Maximising Quality in Residential Care Quality -improving NHS support for care home residents

Transcription

1 My Home Life Conference RIBA, London June 22 nd 2012 Maximising Quality in Residential Care Quality -improving NHS support for care home residents Professor Finbarr Martin President, British Geriatrics Society Geriatrician, Guys and St Thomas NHS Trust 1

2 Summary The recent CQC Report How did we get to this situation? a history of disengagement A geriatrician s perspective on the clinical needs of care homes residents. What are the clinical activities that the NHS needs to provide? What healthcare works best for care homes residents and staff? Some examples The way ahead recommendations for development 2

3 CQC review - March 2012 Aim: To see what PCTs commissioned and how they were monitoring -and how residents etc were involved in care 3

4 Standards and monitoring The setting and monitoring of response standards Services commissioned Response standard set Standard monitored & data provided 144 Chart No. of PCTs (152) Geriat ricians Psych iatry Dietetics Occup Therapy Physio therapy Podiatry Continence Falls Tissue Viability 4

5 How were services provided? 80 Specific provision for care homes Care home specific provider Services undertaking scheduled visits Specific referral pathways no. of PCTs (152) Geriat ricians Psych iatry Dietetics Occup Therapy Physio therapy Podiatry Continence Falls Tissue Viability 5

6 BGS analysis Failing the Frail March 2012 Variable access of care home residents to community health services. Only in 43% of PCTs are older people likely to have access to all the nine selected services. Healthcare commissioners had inconsistent standards and did not monitor them 40% of all services lacked a response standard. Response standards varied greatly between services and areas the general NHS 18 week target was used for 31% of services Despite these non-ambitious standards, they were not met in nearly half of services for which there was data. Limited access for care home residents to specialist geriatrician care. (60% of PCTs) 6

7 Why is care so variable? Privatisation of care in 1980s onwards led to disjunction from NHS clinicians Lack of clarity around NHS obligations NHS continuing care funding NOT followed by NHS care NHS aimed at working age population with single conditions not frail older people with co-morbidity Myth that ordinary general practice may be sufficient Care homes poorly integrated into health and social care environment Ageism? In any case, not designed with the reality of the residents at the forefront 7

8 Clinical needs residents differ Trajectories towards death Median survival is short, ~ a year or so, Some are clearly at EoL and may need mainly palliative care, Many stabilise and may live years 8

9 The Clinical Course of Advanced Dementia (Mitchell et al NEJM 2010) 323 nursing home residents with advanced dementia followed for 18 months in 22 nursing homes 9

10 Therefore.. Residents are different but mostly complex Support needs are different over time but the common problems are common Success needs establishing realistic individual healthcare goals, in context of overall goals and stage of life Balance of palliative and other approaches Realistic long term condition treatments Anticipate clinical challenges 10

11 Common clinical challenges Pain at rest or on movement Disengagement or agitation (depression etc) Behavioural and psychological symptoms Contractures and spasticity Mouth care: Eating and drinking difficulties Positioning in bed or chair Instability and falls Continence and skin integrity Etc Plus Acute illnesses and End of Life Care 11

12 Are the usual clinical approaches suitable? Will the patient set the pace? Is demand led response suitable? Who will notice and report symptoms? Interventions usually involve others as well as the patient, ie a resident in the context of care Are hospital clinics realistic or useful?. The usual approaches do not work 50% of care homes residents who died in hospital could have been cared for elsewhere (National Audit Office Balance of Care, Nov 08) 12

13 Does clinical evidence help? NICE guidance on long term conditions: Not derived from research with care home residents Potential to benefit depends upon which conditions are the main factors at this stage of life Relative benefits differ with frailty etc Burdens of treatments also affected by frailty Guidelines do not integrate co-morbidities Symptom orientated care combining multidisciplinary inputs is good to have but difficult to find 13

14 What does research tell us? Consensus about what makes collaboration work Shared perspective between residents, relatives, staff and clinicians Clarify health- related objectives Assess and anticipate challenges and needs Advance clinical plans Relevant observations and assessments Planned input of the right professionals in collaboration with each other 14

15 Do current service models enable this pro-active approach Mostly NOT haphazard, many GPs with few residents, no co-ordinated specialist support Most care homes find this unsatisfactory Elsewhere plenty of initiatives with average lifespan of 7 years Often provider rather than commissioning led 15

16 Examples of service models in UK Enhanced primary care Dedicated primary care Specialist support teams Integrated primary-secondary care Single issue initiatives But we need the NHS to commit to a consistent and sustainable approach 16

17 Quest for Quality June 2011 BGS led Stakeholder engagement Professional collaboration Inclusion of researchers 17

18 Actions needed Recommendation 1 Local NHS planners/commissioners should agree clear and specific service specifications with their local NHS providers. These need to link with quality standards based on patient experience and appropriate clinical outcomes. 18

19 Actions needed Recommendation 2: Care home residents should be at the centre of decisions about their care. An integrated social and clinical approach should support anticipatory care planning, encompassing preferred place of care and end of life plans 19

20 Actions needed Recommendation 3: Service specification for providing healthcare support to care homes should guarantee a holistic review for any individual within a set period from moving to a care home, leading to healthcare plans with clear goals. This will guide medication reviews and modifications, and clinical interventions both in and out of hours.. 20

21 Actions needed Recommendation 4: Healthcare services to achieve these goals need to be integrated. This should combine enhanced primary medical and nursing care with dedicated input from departments of old age medicine, mental health services, and other specialisms such as palliative care and rehabilitation medicine according to local needs 21

22 Actions needed Recommendation 5: The UK nations health departments should clarify NHS obligations for NHS care to care home residents. 22

23 Actions needed Recommendation 6: Regulators should include provision of NHS support to care homes and the achievement of quality standards in their scope of scrutiny Recommendation 7: Multi-agency and multiprofessional national leadership should be promoted to support the development and dissemination of good healthcare practice in care homes, supported by clinical guidance and quality standards 23