Managing patients in care homes

Abstract

Older people in care homes deserve the best health and social care we can offer. Their care needs are usually high and they are vulnerable either physically, cognitively or both. They are likely to have several long-term conditions and be in the last year or so of life. Although some may have families and friends supporting them with regular visits and advocacy, others may be more alone and socially isolated. Care homes are traditionally classed as either residential homes or nursing homes, with some being dual registered. The main difference is the presence of 24-hour on-site qualified nursing support in nursing homes. This means that, in general, the residents of nursing homes are more dependent and complex. This article will first describe how to approach the planning and delivery of primary care services to nursing homes, and then consider some of the most common problems and conditions. Much of this also applies to residential home residents.

The RCGP curriculum and managing patients in care homes

The role of the GP in the older adults life stages topic guide includes:

Diagnose, investigate and manage older adults taking into account theories of ageing, differences in epidemiology and risk factors of disease in the elderly population

Consider the physical, psychological and social changes that may occur with age

Communicate appropriately with patients, their families and carers, recognising potential challenges in communicating with older patients

Coordinate with other organisations and professionals while taking an advocacy position for the patient or family when needed, including for palliative and end-of-life care planning

Review medications and repeat prescriptions effectively, working with a pharmacist when necessary

Consider the factors associated with drug treatment in the older adult and the hazards posed by multiple prescribing, non-compliance and iatrogenic disease

Offer advice and support to patients, relatives and carers regarding prevention, monitoring and self-management

Ensure care promotes patients’ sense of identity, independence, personal dignity and that the patient is not discriminated against as a result of their age

Emerging issues include:

A demographic shift in the UK population and a rapid increase in the number of older people

Risks of long-term conditions and cancer in older adults are exacerbated by increasing lifestyle factors such as obesity, alcohol and other substance misuse problems

Social care services to help people stay safe and independent at home (e.g. home carers, meals on wheels, day care) are mainly arranged by local councils whose budgets have been significantly reduced

Older people are admitted to hospital more frequently, with longer lengths of stay and occupy more bed days in hospital compared with other patient groups

There is an increase in the number of carers aged 80 years and over. Over half are caring in their home for more than 35 hours a week.

Service development and planning

The following two boxes describe the useful experience of the Enhanced Health in Care Homes (EHCH) vanguards and Health 1000 in developing and planning care home services. Health 1000 was a novel primary care practice that was solely for patients with multiple long-term conditions that operated from January 2015 to September 2018. It was located in outer east London and supported by the ‘Prime Minister’s Challenge Fund’, local GP federations and three local Clinical Commissioning Groups. It evolved to develop a service to nursing homes that was independently evaluated by the Nuffield Trust. The conditions and features described can be used to inform local planning and design. The EHCH vanguards identified conditions that are critical for success in planning services (Box 1).

Box 1.

NHS vanguards conditions critical for success.

Person-centred change

• Putting the needs of the resident or person with care needs at the centre of any changes

• Supporting carers and families as well as those with care needs

Co-production

• Working and integrating with local government, the community and the voluntary and care homes sectors to co-design and co-deliver the model of care

• Acknowledging the value of the care home sector in supporting the NHS and the significant level of healthcare that is delivered in care homes by social care staff

• Adopting a whole-system approach, breaking down organisational barriers between health, social care and the voluntary sector

Quality

• A focus on quality as the driving factor for change

• Using clinical evidence to support as well as drive change

Leadership

• Strong leadership and a joint shared vision for better care

• Recognising the cultural differences between organisations and different types of commissioner and provider and focussing on the shared care aims despite differences in language and process

Reproduced from NHS (2016) . The framework for enhanced health in care homes, under the terms of the Open Government Licence v3.0.

In designing the Health 1000 service the key features are described in Box 2 (Sherlaw-Johnson et al., 2018).

Box 2.

Key features of primary care service.

• A geriatrician is available to support GPs and families, including supporting family members when a patient is approaching the end of their life

• Comprehensive medicines reviews

• A named clinician and key workers as dedicated contacts for each nursing home

• Support to the nursing homes from 8 am to 8 pm, 7 days a week

• Support to the nursing homes for providing end of life care

• During ward rounds at the nursing homes, staff members are given advice and/or are educated in more appropriate or better care techniques

• Acute assessments are provided by Health 1000 for nursing home patients with acute presentations and are carried out while still residing in the nursing home. Responses to such assessments may be advice to send the patient to hospital, to arrange a Health 1000 clinical visit or to prescribe appropriate medication

Principles for services

There are lots of different examples of successful nursing homes support by primary care. The local development of such services may depend on the local workforce, number of nursing home residents and local relationships. Thus, there is no ‘perfect’ model but there are important principles.

Single primary care team to cover the nursing home

NHS England recommends that nursing and residential homes should be covered by a single primary care team or practice rather than multiple different practices (NHS, 2016). This allows the development of a trusting and supportive relationship between the home and primary care. Health 1000 found that after a period of 3 months, out-of-hours calls could be managed with fewer visits and more telephone advice. This does suggest that when planning new services to support nursing homes there should be a period of increased resourcing in the initial months, as trust and support develop.

Specialist care of the elderly support

There have been numerous models of primary care support to homes (Lloyd et al., 2019; NHS 2016). An approach that utilises an extended primary care team, along with specialist nurses and support from specialist care of the elderly consultants, has been developed. Evaluations have been generally, but not universally, positive. Specialists in care of the elderly have the training and expertise to work with this most vulnerable population, and their involvement and support should be core for services to nursing homes. Access to timely immediate specialist advice and support (without the necessity to move the resident) should be the starting point in planning such services.

Regular scheduled visits

Getting to know residents and providing some continuity of care is vital when they are likely to have complex histories and conditions. Providing continuity will help reassure residents, relatives and staff. In many homes with high staff turnover such continuity becomes even more crucial. It is also vital to develop a trusting relationship with the staff of the nursing home, and to support them in their education and development, as well as the care for the residents. It allows the team to influence and co-develop protocols for common conditions and problems.

Medication reviews

Many residents will have multiple medications. Although this is covered elsewhere in this issue, it is a vital intervention. Multiple medications bring multiple potential interactions and may have limited benefit for residents in the last years of their life. This requires a sensible risk-to-benefit discussion with residents and their relatives. Recognising the limits of treatment and concentrating on symptom relief are important guiding principles. Using established tools such as STOPP / START can reduce falls, episodes of delirium, hospital length-of-stay and primary and emergency care visits, as well as medication costs (Hill-Taylor et al., 2016).

Advance care plans

Having built a continuity relationship with residents, their friends and family, and the nursing home staff you are better placed to have discussions about future care and extent of treatment. This goes beyond the decisions about cardio-pulmonary resuscitation and covers the resident’s wishes should their health deteriorate. It should include the extent of treatment and the location. If discussed and agreed in advance it allows the resident’s and family’s wishes to be respected should they become too ill to communicate (Nakajima et al., 2015). This process does not need to be concluded in a single meeting or discussion, as it is often best to outline and explore the issues first and then give the resident, their family and friends time to think and discuss further.

Where residents lack capacity, it is important to involve their next of kin. In many cases residents have already delegated power of attorney for these issues. It is possible that the resident may lack capacity and have no friends, family or next of kin to advocate for them. In these circumstances, an Independent Mental Capacity Advocate should be included in the discussions. They are usually provided by the appropriate local authority and accessed through social services.

Various types of pre-planning documents have been developed, PACE, PEACE, and RESPECT are examples. It is the discussion and resulting agreement of expectations that is most valuable.

Timely response (todays work today)

These residents are vulnerable to deterioration in their health. Early detection and management limits associated morbidity for patients. The simple principle of a same-day response to all concerns and enquiries is appropriate. The complexity of residents’ conditions means it is not always possible to resolve problems immediately, but a management plan can be discussed and agreed. Visits may not always be necessary, and telephone advice is often an appropriate response. Drawing on Health 1000 experience, it appears that such a response is possible after regular visits and a trusting relationship has developed. A timely response is still challenging for a single primary care practice and may be best suited to evolving primary care home or network models where practices come together and collaborate to provide such services together at-scale.

Nutrition and nutritional supplements

At Health 1000 we developed a guide to managing residents with weight loss. Some residents with specific conditions required, or were already receiving, specific dietetic and nutritional support. Others who suffered some mild weight loss or recent inter-current illness had been put on nutritional supplements and not reviewed appropriately. We set out some background information for nursing home staff, which is reproduced in Box 3.

Box 3.

Background information to guide nutrition.

• Elderly residents have diminished taste and thirst sensation

• With advancing dementia weight does tend to reduce often associated with reduced appetite

• Loss of appetite might be transient and linked to inter-current illness

• Although nutritional supplements have been shown to reduce weight loss, there is no evidence that they improve mortality and little evidence regarding morbidity

• Use of nutritional supplements may alter a resident’s appetite so they become less likely to eat usual meals

• Although residents with neurological swallowing difficulties may be prone to weight loss, they are best served by fortified foods, as nutritional supplements will often need to be thickened

• Where evidence does exist, the use of nutritional supplements for short periods is suggested rather than long term

• Pressure sores are caused by a combination of factors, of which pressure, skin age elasticity and circulation all play a part. As such they are rarely caused by poor nutrition alone, but more often to acute on chronic illness which often reduces appetite and weight

We then considered the questions in Box 4 before supplements were prescribed and only if we had addressed all of these did we use nutritional supplements, and then only for 4 weeks, after which the prescription was reviewed.

Box 4.

Prescribing nutritional supplements.

• Is their appetite normal?

• Have they got an inter-current illness affecting their eating and/or appetite?

• Do they have any ongoing swallowing, mouth (ulcers) or dental issues that need addressing?

• Are there any medication that may be contributing?

• Are there particular foods they like or dislike?

• Do they need prompting and support to eat?

• Have we offered extra portions of food they prefer?

• Have we fortified their foods?

Infection control

Leading, encouraging and supporting best infection control practices is important. Flu vaccination of not only residents but also staff, hand-washing facilities and freely available alcohol gel are all important.

An approach consisting in vigilance, early management and isolation of residents with diarrhoea and vomiting is important in reducing the risk of outbreaks in homes (particularly norovirus). If an outbreak does occur following guidance about closing the care home to admissions and visitors, informing and seeking advice from local specialist services is important (Department of Health, 2013).

Aids and adaptations: Movement, fall detectors, etc.

Having the right seating, beds, walking aids, etc. is important for residents to maintain independence. Modern technology offers opportunities to help maintain the safety of residents. Use of fall detectors and movement detectors helps early identification of risk, for example, by detecting when a high-risk resident is moving unsafely. Modern communication methods, such as Skype consultations, can allow remote assessment in some cases. Video consultations also allow the team to communicate better, including for example, when accessing specialist support. Data-sharing agreements can be helpful to aid communication and care, for example, by allowing the nursing home’s senior staff to review patient records including medication.

End of life

Many nursing home residents will be in the last year of their life. They are often at the limits of treatment with conditions that cause progressive deterioration in health, including cancers, but also progressive long-term conditions. The value of advance care planning should not be underestimated. It is important to recognise when a resident is deteriorating and approaching the last weeks and days of their life. Recognition of this allows everyone to prepare and plan for the best care. This may include not only discussions with the resident, their family and friends, but also preparing and supporting staff and prescribing anticipatory medication. Support from local hospices and charities such as Macmillan and Marie Curie may also be available. This can be helpful in supporting staff training and in developing and improving end of life care. This may be framed by guidance such as the Gold Standards Framework (Gold Standards Framework, n.d.).

Common conditions and their management

In delivering primary care services to nursing homes it is essential to have a good understanding of the common problems encountered in this group of patients. The following is not intended to be a complete list, but rather it is a guide to the management of the most common problems.

Urinary tract infections

Urinary tract infections (UTIs) are common in nursing home residents, but require a full assessment for clinical diagnosis to be made. They are the most common infection causing admission to hospital (Tsan et al., 2010). The National Institute for Health and Clinical Excellence (NICE) notes that good hydration and minimising the use of catheters can reduce the incidence of UTIs (NICE, 2018).

The value of dipstick testing is limited, as it is less sensitive and specific in these residents. Although the incidence of asymptomatic bacturia is very high (up to 20% in older people) this figure rises to nearer 50% in nursing home residents (particularly in frequent hospital attendees). The incidence is even higher in patients with urinary catheters. When positive dipstick test urine is cultured, only 50% of samples are culture positive. It is also not uncommon for false negative results to occur (6–30%) in residents. Such false positive and false negative results suggest that it is the clinical assessment of the resident that should inform the diagnosis and treatment. Using dipstick tests as a discriminator is likely to be unhelpful and can lead to both over- and under-treatment. This should not, however, discount the importance of a urine culture before starting antibiotics.

The consequences of overtreatment include antibiotic side effects (some serious, such as Clostridium difficile) and increasing antibiotic resistance. Therefore, it is most important that a full clinical assessment is undertaken and antibiotics used only when there is further evidence of infection (Public Health England, 2018)

Constipation

The incidence of constipation is significant in nursing home residents, often because of medication or reduced mobility. Between 50 and 74% of elderly institutionalised patients report daily use of a laxative (Leung et al., 2011). It can cause non-specific deterioration. It can lead to incomplete bladder emptying and retention. Constipation may also cause impaction and liquid overflow, which may confuse less-experienced nursing home staff. Stool charting using the Bristol stool chart is helpful as part of regular review and helps inform whether laxatives may be indicated or are effective if prescribed. Residents are likely to have different individual bowel habits, and thus, individual assessment and plans for bowel management are required. The use of suppositories and enemas is helpful for severe constipation provided full clinical assessment has been undertaken.

Pain

Recent surveys estimate that one-in-five residents in nursing homes in the USA have persistent pain, and of those 6% may have no treatment at all and around third are undertreated. This lack of treatment was more common in residents with dementia (Hunnicutt et al., 2017). The cause of pain (muscular skeletal, neuropathic, vascular, etc.) needs to be reviewed and the most appropriate pain relief for the condition considered. This may include simple paracetamol, opiate analgesia, and / or drugs specific for neuropathic pain. Non-steroidal analgesics are best avoided in elderly residents, at least in longer-term treatment, in view of their gastrointestinal and renal side effects. There is a place for short-term use in acute inflammatory conditions, such as gout. Pain is an important consideration when the behaviour of a resident with advanced dementia noticeably deteriorates. It is important to consider ways of managing painful conditions other than medication, for example, with appropriate positioning, seating and walking aids.

Mobility/falls

Care home residents are three times more likely to fall than their peers living in the community, and 10 times more likely to suffer injury. The risk factors for falls, including physical frailty, multiple long-term conditions, physical inactivity, multiple medications and unfamiliar new surroundings, are all common to nursing home residents. This is the point at which a Comprehensive Geriatric Assessment (CGA) should be performed; a CGA is a multifactorial complete assessment of the resident (British Geriatric Society, 2019). There is evidence that fall-prevention-specific tools may also help, and allow development with the nursing home of a personal prevention plan for each resident (Care Inspectorate, 2019; Cooper, 2017).

Pressure areas

Nursing home residents are vulnerable to pressure sores, particularly when there are exacerbations of illness. It is important that the whole team understands this point and pays attention to the overall health of the resident, not just the pressure areas. NICE have a simple guide to help care homes (NICE, 2019) and there are various simple tools to help prevention and identification like SSKIN (NHS Improvement, 2017) (see Box 5).

Box 5.

SSKIN tool for prevention and identification of pressure sores.

Surface: Make sure residents have the right support

Skin inspection: Early inspection means early detection - show residents and carers what to look for

Keep your residents moving

Incontinence/moisture: Residents need to be clean and dry

Nutrition/hydration: Help residents have the right diet and plenty of fluids

Behavioural challenges, dementia and depression

In nursing home residents, the incidence of dementia and delirium is high. Patients with dementia should have had a formal diagnosis and assessment to determine whether medication is indicated. A calm environment, with staff known to residents helps make residents feel comfortable and less agitated. Some residents may have episodes of challenging behaviour, which may be transient and associated with inter-current illness with delirium. Some may have more persistent behavioural issues. This can be difficult to manage and may require specialist psychogeriatric support.

A pattern of behaviour that can be exaggerated in nursing homes is Sundown Syndrome, when confusion and agitation present more often at the end of the day in the early evening (Khachiyants et al., 2011). Anticipating this and working to find the right environment for each resident can help reduce this pattern of behaviour.

Management of these issues requires a holistic approach. A general assessment is important, as inter-current problems with pain and constipation, for example, can present with increased agitation and confusion. Working with staff and families can help identify the most calming environment, position, activities and music for the resident.

When a resident’s behaviour puts themselves, other residents and staff at risk, then medication may be indicated (not just because the behaviour is annoying or disruptive). Where medication has to be used, it should be reviewed regularly. Any medication to control behaviour may in effect be viewed as a chemical straight jacket. The use of traditional anxiolytics (benzodiazepines) may not be helpful longer term and may just lead to episodes of drowsiness with an increase in the risk of falls. Short-acting night sedation (sleeping tablets) may help night-time disruption. The use of low-dose modern psychotropics (risperidone, quetiapine, olanzapine) can be helpful, but this should normally be under the advice of a specialist.

It is important to consider depression. Recent evidence suggests that depression has an incidence of up to 26% in care home residents often co-existent with dementia or multiple long-term conditions (Stewart et al., 2014). This can make the diagnosis more difficult. It is important to consider the diagnosis and seek specialist advice on management when appropriate.

KEY POINTS

Nursing home residents are often vulnerable and likely to have complex problems

Timely primary care with specialist support is important; regular visits help build trusting relationships with care home residents and staff

Advance care planning and well delivered end of life care are essential and should be targets for quality improvement

Good nutrition should be supported by appropriate use and review of nutritional supplementation

Optimal management of common conditions or symptoms requires good information, communication and appropriate clinical assessment

Management of dementia, delirium and associate behavioural issues requires full assessment to optimise management of any co-existent conditions and environmental interventions before recourse to medication

Footnotes

ORCID iD

Dr Michael Gill

References

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Department of Health (2013) Prevention and control of infection in care homes – an information resource. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/214929/Care-home-resource-18-February-2013.pdf (accessed 21 July 2019).

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