VOL: 98, ISSUE: 07, PAGE NO: 39
Fiona Lewis, BN, RGN, is an infection control nurse specialist at Sherwood Health Centre in Nottingham
Amanda Jones, RGN, DN, is a continence adviser at the Continence Advisory Service, NottinghamBernard Jewell is a 75-year-old man who lives in a nursing home. He has multiple sclerosis and has just suffered a relapse. He is losing weight, his urinary incontinence is becoming worse and he has a grade 2 sacral pressure ulcer with a possible methicillin-resistant Staphylococcus aureus infection. He has been isolated within the home and his incontinence has become unmanageable.
Bernard Jewell is a 75-year-old man who lives in a nursing home. He has multiple sclerosis and has just suffered a relapse. He is losing weight, his urinary incontinence is becoming worse and he has a grade 2 sacral pressure ulcer with a possible methicillin-resistant Staphylococcus aureus infection. He has been isolated within the home and his incontinence has become unmanageable.
This kind of scenario is not uncommon in long-term care, and it raises a number of questions for care homes staff. What care should this man expect to receive? Is hospital the best place for him or should he remain in the nursing home? We explore how a primary care initiative in Nottingham has tried to address the complex needs of older people in nursing homes.
Primary care support
Older people in nursing homes are one of the most vulnerable populations in the UK (Nazarko, 1996). The Report of the Joint Working Party RCN/British Geriatric Society/Royal College of Physicians (2000) states that the health care services they receive should be of the same quality as that received by the general population and must meet their continuing care needs.
In Nottingham, the health authority developed the idea of a primary care team to support nursing homes and to ensure service equity for adults in long-term care.
Discussions between Nottingham Health Authority (NHA) and the local medical committee took place in 1998 to decide how to meet the requirements of its continuing care policy which states that:
- The delivery of care should be seamless;
- The needs of the whole person and the dignity of the resident and carer should be maintained at all times;
- It is an equitable service, which is needs-based.
The health authority decided to address the definition of 'community' in its broadest sense and to include residents cared for in nursing homes.
Initially, the talks focused on enhancing GP support to nursing homes, but further discussions within NHA and the Total Commissioning Pilot revealed that to address the needs of nursing home residents, the project should focus on the provision of specialist nursing and other paramedical support. These moves would also lead to a decreased workload for family doctors.
The talks were led by one of the senior public health nurses from the health authority but representatives from the hosting trusts of the specialist services, the local medical council (LMC), owners and matrons of the 98 nursing homes in Nottingham were also heavily involved.
Anderson (2000) notes that over the previous 10 years, the health care needs of residents in nursing homes have become more complex, but the level of input - in the form of formal research and also access to nurse specialists - has not increased. Therefore, nursing home staff are given very little support and education in managing these needs effectively (Nazarko, 1996).
In the end there were three main factors that led to the LMC, the health authority and specialist services deciding to support the project:
- The complexity of the health care needs of nursing home residents;
- A perception that nursing home patients could miss out on some of the expertise available via community services;
- Concerns about the level of prescribing within nursing homes, in particular addressing the issues of polypharmacy and drug interactions.
The health authority-led group was aware that any moves to enhance the care of nursing home residents would need to address a number of issues including:
- Bringing services and care closer to residents;
- Supporting vulnerable people in the community;
- Increasing equity of provision and equity of access to specialist services;
- Developing primary care and a primary care-led NHS;
- Reducing emergency admissions.
A recurrent budget of £200,000 was earmarked to fund the new team that would provide primary care support to nursing homes. For tissue viability, infection control and dietetics this was a half-time post and for occupational therapy and pharmacy this was a full-time equivalent post.
It was anticipated that the team should provide information and expertise in the following areas:
- Tissue viability;
- Infection control;
- Rehabilitation support;
- Prescribing advice.
Existing teams were already providing these services to acute and community trusts. With the additional funding, they were able to incorporate nursing homes into their remit by recruiting the extra staff member to join their teams. These teams, although based within different trusts, already had a good working relationship with each other, being involved in the provision of seamless care across the acute and community trusts.
However, the new team members did require continued training and support, therefore, quarterly network meetings were set up as a way of encouraging the team to help each other.
After searching for information relevant to setting up such a scheme, the health authority, Total Commissioning Pilot and LMC met again to define some general principles, as follows:
- Nursing homes need to develop sustainable knowledge and expertise in specialist areas, in addition to accessing specific clinical advice when required. Links need to be made between specialist services supporting nursing homes;
- Nursing homes need to identify link personnel to access the advice and training available;
- Appropriate links need to be made with the Nursing Homes Inspectorate;
- Nursing homes and GPs should sign up to any training packages to improve access to the available services;
- There is potential for developing records, which hold all the specialist services information for each resident. This information could help to audit/evaluate the project and requires further consideration;
- GP practices and nursing homes need to negotiate a reasonable and practical arrangement for the regular review of residents. This would be formally agreed via a service-level agreement signed by both;
- Residents can still remain with their original GP, but nursing homes can inform new residents that they belong to the scheme, as some may wish to change their GP accordingly.
After the guiding principles were established, the structure of the team was agreed. It included a continence adviser, an infection control nurse, tissue viability nurses, occupational therapists, dietitians, pharmacists and Macmillan nurses.
A programme of training sessions for GPs and senior nursing home staff was planned for February and March 1999. This comprised short briefings from each of the nurses outlining the services they could offer. GPs and nurses were told that they could access the services at any time. The emphasis is very much on working in partnership with nursing home staff to facilitate effective management of nursing home residents.
One of the issues we faced was how to work as a team given that members came from different trusts and are in different locations. We agreed to meet every two months to share information, offer support, and work on joint ventures. A referral guidelines booklet was produced for each discipline detailing the services available.
A spin-off benefit has been to increase collaboration between the four trusts and also raise the profile of the team. Due to the closer working relationships, residents are transferred more smoothly between primary care, hospitals and nursing homes.
We planned a conference for March 2000 to raise the profile of the service and highlight areas of good practice, teamwork and working in partnership. The theme that linked all speakers was a case study of a fictitious female home resident. The presentations showed how the nursing home support team could help the care home staff to care for her, from her admission to the home through subsequent changes in her general health.
What emerged from the conference was the need for a comprehensive assessment of each resident's problems, and how the specialist team members could help the nursing home staff to achieve this.
By providing study days like these, nurses are given the opportunity to meet others in similar situations to themselves, so helping to reduce professional isolation and encouraging the sharing of ideas. Anderson (2000) says: 'Nurses who work in nursing homes have had to put up with being ignored or dismissed as professionally second rate'. But hopefully, with a government emphasis on intermediate care, this should begin to change. As more collaborative projects are being developed across the country, things can only improve.
Our second annual conference was held in May 2001. Aimed primarily at trained nurses and GPs, it explored reflective practice while still retaining a clinical element. A third conference is scheduled for April this year and is aimed primarily at care assistants.
If our original nursing home resident, Bernard Jewell, had been in the collaborative project he would have received support and input from dietitians, infection control, tissue viability and continence advisory service nurses. This support and input would have enabled the nursing home staff to manage his care so that he was no longer isolated.
Without a support service of this nature, Mr Jewell would have been admitted to hospital almost immediately because staff would have been unable to manage his care appropriately. Through the collaborative working of the nursing home staff and the primary care support team, his needs were effectively addressed without having to remove him from his home environment and away from the people he knew and trusted.
Most staff in nursing homes and the primary care team have been enthusiastic about the project. However, there has been some resistance because a few of the changes suggested have incurred costs for the home, for example, providing equipment following audits. Also, some nursing home staff have felt threatened by the input - but this can be overcome if handled sensitively.
As regards updating data, all staff when visiting residents in the homes write comments in the residents' care plans and retain a copy for their own notes. Letters are usually then written to the resident's GP passing on the information.
The scheme is being evaluated partly by monitoring the number of admissions from nursing homes to hospitals. All services keep statistics of number of visits, link clinicians and education provided and all produce an annual report.
If other areas wanted to set up a similar scheme they would need to ensure they could get support from their LMC, nursing home proprietors and matrons.
Overall, we believe the project has encouraged a proactive approach and that it is imperative for all residents in long-term care that the impetus is maintained.
Referrals continue to grow for most services as more homes become aware of the input and support that can be provided.
Aspirations for the service include:
- To continue to expand the scope of the existing service, working with nursing home proprietors, staff, residents and families;
- To expand the scheme into private residential care homes to ensure that these residents who may also have complex health care needs receive an equitable service;
- To extend the service to include other health care support, such as physiotherapy, speech and language therapy.