospitals and only 17% in care homes (DH, 2008). In order to enable more residents to die in their care homes rather than in hospital, staff were given education, advice and support on the Gold Standards Framework in Care Homes, which is a national system-focused approach that enables care homes to provide quality care for all residents nearing the end of life (National Gold Standards Framework Centre, 2010).
Advanced care planning and “thinking ahead”, where a voluntary discussion about an individual’s future care and wishes takes place, are key aspects of the Gold Standards Framework to enable services to provide high-quality end-of-life care. A local audit was completed to compare local and national figures to review the transfer of residents at the end of life from care homes to the acute hospital within this locality.
Timely and appropriate communication is vital both within organisations and with external organisations. We encouraged care home staff to use the Situation, Background, Assessment, Recommendation (SBAR) tool (NHS Institute for Innovation and Improvement, 2008). This should help to improve communication and enable the staff to be more assertive when communicating with other health professionals.
Impact of the role
The community matron for care home service has shown positive results in both nursing and residential homes. Fig 1 (see page 21) shows the number of ambulance calls made by the six nursing homes that were above the benchmark, before and after the target work. Overall, there was a reduction of 9.1% in calls to the ambulance service in the following six-month period (329 reduced to 299 calls).
The most recent quarterly audit showed that 79% of residents died within the nursing homes rather than in hospital, which is significantly higher than the national average of 17% (DH, 2010).
Fig 2 (see page 22) shows the number of ambulance calls made by the five residential homes that were above the benchmark, before and after the target work. Overall, there was a reduction of 15% in the following six-month period (621 reduced to 529 calls). Following the successful results the local benchmark for the residential homes has been reduced.
Care home managers and staff initially did not understand that the community matrons for care homes were offering support rather than undertaking inspections like the CQC, while other health professionals did not see how the role differed from the already established community matrons case management role. It was essential to build effective working relationships as we had no managerial authority over the care homes.
Changes in care home management and a rapid turnover of staff in some homes was problematic as it resulted in a lack of continuity of care. This was also evident with multiple GPs or GP practices covering individual care homes. We also found there was an inequity in access to staff training, which was associated with what was provided by local healthcare services or individual care homes, as well as the fact that some of the care home proprietors/managers did not make it a high priority to give time for their staff to attend.
A useful service
In 2011, we sent out 35 service satisfaction surveys to the care home managers and achieved a 79% response rate. Generally there was positive feedback on the service. Comments included:
“We have reduced our 999 calls by 50% with the support of the community matrons.”
“This is an excellent development for the nursing homes. It makes us feel valued and acknowledges the complexity of our role. The forum is essential. It gives us the opportunity to discuss problems and how we can solve them. Meeting the hospital staff has been particularly beneficial. It is reassuring to have someone to contact as we can often feel isolated. Both our community matrons provide a valuable service.”
“They are always available for advice and support regarding clinical issues before they become urgent and necessitate admission into hospital.”
“This service is invaluable to the care homes. With this support, it has reduced hospital admissions and improved end-of-life-care. There are good communication channels within the multidisciplinary teams.”
“The community matrons provide an invaluable service to nursing homes, as at times we can become very isolated from the PCTs, acute hospitals and wider multidisciplinary team. They ensure we are kept updated on changes and developments.”
The community matron for care homes role can help reduce avoidable hospital admissions and emergency ambulance calls. This advisory, supportive, facilitative approach aims to promote a learning and empowerment culture within care homes, encompassing the RCN’s (2006) Facilitation Standards, which will improve outcomes for the residents within these homes.
The King’s Fund GP and Whole System Leadership Programme is looking at strategies of care for frail older people within the locality, and is keen to develop the support available to those living in care homes to avoid unnecessary hospital admission. Staff at care homes in the area were invited to attend an innovative workshop to help inform future service development.
The community matron for care homes service has been allocated additional funding enabling us to offer Gold Standard Framework facilitation two days a week. This will enable us to provide ongoing support to enable all the care homes to adopt aspects of the GSF; it will also enable those undertaking the national GSF programme an opportunity to fully embed the framework and complete the accreditation process to improve end-of-life care for their residents.
Work will continue on advanced care planning and thinking ahead with a focus on supporting care staff to use prognostic indicator guides (National Gold Standards Framework Centre, 2010). We hope they will become more confident in recognising end-of-life stages, especially for residents with dementia.
There has been new local guidance and documentation on do not attempt cardiopulmonary resuscitation (DNACPR). Proactive work will continue in encouraging the clinical decision by the GPs and completion of documentation, if a DNACPR decision is made, to avoid unnecessary hospital admission at the resident’s end of life.
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Care Quality Commission (2012) The State of Health Care and Adult Social Care in England. London: CQC.
Department of Health (2010) Quality Outcomes for People with Dementia: Building on the Work of the National Dementia Strategy.
Department of Health (2008) End of Life Care Strategy - Promoting High Quality Care for All Adults at the End of Life. London: DH.
Department of Health (2004) Avoiding and Diverting Admissions to Hospital - A Good Practice Guide. London: DH.
Department of Health (2001) The National Framework for Older People. London: DH.
National End of Life Care Programme (2010) The Route to Success in End of Life Care - Achieving Quality in Care Homes.
National Gold Standards Framework Centre (2010) Gold Standard Framework.
NHS Institute for Innovation and Improvement (2008) Situation, Background, Assessment, Recommendation Tool.
Royal College of Nursing (2006) RCN Facilitation Standards - Version 1. London: RCN.
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