Leads: Prof Dan Lasserson, Dr Thomas Knight, Dr Sarbjit Clare (Acute Care Interfaces), Dr Denise Tanner (Social Care) and Dr Laura Quinn (Meths)

Dates: January 2020 - December 2022

Background:

Older people living with frailty and multiple morbidity are at high risk of acute deterioration in their function and this can lead to hospital admission. In particular, residents of care homes are among the most complex patients in the health and care system, related to a combination of multimorbidity across physical and psychological domains, polypharmacy and frailty and many are very dependent on support for all elements of care. There is a need for a rapid and comprehensive response after the detection of an acute illness syndrome in the older adult, whether they are living at home or in institutional care. Many acute conditions will share a similar non-specific presentation in this patient group and so the capability to investigate multiple conditions at the same time is needed. However, the care models needed to deliver a rapid diagnostic capability in the community are currently lacking.

In the UK, the medical care for older people living at home or in a care home is organised through general practice with varying levels of expertise in the care of the complex older adult and the main primary care team is only accessible during traditional office hours. Care home staff are therefore the primary deliverers of complex care with variable support from external providers. This poses a significant challenge for care homes where there may be multiple practices providing care to a single home, and different access to care throughout the 24 hour day and on different days of the week. The main access to general practice itself is through a telephone-based appointment system, which requires a considerable degree of function and persistence to navigate. This may limit the ability of those who are older and frail to access primary care at a time of acute illness.

The capability to provide diagnostic testing together with parenteral treatment in the community could increase the breadth of care models that are offered to older people when they become acutely unwell. For those who prefer to remain in the care home, point of care diagnostic technology embedded within a rapidly responding clinical team would ensure that appropriate acute diagnostics can be delivered within a timeframe that is as good, or in fact exceeds, that provided by traditional transfer to an increasingly congested acute hospital setting.

The need to increase the health system capability to deliver ‘care in place’ is recognised across Europe and in particular the need to deliver the processes of acute care that are needed to ensure correct diagnosis and treatment outside hospital. This change in focus for acute medical care within the community can contribute to developing resilience in the acute care system, as there is less reliance on one setting (acute hospitals) for rapid access to acute diagnostics and differentiation of illness syndromes.

Policy and Practice Partners:

Awaiting information.

Co-Funding Partners:

Sandwell and West Birmingham Hospitals NHS Trust.

Aims and Objectives:

1. Describe the organisational barriers and facilitators in the implementation of point of care blood testing and ultrasound/echocardiography in an Acute Hospital at Home Service (Sandwell and West Birmingham NHS Trust funded Acute Medicine PhD student).
2. Describe the barriers to integration of acute physicians in a care home setting from the perspective of a social care organisation (ARC WM funded Social Work PhD student).
3. Determine the impact of an Acute Hospital at Home intervention on emergency medical admissions from care homes.

Methods:

1. Observational mixed methods study of organisational attitude and barriers to set up and delivery of point of care blood testing and point of care ultrasound and echocardiography. Source data include observations from meetings, process mapping of embedding the diagnostic model within clinical workflows and governance approvals, data from process of care, interviews with clinicians, managers and patients.
2. Ethnographic study of delivery of acute medical care in the care home settings including non-participant observation of care, interviews with care home managers, interviews with patients and families.
3. Interrupted time-series to evaluate Acute Hospital at Home intervention in reducing emergency admissions from care homes.

Main Results:

Awaited.

Conclusions:

Awaited.

Implications for Implementation:

Care homes may wish to adopt this method; integrated care organisations and commissioners would find it cost-effective to incentive care homes to adopt point of care testing. It may turn out that some types of point of care testing are more useful or more practical than others.