Having a care

A comprehensive framework set out by a clinical commissioning group (CCG) could support care homes in improving and monitoring quality to meet the complex needs of their elderly, frail residents. General practitioner led commissioners have a unique opportunity to lead these improvements through providing a range of clinical support and staff training. Through these efforts, focus is directed on keeping patients well, out of hospital and extending their quality and length of life.

Frequently, older residents are admitted to secondary care due to falls, urinary tract infections (UTIs) and pneumonia. CCGs could liaise with GP practice members to focus on reducing rates of admissions due to these factors, preventing avoidable, unplanned admissions to hospitals.

Information sharing between organisations and agencies could provide a greater level of intelligence. The profile of care home settings has risen due to media coverage, for example the BBC’s ‘Panorama’ programme raising public awareness of poor quality services in homes. For example the Winterbourne View scandal, and the financial collapse of Southern Cross, a large nationwide Care Home provider which led to a direct impact on frail elderly residents who had to be relocated. As a consequence, there has been more intensive scrutiny of care home providers by regulatory and commissioning organisations.

Background

There are 20,000 care homes in the UK in which some 400,000 people reside.

There were 112,000 cases of alleged abuse referred to English councils in 2012-13; the majority involved over-65s. Of those that have been investigated, nearly half have been partly or fully substantiated.

An Age UK survey this year found that just 26% of the general public are confident that older people who receive social care are treated with dignity.

A population projection suggests the population of residents over the age of 65 is expected to rise from 2015. In 2011, 16% of total population living in England and Wales were over 65 year of age; equivalent to 9.2 million.

Challenges

Poor collaboration between secondary and primary care.
Various GPs visiting a care home where residents are registered with multiple practices; alignment of GP practices with care homes could be implemented.
The care home market is complex, with a wide variety of providers who have their own concepts about care delivery and quality.
By working together with providers, commissioners and regulators, a comprehensive and consistent framework for monitoring quality can be provided.
The lack of resources within the CCG to proactively monitor care homes and deliver full quality assurance.
Admissions due to adverse effects of medication. Commissioning a care home pharmacist to optimise medication would prevent unplanned admissions. Pharmacist input would also help reduce waste through medication reviews.
Optimising medicines help people to get the most out of their medicines.
Medicines optimisation requires health and social care professionals, patients and carers to work in an integrated model of care.

Case Study

Mr B is 84-years-old.
Lives in a residential care home.
Weight – 49 kg.
BP – 145/80.
Smoker – 10 a day – attempting to stop.
Alcohol – five units a week socially.

Medication

Paracetamol tablets: two to be taken when required up to four times a day. No more than eight tablets in a day.
Amlodipine: 5mg tablets. One to be taken daily for hypertension.
Diazepam: 5mg. One twice a day.
Furosemide: 40mg. One daily – for ankle oedema.

Diagnosis

History of falls and fractures.
Other than hypertension he is healthy.

Q1. Mr B starts to feel unwell and confused. Care home staff order an ambulance and Mr B is taken to hospital. On examination he was found to have a UTI and was dehydrated. What issues need to be addressed in this case?

Answer

The care home staff could have done a dip stick test of urine sample.
The staff should ensure patients drink plenty of clear fluids. A fluid chart
should be in place for elderly patients who need to drink more and are on a diuretic.
The staff should consult the community matron wherever possible and avoid calling an ambulance.
The CCG could commission a community matron service in order to prevent A&E visits. Senior NHS officials report that up to 40% of older people being cared for in hospitals could be treated elsewhere.

Q2. Mr B’s daughter is concerned he is always drowsy and does not seem to eat very well. What could be causing this?

Answer

A medication review should be done. He may be drowsy due to his 5mg diazepam twice a day.
Day time diazepam can be stopped to prevent him being drowsy. Long term use of benzodiazepine is not recommended. According to the British National Formulary (BNF), benzodiazepines are indicated for short-term relief (two-four weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness.
No clear diagnosis has been made for the use of diazepam. The patient should be reviewed and diazepam stopped. If he has been using it long term, the BNF dose titration guide should be used to withdraw diazepam.
If a patient is drowsy during the day he may not eat well and this could explain the weight loss. Given that he has a history of falls, his drowsiness could cause a fall and end up with him having a hip fracture and admission to hospital.
Furosemide 40mg should be reviewed and stopped as there is no evidence of efficacy for the use of loop diuretic for dependent ankle oedema. Compression hosiery is usually more appropriate.

Conclusion

Commissioning appropriate clinical multi-disciplinary services and providing education and support to care homes would:
Reduce or minimise risk of harm, abuse or serious untoward events for vulnerable people.
Improve frail, elderly patients’ experience of health.
Social services should be joined up and provide timely social care.
Identifying frail and elderly patients at risk of worsening health could prevent unplanned hospital admissions.
Carers experience would be improved.
High clinical standards across all care homes could be achieved.
Reduce admissions and waste by optimising medication.
Support patients to die in their place of choice.
Help with organising better end of life care.