The Frail and Older People Workstream is a collection of related projects that focus on improving care for older people, in nursing homes and elsewhere. The Workstream offers a range of modules covering a wide array of subjects relevant to the care of older patients, with the core aim of improving overall standards of care whilst reducing unnecessary hospital admissions.
Why is this important to the HEEM?According to the Health and Social Care Information Centre, around 1.1 million patients were admitted in hospitals across the East Midlands during 2011/2012. Approximately 54% of these admitted patients were over the age of 60. For East Midlands alone, it is estimated that by 2016, the population aged 65 and over will increase by 11.1%. As a result, the following predictions for health have been made for 2016.
• 11.2% increase in falls that require a hospital admission
• 11.7% increase in limiting long term illness
• 11.9% increase in continence related issues
• 12.5% increase in dementia
• 12.2% increase in stroke
(Poppi.org.uk database, 2013)
It is also known that frail and older people tend to have the longest length of stay in hospital, and the highest rate of in-patient complications. From a nursing home perspective, it is well known that district nurses are regularly called in to perform basic duties. Furthermore, many admissions into hospital from nursing homes can be avoided provided the right training is delivered.
Proposed education interventionAfter careful monitoring and assessment of nursing homes in Northamptonshire, the quality improvement team at NHS Nene and NHS Corby Clinical Commissioning Group were able to identify homes that required training support and the most common issues faced within these homes. In response to service needs, an educational toolkit was then devised to impart education regarding the emerging issues being faced by the nursing homes. In the initial stages, the homes were provided educational training on aspects such as Falls, Nutrition, Venepunctures, Tissue Viability, Syringe Drivers, Anaphylaxis and Diabetes.
During this time, the former EMHIEC partnership had also funded other projects relating to the frail and older people population such as Falls and Fracture Management, Urinary Catheter Management and Delirium Assessment. Realising the benefits that these projects individually offered for the frail and older people, as an effective dissemination strategy it was decided to formulate a single educational toolkit that would include the initial nursing home package as well as the education from the additional projects. Effectively, all this could then be offered as one package to nursing homes and adapted for training needs at trust level.
The current package includes:
Care Home Quality:
This module educates nursing home staff with the necessary skills to enable either prevention, or the early intervention and treatment, of conditions that are often associated with an older population. These skills include administering sub cutaneous fluids, venepunctures, tissue viability, diabetes care, pressure ulcers, anaphylaxis, nutrition and reducing anti-psychotic prescriptions.
Falls and Fracture Management:
This module aims to increase staff confidence in managing falls within their own working environment and promote proactive strategies to prevent and/or reduce falls and fractures in older people.
Reducing Falls in Care Environment:
This module delivers an innovative and flexible educational programme using different media, including a DVD depicting common falls scenarios and a self-assessment booklet to encourage active learning.
Delirium Risk Assessment:
This module teaches health care professionals to effectively and confidently assess for delirium, understand delirium risk factors and be able to take appropriate action when delirium is presented.
Urinary Catheter Management:
This module raises awareness of the benefits associated with promoting continence, thereby reducing the risks associated with urinary catheters, unnecessary urethral catheterisation and urinary catheter related infections. It also covers appropriate urinary catheter management so when a catheter does have to be inserted people should know how to care for it appropriately and be aware of how to prevent infections occurring.
Benefits to patients and serviceFor patients, this programme promotes the improvement in quality of care delivered; for example by reducing falls and subsequent hospitalisation of nursing homes clients, the client avoids a potential life limiting event. In addition, this programme provides positive reassurance for carers, relatives and friends of the client that the environment in which they are being cared for is fit for purpose.
From a service prospective, in addition to having cost benefits, this programme brings advantages in the form of cultural changes. Through the spread of this programme, there will be a reduction in reactive contact with clients in nursing homes from NHS professionals. This will then allow the time saved through not having to attend to clients within the nursing home environment to be used for other activities that have a positive impact on outcomes for the local population and not just the nursing homes.
The programme also allows staff to have fulfilling roles within the nursing home and an appreciation that they are making a difference. The processes set up for this programme can also help in quantifying this impact through the analysis of district nurse visits and GP visits, as the time taken from referral to visit should be reduced.
Productivity and impactThe programme has showcased significant impact in terms of education delivery and on nursing home reported measures. Overall the programme has led to:
Improved Knowledge and Confidence:
Staff that undertook the training felt that their confidence and knowledge on the subjects offered as part of the package had improved significantly. In particular staff felt that they were better able to:
• Identify factors that increase the risk of falls and those that were at a greater risk of falling
• Understand the impact of a fall on the patient
• Recognise the signs and symptoms associated with delirium
• Distinguish between delirium, dementia and depression
• Administer Sub-Cutaneous fluids and take bloods
Improvement in nursing home reported measures:
With the help of the quality improvement team at NHS Nene and NHS Corby Clinical Commissiong Group (CCG), a number of measures were identified and then collated to assess the overall impact of the training. Reported measures from 9 nursing homes that received training show that there has been a:
• 13% reduction in all falls incidents, with a 50% reduction in falls incidents referred to hospitals
• 35% reduction in urinary tract infections
• 47% reduction in referrals to emergency departments; and
• 12% reduction in GP callouts
Establishment of EMAS CQUIN:
Data collection and information from care homes is often difficult to acquire. With demographic trends indicating an increase in the frail and older population, an increasing demand on the acute trusts, and the need for effective community services, the requirement for accurate data from care homes has become more critical. With this in mind the NHS Nene and NHS Corby CCG quality Improvement team suggested and developed a CQUIN for 2013/14 with East Midlands Ambulance Service (EMAS), to understand the numbers of and the reasons why patients from care homes are transported by EMAS to accident and emergency departments (AandE) and to establish which homes and localities are the highest users of the service. Other information collected in the CQUIN included:
• Name and type of care home
• Time of call
• Ambulance requested by
• Reason for transfer
• Interventions undertaken by care home staff
• Interventions undertaken by GP
It is anticipated that on-going data collection through this CQUIN will support targeted commission activities and help better monitoring of care homes.
To learn more about Health Education East Midlands’ work on the Improving Care for Frail and Older People programme please contact 0115 8233300 or email firstname.lastname@example.org.